Who We Are and Might Be: In Global Health, Excellence Demands Equity

A Broader View 

In the larger Kashmir region, at least 73,000 people died, most after their homes or workplaces collapsed on top of them.3 No one knows how many succumbed to treatable injuries, or more specifically, to AKI and other injuries amenable to interventions by nephrologists. While the Renal Disaster Relief Task Force, Médecins Sans Frontieres, and other groups’ heroic efforts reflect the best our profession can offer, there is a sobering reality underlying the dialysis rates per number of people killed in the large-scale disasters since Spitak. In order to compare “renal” response rates in various disasters, the ratio of the number of AKI cases receiving dialysis to the overall number of deaths is calculated and then multiplied by 1,000. When disaster struck Kobe, Japan in 1995, this ratio was nearly 25. After the devastating earthquake in Marmara, the ratio was over 27.

Yet when disaster struck the Kashmir region of Pakistan in 2005, the ratio of those receiving dialysis to the number of deaths (× 1,000) was a mere 0.8. Despite the heroic efforts of the many local and few visiting health personnel involved, just 55 people received life-saving dialysis during an earthquake that claimed 73,000 lives. Presumably, many suffered AKI from crush injuries that would have been amenable to treatment by dialysis. Yet only a small fraction received it, which leaves us with a rather disquieting question. For all of the scientific advances of our age and our miraculous ability to heal, why did so many have to die?

Certainly, local factors played a major role. The Kashmir region of Pakistan is mountainous, and the few roads leading in were significantly damaged during the initial quake, making transportation particularly arduous. The lack of local infrastructure, hospitals, and equipment meant that supplies and people had to be imported, delaying potentially life-saving interventions. Additionally, the terrain and climate made helicopter rescue difficult. Helicopters were scarce at the outset, and 2 crashes early on further delayed victim transport to treatment centers.

Yet, the local terrain and difficult rescue conditions provide us with only a part of the answer. The rest comes through the larger structural issues that defined life for the local populace long before the quake struck. The truth is that people of the region have been dying far younger and suffering the ravages of treatable illness far more than their counterparts in Japan and Turkey for generations. But not solely because of weather and local geography. The underlying factors that contribute to these premature deaths and unnecessary suffering derive less from the laws of nature than from the choices of people. Just as dialysis rates for disaster victims are far greater in places like Japan than Pakistan, there are parallels in life expectancy, infant mortality, and other morbidity data in the different regions of our world. Dialysis rates are but an allegory of a much darker tale, best explained by the concept of structural violence.

The World at Large: Structural Violence 

A cursory look at our world reveals the profound differences in life quality and duration between different countries and regions. A comparison of morbidity and mortality data between just 2 of the above-cited countries is illustrative, and that between the wealth poles of the world even more so.4 According to the World Health Organization, life expectancy in 2004 was 20 years longer in Japan than in Pakistan (82 years versus 62 years). On a per capita basis, Japan has nearly 3 times as many physicians and 17 times as many nurses. Fertility (the average number of children a woman will bear in her lifetime) is over 3 times higher in Pakistan (4.1 versus 1.3); typically, fertility rates are inversely proportional to a nation’s wealth. High fertility compounds the problem of endemic poverty, spreading little among many. It also fuels environmental degradation, spawns regional conflicts,5 and increases the vulnerability of women and children. A child growing up in Pakistan has a 25 times higher likelihood of dying before age 5 than a child growing up in Japan.6 One can only assume these differentials would be far greater if regionally disaggregated data were factored in, given the severe poverty that characterizes the Kashmir region. Given the above, it is easy to see why someone living in Kobe was far more likely to receive life-saving dialysis after an earthquake than someone living in the Kashmir region of Pakistan. Even the most heroic interventions from abroad cannot begin to make up the differences.

