The W(h)ealth of Nations

What is our role in health of the world? The answer to this question has been decades in the making. Dr. Packard defined “global health” as the history of interventions into the health of other peoples. And in his presentation, Dr. Packard gave us a glimpse of the long and tortuous path global health has taken past century.

From the hygiene movement to the development of social medicine in countries such as China, from the war on diseases to the rise and fall of primary care, the approach to global health has been teeter-tottering between a broad-based, comprehensive view of health and a narrowed, disease-based focus on health improvement.

The question arises, what is the best approach? In the present day, the balance has swung toward selective care – targeting certain populations such as children for health interventions and addressing select diseases such as HIV for prevention and treatment. However, I feel that this narrowed focus is not the best approach to improving the health of nations because it is does not fix the root cause of health issues present in the population. Sure, we could provide antibiotics that can help fight off an infection, but medications cannot prevent the injury that became infected in the first place. Indeed, we can give anti-retrovirals to HIV-positive patients but these pills do little to prevent the rapid spread of the infection across nations. However, we tend to veer toward solutions based on science technology because they present appreciable and immediate results – can see the values change, the percentages decrease, the numbers of people we help rise. It is much harder to invest time and money in something such as infrastructure, education or other social determinants of health because the benefits are not instant, the results are unclear, and the charts and graphs are seldom satisfying.

Yet, in many ways, a nation is only as healthy as the education and knowledge of its people – no amount of scientific technology can guarantee health if the people do not know how to live their lives in healthy ways.

Thus, I feel that the best approach to global health is one that involves the people of the nation, one that moves the decision making power from external forces (e.g. wealthier developed nations, international organizations such as the WHO) to the hands of the people whose lives are intimately impacted. Further, I feel that global health approaches should move away from big science and towards education because only through knowledge can people be empowered to help themselves become more healthy.

Ultimately, the health of a nation is an indication of the character of its every-day citizens rather than the quality of its leadership. As former Colorado governor Richard Lamm stated,  “Great nations must have great citizens, and the kind of future we will have depends on what kind of people we are and what kind of kids we produce.”

To Do No Harm

“We go into medicine because we want to save lives. We go into medicine because we want to do good. We go into medicine for the rush… for the high… for the ride. But, what we remember at the end of most days are the losses. What we lay awake at night replaying the pain we caused or failed to cure. The lives we ruined or failed to save. So the experience of practicing medicine rarely resembles the goal.” – Grey’s Anatomy

As I listened to Dr. Calvello’s talk on the medical response to the humanitarian crisis in Haiti, as she described the struggle to treat the hundreds of thousands injured by the earthquake, and spoke of the difficulties imposed by limited time and scarce resources, I was reminded of how incredibly complex medicine was. In SFM, we learn that medicine is science – real, tangible, and concrete facts of life that can be uncovered with the right tests and studied with the proper tools. However, medicine encompasses so much more than the lessons we learn in lecture halls. Medicine is the patient we treat – the decisions we make in their care and how their lives change as a result. Medicine is about people.

That is what really struck me during Dr. Calvello’s presentation – when doctors are removed from the menagerie of tools, drugs, and technologies, when they are transferred from the sterile halls of the hospital to countries destroyed, ravaged, and desperately lacking even the most basic supplies, how do they do their job?

In such situations, it is difficult to balance between being efficient and doing the greatest good for the greatest number of people. Each doctor must draw their line at their own point – they must decide for themselves how much time each patient is “worth”. However, by drawing this line, by giving a numerical value to a human life, we are dehumanizing the very people we hope to heal.

Medicine is tough. Sure, it is difficult because of the massive amount of information we must commit to memory. Indeed, it is challenging because we must persevere through years and years of long hours and sleepless nights. However, what makes medicine such a truly tough career is power. Patients trust us with their darkest secrets, their greatest insecurities, and their deepest pains. They trust us because with our hands, we promise to heal. With out hands, we promise to treat our patients to the best of our capacity.

However, in situations like Haiti, doctors must do as much as they can with what little they have. In doing so, they will turn down patients that they could have otherwise easily treated had they had been in a well-supplied hospital, they will give inadequate care because they lack the resources to fully address an illness, they will not heal to the furthest extent of their professional capacity. Medical crisis like that which Dr. Calvello faced in Haiti shakes the very core of medicine: the oath of a doctor to heal. And unfortunately, in these cases, there is no clear solution. We can only hope that our training as physicians will have properly prepared us to make the best choices and save the most lives.

“[The] craft is long, life is short, opportunity fleeting, experiment dangerous, judgment difficult.” – Hippocrates