Charity care may mean crossing U.S. borders

Medicine can save thousands in developing countries who die daily of malaria, tuberculosis, diarrheal diseases and measles. What role should American physicians play in stemming this tide?

Reply:

My first experience in West Africa was life changing. A series of medical school classes during the prior term had revealed the startling fact that many of the most deadly tropical illnesses had once been prevalent in Europe and the United States -- malaria, tuberculosis, diarrheal disease, measles. Despite being almost eradicated in richer countries, they continued to take their toll on the millions in poorer countries of the world. In addition to being called tropical diseases, they could also have simply been called "diseases of poverty." The medical and cultural experiences that awaited me in Africa were profound.

Living in a village among people in extreme poverty, receiving women who had walked for miles to our half-stocked clinic, watching children die of measles and anemia and malnutrition were at least sobering, and at best motivating, experiences. The inequalities of our world and its consequences on people -- whose names I now knew, whose children played outside our door, with whom I walked to the market in the blazing sun -- became all too real. Any subconscious distinction between "them" and "us" was gone. My moral compass no longer could be distracted by some notion that this was not my problem.

While overseas, I was asked by a friend, "When are you coming back to the real world?" I felt saddened because I knew that in fact this was the real world; this was the world where the vast majority of the people on the planet lived with hunger and without health care, and although I could catch a plane home when things got to be too much, they could not.

Medical knowledge itself is really a gift, a combination of the science of facts and figures, technical skills, acumen and the art of bedside manner, tumbled around and refined over years of training and apprenticeship. What are we to do with this knowledge? That is perhaps the ethical question at hand, and we surely have an imperative to serve those most in need of our services. To whom much is given, of them much is asked. "Physicians are the natural attorneys of the poor," said Dr. Rudolph Virchow, one of the fathers of modern medicine. Doctors are called upon to defend the poor because their illnesses result often from their social circumstances and largely from preventable and treatable disease.

A cursory look at much-quoted statistics provides ample evidence of the overlapping epidemics of poverty, hunger, AIDS and deaths from preventable and treatable maladies such as malaria, tuberculosis and diarrheal disease. Half the world lives on less than the U.S. equivalence of $2 per day. And 11 million children younger than 5 die every year from treatable causes.

When inequities are so tremendous, when deaths are so senseless, when we have medical knowledge, when our voices are loud, are you still asking, "Why are we compelled to act?" How could we not be compelled to act? With the privilege of knowledge that is not universally known and that can have such an impact on another's life, we are bound by our ethical conscience to act.

It has been my great privilege to work in rural Haiti for the last four years at a small public health hospital that is part of a larger nonprofit organization, Partners In Health. In addition to clinic-based care, we visit patients in their homes, attempting to understand and address the socioeconomic aspects of their diseases.

The warmth and the hospitality of the people of Haiti, the dedication of my Haitian colleagues in the face of extremely difficult working conditions, the resolve of the desperately poor to lift themselves from the circumstances thrust upon them and their hope that the future will bring what they so desperately need all motivate my continued service there.

A Haitian Creole saying goes: "Si ou pa pase maladi ou pa ka konn remed." If you haven't had the disease, you can't know the treatment. Participating in the service of the poor, for even a short time, in the real "real world" is sometimes all the motivation that one needs to continue. Disease is addressed not only by analysis of pathogens and physiology, but by understanding the social, economic and structural issues that cause it. In facing the reality of the situation and the gravity of the inequity, the ethical imperative becomes self-evident.

Louise Ivers, MD, MPH, DTM&H , director, HIV Equity Initiative, Partners In Health, Haiti; instructor in medicine, Harvard Medical School, Boston; associate physician, Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston

Reply:

Why did I get involved in international health? As always, the "why" questions are the most profound. When we find answers, however tentative, to these questions, they are always personal.

Motivations for global health involvement are myriad. Most health professionals who have reflected on international health ethics, as has Edward O'Neil, MD, in several AMA publications, would place justice or equity as the most salient of global ethical imperatives. But there also is a spectrum of more practical and personal rationales that I'll call the five P's. Profit is an enduring motive, more significant as international medical corporations grow with globalization. Protection of self or nation against globalized disease is fundamental on Maslow's hierarchy of needs; it has spawned the specialty of travel medicine. Proximity to international borders or immigrant communities dictates that some doctors' patients originate in those communities. Professional dissatisfaction with U.S. practice leads us to look beyond our borders. But personal history and the sense of purpose that arise from our own autobiographies are the most likely bedrock answers to "why."

Like Dr. O'Neil and countless medical students, I first saw global health service on a fourth-year tropical medicine rotation. Destined for the "doctor draft," and probably Vietnam, instead I fulfilled my obligation via another uniformed service: the Commissioned Corps of the U.S. Public Health Service, in the Centers for Disease Control's Tuberculosis Branch. But I extended my CDC commitment to serve an additional two years, this time in eastern Nigeria with the Smallpox Eradication Program. At the CDC I met its future director, Bill Foege, MD, who simultaneously served as the medical missions director for the Lutheran Church. Tapping into my rural Montana faith heritage, Dr. Foege, and perhaps providence, convinced me and my family of a vocation as a clinician in a joint church/government hospital in Papua New Guinea. Our six years there furthered an intensive immersion in global grassroots health.

Convinced that lessons from such settings could be translated into intellectually lean and values-oriented "learnings" for North American medical students, I have been able, since 1979, to come full circle as a faculty mentor for medical students preparing for their own experiences in international and other resource-constrained practice settings.

Strictly speaking, I am not a virtuous volunteer. Rather I have traced my steps backwards through the five P's, arriving at "profit." While I have not become financially rich, these experiences make me feel genuinely prosperous. But when we scrutinize our international efforts in light of the four classic ethical principles, do we engender justice, in the biblical sense of Micah 6:8, "What does the Lord require of you but to do justice, to love kindness, and to walk humbly with your God?" Physicians working in international and other underserved areas may be seen, without second thought, as paragons of beneficence and nonmaleficence. Those willing to entertain that second thought, however, will conclude that many medical volunteer organizations are mixed blessings at best.

In cross-cultural medical endeavors, respect for autonomy, often ignored, may be the most important ethical virtue. Respect for our global health counterparts and the cultures that nurture them often comes when we finally, often unwittingly, realize the valuable lessons we are learning "in the house of our hosts," to borrow the Rev. Bernard Joinet's phrase. First comes an appreciation of challenges our host colleagues (as well as we expatriate volunteers) face, then our admiration as they surmount these barriers, and finally comes true affiliation. In the end it is the people, not the procedures; the inspiring insights, not the inpatient intensive care; and the spiritual, rather than the material challenges that leave us the more lasting legacy.

Superseding the "why" of volunteerism, and its distinctions between long vs. short term, faith-based vs. government/philanthropic, or sacrifice vs. comfort, is the "why" of vocation, of calling. To paraphrase Frederick Buechner, "deepest gladness" may, paradoxically, overtake us in moments of personal loss.

When our son, newly born in a hospital distant to ours in Papua New Guinea, succumbed to sepsis, the most profoundly comforting meaning came through the quiet ministry of Waima Waesa, bishop of the local Gutnius Lutheran Church with which we worked, who had, like most of his parishioners, experienced similar losses. It was then, and continues to be now, D.T. Niles' quiet good news of "one beggar telling another where he found bread."

Ronald Pust, MD, professor of family and community medicine and public health, director of curriculum in international health, University of Arizona College of Medicine, Tucson