Regional comparisons illuminate these disparities more clearly still. The global poles of health and wealth lie between the club of the wealthiest nations (members of the Organization of Economic Cooperation and Development), and the poorest region, sub-Saharan Africa. Life expectancy between the 2 differs by over 30 years, and is increasing, largely due to AIDS, which claims a life every 8 seconds.7, 8 A trip from Boston to Nairobi represents a step back in time; people in Africa now live roughly as long as Americans did in 1900, before modern public health measures, antibiotics, and Abraham Flexner. In Africa, infant mortality is 18 times higher, while under-5 mortality is nearly 30 times higher. The continent with the world’s greatest concentration of AIDS, the birthplace of HIV, remains the least able to confront it. The health care worker shortage in sub-Saharan Africa remains one of the world’s greatest challenges, where just 3% of the world’s health workforce, using 1% of world health care spending, attempts to treat 24% of the global burden of disease.9 By comparison, the region of the Americas has 37% of the world’s health workforce and uses over half of global health care dollars to fight just 10% of the global burden of disease. It is far more likely that an American will receive inappropriate antibiotics for a cold than an African will receive life-saving antiparasitics for malaria.

While physicians and nurses flock toward the United States and other wealthy nations, Africa and many poor countries remain decimated, more suppliers of health care talent than supplied.10 One-fifth of the US physician workforce comes from other countries, including many developing nations unable to meet the demands of their own people.11 Comparative data abound. During the late 1990s, while there was 1 physician for every 362 people in the United States, there was just 1 physician for every 100,000 in Burundi, and 1 for every 33,333 in Ethiopia.12 Five African countries now have fewer than 1 physician for every 20,000 people. Some have blamed the exodus from concentrated centers of poverty on the frustrations of working with meager supplies and overwhelming burdens of illness. Those who aspire to save lives find it difficult to function as “morgue attendants,” a role that many health providers in the AIDS belt now play.13

The fact that poor people around the world have shorter and harder lives is the result of human design, a phenomenon called “structural violence.” The increased rates of death and disability among those who occupy the lowest rungs of the class systems in unequal societies result from the choices made both by individual countries and the world community regarding allocation of resources. The forces that contribute to structural violence are complex and largely invisible. As such, they receive only a smattering of attention from world leaders, the American press corps, and our rather undiscerning populace.

Many researchers have tried to assess the damage inflicted by structural violence. In 1993, the World Bank developed a standardized system, used ever since, called DALYs, or disability-adjusted life-years, to track national and regional disease burdens that trace directly back to structural violence.14 In 1976, researchers Kohler and Alcock postulated that if all the world’s countries had similar resources and allocated them in similar fashion, structural violence—and its resulting higher mortality for the poor —would disappear.15 Taking the year 1965 as a model, the researchers used Sweden and its 75-year life expectancy as the society closest to ideal resource allocation and compared it with one of the world’s poorest countries, Guinea, with its average life expectancy of just 27 years. The authors concluded that 83,000 deaths in Guinea could have been avoided if life expectancies were identical in the 2 countries.

By expanding the model to all countries, the authors concluded that 18 million people died as the result of structural violence in 1965, more than all of World War II’s battlefield casualties and 150 times more than in all of 1965’s armed conflicts. Two other researchers found that during the years 1948 to 1967, structural violence claimed over 300 times the number of lives lost to “civil conflict.” Although such studies have their limitations, their chief points are both compelling and correct. Poverty—and the structural violence that perpetuates it—kills and it does so relentlessly, invisibly (at least to those of us on the wealthier side of the equation), and in far greater numbers than the armed conflicts that understandably command our attention. I should add that discussions like this one about structural violence are not veiled attacks on capitalism or subliminal appeals for socialism. Rather, the concept of structural violence should force us to re-examine the structure of the world around us. Given the inequality and suffering that defines our world order, shouldn’t the healers’ quest be to better understand why?

Why Things Are as They Are 

In the larger world order, few of us see the true extent of suffering, or fully understand the underlying forces that propagate extreme poverty. Perhaps a quick review of the normative is in order. Today alone, some 28,000 children under age 5 will die of treatable illness, while 10,000 Africans will die from AIDS, TB, and malaria, infectious diseases for which we have treatments.16, 17 Over the course of this year, some half a million women will die in childbirth in poor countries at rates 10 to 100 times that of their wealthier counterparts.7 As recently as 2001, more than 1.1 billion people lived on less than $1 per day, while another 1.5 billion lived on less than $2 per day.18

Those interested in explanations for the current world order, in which unimaginable wealth for some is matched by unimaginable suffering of many others, need only turn on their television sets or pick up the daily papers. There is no shortage of people who profess knowledge of the causes of global poverty and inequality, theses which Paul Farmer has rightly called “immodest claims of causality.”19 While the list is long, some of the more common explanations include: immorality or laziness on the part of the poor; cultural or racial explanations (“That’s just the way they’ve always done things in Africa”); or, one of the favorites, corruption. Such explanations serve an important function in our world, reducing the dissonant, at times intrusive, notions that we live in abundance while over a billion of our neighbors live on less than $1 per day—and nearly half their kids won’t reach age 40. It is no surprise that “we” collectively search for reasons to blame the poor for their suffering, and the sick for their illness. We conveniently ignore Job’s insight that the poor are those to whom fate has simply dealt a difficult hand; it makes it easier for us to get through the day.

Yet for us to truly understand the factors that drive global inequality we must undertake a far more arduous journey. These “forces of disparity” are often invisible to those of us accustomed to comfort and relative affluence; yet readily apparent to those living in the slums and barrios of the developing world. The list of forces is long, but includes the following: trade imbalances, debt, racism, sexism, history, governance, militarism, AIDS, other infectious diseases, population growth, the environment, and the basic “trap” of poverty.20 While there are good and bad in the global poor Diaspora, the overwhelming majority of poor are there because the sum of the forces aligned against them predetermines their fate at birth. Sure, corruption is a problem in many developing countries, far greater than the excesses seen in the United States in recent years.21 But it is not the problem.22 Many other forces play far larger roles.

Those of us in the health professions don’t routinely study these larger forces. Many might rightly question why an academic or clinical nephrologist should be asked to care about the latest decisions of the United Nations, or how negotiations at the Doha Round of the World Trade Organizations are progressing. Yet even a quick glance at the realities of life for those in the developing world should prod us to probe more deeply. Anyone who has visited one of the slums that have become an inextricable part of the large industrial areas in the developing world will meet slum dwellers that are displaced farmers. Paul Farmer once wrote that a poor Haitian farmer told him, “I’m sick because I lost my land.” Shouldn’t such comments prod health providers to try to develop at least a basic understanding of the structures of global trade or the impact of our nation’s farm subsidies? There is a well-established connection between poverty and illness, both nationally and transnationally.23 There are equally strong connections between the decisions of governments and governing bodies like the World Trade Organization, and the health and life quality of the global poor. Is it any surprise that those with no jobs, who are forced to pick through the refuse of others, have abysmal survival rates? And what of their children?

Oxfam has rightly termed global trade analogous to a hurdler’s race in which the “weakest athletes face the highest hurdles.”24 More than three-quarters of the world’s poor live in rural areas and depend on farming for their basic survival. Yet, farmers in the world’s poorest countries cannot compete with the heavily subsidized products of their counterparts in rich countries, and the ensuing fight has caused the virtual collapse of the most recent round of global trade talks, the Doha Round.25 Rich country subsidies give a clear advantage to rich country farmers over their poor counterparts, who should have a competitive advantage through far cheaper labor and land costs. These subsidies are not small. The Farm Bill is, as of this writing, winding its way through Congress. At its last inception in 2002, President Bush signed the $248.6 billion bill, of which 70% of the payments went to the largest 10% of producers, forming, in the words of New York Times reporter Tina Rosenberg, a “huge corporate welfare program.”26 Globally, annual rich country subsidies constitute a $300 to $350 billion obstacle that far too many poor farmers simply can’t overcome. One United Nations official estimates that such subsidies cost African farmers over $50 billion annually, while former World Bank President James Wolfensohn said, “these subsidies are crippling Africa’s chance to export its way out of poverty.”27 These realities are all the more difficult for Africans to bear since they are repeatedly told they should trade their way out of poverty, not seek foreign aid. Trade is but one of many forces conspiring to keep change from the global poor. Contrary to our self-view as the world’s saviors, we are very much complicit in maintaining orders of inequality in our world.

Why Should We Respond? 

When disaster strikes, as it did in Kashmir, few question whether or not we should respond. From massive relief efforts following the Indian Ocean tsunamis of 2004 to any number of hurricanes, earthquakes, or other natural or man-made disasters, the world has responded, and health professionals have often been in the forefront. But what about our response to the larger, structural factors that drive so much of the world’s suffering? Our first step must be to broaden our understanding of these complex issues. But what then? Once we know more, why should we respond at all? As a practicing clinician, dedicated to enhancing the quality and duration of life, it is a difficult question to have to answer. Yet given the lack of resources with which we in the rich world have addressed this concern thus far, history demands that we answer.

We can view the answers to why we should respond through 2 distinct lenses: moral and pragmatic. In the former, we can turn to one of the icons of our profession, Albert Schweitzer, who, in postulating the ideal of Reverence for Life, challenged us to care for all of the life around us, including those people not in our traditional realm of concern.28 These sentiments resonate with the core beliefs of most world religions, which refer either directly or obliquely to social justice and compassion for the poor.29 These views coursed through the writings of the framers of the Universal Declaration of Human Rights, championed by Eleanor Roosevelt, and brought to life in the aftermath of World War II.30 The human rights paradigm informs us that we all, by mere inclusion in the human race, are born with certain undeniable rights, among which are life, health, education, and the chance to lead a dignified existence. The Universal Declaration of Human Rights may represent the pinnacle of human ambition, yet stands in striking contrast to the lived experience of most of the world’s extreme poor. More dream than reality, yet possible if enough believe and heed the calls for change.

Turning to look through the lens of pragmatism, we find equally compelling reasons to care about the global poor. Many of the world’s problems, including terrorism, infectious disease epidemics, drug trafficking, refugee movements, environmental degradation, among others, arise in failed states like Sudan, Somalia, and Afghanistan. By helping the people in these places develop, we help ourselves. The US Central Intelligence Agency documented as much in a 1994 study, and the Bush Administration rightly elevated development as the “third pillar” of the 2002 National Security Strategy, along with defense and diplomacy.31 The merits of development are borne out by the rapidly rising economies of India and China, which have pulled millions out of poverty in recent decades. Such is the goal of development everywhere. While we will never stop the next infectious disease epidemic from arising, we can limit the amplification that occurs in areas of concentrated poverty, where hordes of people, immunologically depleted by starvation, pose a veritable nirvana for emerging pathogens.32 Those interested in the environment should know that the United Nations projects human population growth to reach 9.5 billion by 2050, with 8 billion in developing countries, where 98% of the annual population growth now occurs.33, 34 Imagine an additional 3 billion people, all climbing the ladder of development, all using carbon-based fuels and greatly speeding up the process of global warming. Will we really be able to respond in time?35 Jeffrey Sachs is no doubt correct, that development, with larger investments in health and education in poor countries, is the best weapon to curb population growth; as incomes and services rise, fertility rates plummet.36 Considering each of the above in turn, it is clear that our historic paradigm of largely ignoring the developing world will have to change.

There are many who rightly ask, “Why should we respond to problems overseas when we have so many problems here?”37 First, we should reject the premise. Why do so many people share the view that either we help those at home or we help those abroad? We have the resources to do both and should do so. The US federal budget in 2006 was $2.6 trillion, and our national economy generated $13 trillion, roughly 28% of the world’s total gross domestic product.38 Yet we remain near the bottom of foreign aid donors at just 0.22% of gross domestic product, the third smallest allocation of the world’s wealthiest 22 countries (the Organization of Economic Cooperation and Development), behind Portugal and Greece in dollars given per size of gross domestic product.39 (And that includes the $12.1 billion in reconstruction efforts in Iraq and Afghanistan.) We have the resources to help the less fortunate both at home and abroad; only the will is lacking. Second, those who serve overseas tend to be the same people who care for the marginalized and poor in the United States. That’s no accident. Most who work abroad have transforming experiences that help them see more clearly the problems at home, and their returning passion and energy helps us all. Third, despite the myriad of problems in the United States, the problems confronting the poor in sub-Saharan Africa, Asia, and Latin America are orders of magnitude greater; there is simply no comparison. As members of a healing profession, our obligations are to our patients, and there is no nationalistic component to the Hippocratic Oath, or to the unspoken ethic of what we do. Our profession has an honorable heritage that should incite the better angels within us.

Who We Are and Might Be: How We Can Respond 

We should first take stock on just what “we” have done thus far. One of the few studies on physicians and nurses working overseas comes from Johns Hopkins’ Dr Timothy Baker, who found that just 1 in 300 physicians and 1 in 1,000 nurses had been active in global health prior to the study’s publication in the Journal of the American Medical Association in 1984.40 More recent data from the Association of American Medical Colleges provide some basis for optimism. In a 2006 survey, the association found that 27% of US medical students reported having taken electives abroad, compared to just 6% in 1984.41, 42 Interest in global health is rising. It seems that today’s medical students take their global health responsibilities far more seriously than we ever have before. In so doing, they follow in the footsteps of some icons of our profession, like Albert Schweitzer, Tom Dooley, and Paul Farmer. A host of nongovernmental organizations like Médecins Sans Frontieres, Physicians for Human Rights, Partners In Health, and many others remind us of all that we can be as clinicians.

If we can agree that we should respond, then how, exactly are we to do so? Our first steps should be to enhance our understanding of why things are as they are in our world, and then work toward change. The forces that maintain global disparities in health are both powerful and largely invisible. Many stem directly from decisions made by governments in the United States and other industrialized countries. Yet, doctors, administrators, nurses, and other health professionals remain widely respected. When they speak, the public usually listens. If more health providers would take an active role in speaking out against global health inequalities, great change would result. A focused effort to sway the leaders of the world’s most powerful country may provide more help to the global poor than an army of doctors serving overseas. We should use the moral strength of our profession to agitate for political change: fairer trade practices, a reduction in farm subsidies, increased and more effective development aid, and legislative efforts to develop a “US Global Health Service,”43 to enhance health care capacity in sub-Saharan Africa (see44 to track progress of the The African Health Capacity Investment Act of 2007), and boost US volunteerism through the creation of a global service fellowship program.45 Perhaps more of our medical societies could draft resolutions that support some of these larger, ambitious initiatives.

Certainly, we should honor and possibly join those who respond to the complex humanitarian emergencies that routinely arise in our world, like the earthquake in Kashmir. Thousands within the medical profession routinely take extraordinary risks to save the lives of those caught up in unspeakable tragedies. I was in Tegucigalpa, Honduras following Hurricane Mitch in 1999 when we got word that an Médecins Sans Frontieres helicopter had crashed, claiming the lives of everyone aboard, including the pilot, patient, nurse, and physician. Such are the risks borne by these heroic individuals, who elevate the status of the profession through their work.

Yet, most of us simply don’t have the experience or training to parachute into a disaster area and provide useful assistance. In fact, many of the organizations that do such work strongly prefer those with considerable international experience already. The untrained and poorly prepared often take more than they give in emergent situations, requiring help with language, logistics, cultural adjustments, disease entities, etc. For many of us, the best advice in disasters is the old adage, “Stay home; send money.”

But there are ways that many more of us can get involved directly, and I would urge all readers to consider doing so. From the experience of having given many talks on this subject, I know that I can make people think, but can’t make them feel. Only direct experience can provide the latter. One should heed the words of Gustavo Gutierrez, the father of liberation theology, who urges all of us to take a “foot trip” in lieu of a “head trip.”46 The difference between the 2 is of enormous consequence; many who have worked overseas are so moved by their experiences that they undergo a personal transformation, and often seek to better understand the global order. The stories are legion of lives irrevocably changed by the sheer power of the experience. Many health providers who venture overseas to work and serve find themselves returning again and again, experiencing what so many call the greatest experience of their professional lives.

Martin Luther King, Jr once said, “The racial problem in America will be solved to the degree that every American considers himself personally confronted with it.”47 We can extend a similar analogy to the problem of global health inequality. This problem too will only be solved to the degree to which each of us feels personally confronted by it—particularly those of us in the health profession. That remains difficult if the overwhelming majority of health providers remain secluded away in the relative comfort of the industrialized world. It is only through an active and direct engagement with the global poor that our perspectives can evolve. Poverty remains the most important killer in the world, and the best way to understand it is to work with those who live under its yoke. Only then will enough of us be sufficiently motivated to work for a more just world.

When John F. Kennedy founded the Peace Corps, he saw the volunteers as playing a far greater role in the world than the direct service they would provide. “Imagine,” Kennedy told a few Peace Corps founders in its fledgling days. “If we can send 100,000 Americans overseas each year, by the end of the first decade there will be over a million Americans with direct experience in Africa, Asia, and Latin America. What will that mean for our foreign policy?” (personal communication from Senator Harris Wofford, former special assistant to President Kennedy and a founder of the US Peace Corps, October 2007). Kennedy’s vision remains compelling all these years later. Two of the greatest obstacles facing the global poor are our indifference and lack of understanding. We mistakenly think that there is little we can do, and that we are doing enough already. We who could so readily change their lives simply must engage in far greater numbers.

The good news is that there are many ways to get involved. There are now more opportunities in global health than ever before, and funding for global health has increased dramatically.48 A number of students and I spent years compiling organizations that send health professionals overseas; there are hundreds of them. In A Practical Guide to Global Health Service, we listed over 300 such organizations (including 50 organizations looking for nephrologists on page 321), along with many more working on the political and advocacy side of global health.49 It is easier now to serve than it ever has been before. Several organizations, like Health Volunteers Overseas, the International Medical Corps, and the organization I founded and run, Omni Med, focus efforts on training, such that a volunteer’s gifts remain long after he or she departs. While relief efforts are of great importance, we should keep in mind that many more people around the world will die of complications of hypertension and diabetes than from disaster-induced crush injuries. Wouldn’t it be of greater value for nephrologists to teach colleagues in developing countries how to manage these illnesses and prevent chronic renal failure than to intervene after crisis strikes? There is an obvious need for both long-term training and acute interventions in times of crisis. The bottom line is that more us of need to get involved.

Conclusion: A Death in Kashmir 

Somewhere in a remote village in the Kashmir section of Pakistan on the night of October 8, 2005 someone, perhaps a young woman trapped in rubble, cried out for help. No one heard her, and she died in the silence of history, her long muted voice ringing out, puncturing the stillness around her. She had no doubt witnessed, or at least heard rumors of, dramatic scientific and technological advances in the world around her. Yet for her these advances held no personal significance; they might just as well have occurred in another world. Her cries, like those of millions of others like her in our unjust world, went unanswered.

If the legacy of twentieth century medicine is excellence, then the legacy of the 21st century must be equity. Our storied profession has an Achilles’ heel: that our knowledge and talents remain concentrated among those who can afford them. We, the inheritors of the legacies of Schweitzer, Dooley, and Virchow simply must rise to the greatest challenge facing our profession and our world. If we choose to ignore the rising storms around us—many caused by the inequality that defines our world—we will truly reap the whirlwind. There was a time when doctors were men (and women) of the world, where to have scientific training meant that one also had an engagement in and concern for the larger issues shaping the world order.50 It is time that we again find our collective voice and venture forth into the world, leading others in a struggle to bring social justice and health equity to all people. We ignore this call—our calling as physicians—at our own peril.