On medicine abroad

November 8, 2006 at 8:50 pm (AE Beacon's Posts)

Liberal doctrine has increasingly disparaged the concept of the Western actor in developing world medical settings. Utilizing phrases like “sustainability” and “development”, the idea of an American or European physician entering an impoverished area as a first line health worker or a medical administrator has become a frowned upon concept. However, with most of the world’s medical resources and biomedical research capacity, what role should the developed world play in low resource and low access settings?

Brain drain, while one of the worst contributions of developed countries to health abroad, offers an interesting example of medical exchange. In many hospitals around the US and certainly around Europe there are doctors who immigrated from Africa, South Asia and
Latin America. These doctors undoubtedly face a variety of cultural and logistical problems upon their arrival and likely for a prolonged period thereafter. However, I find no indication that Americans (or Europeans) are particularly ambivalent about being treated by these physicians despite the supposed boundaries that we proclaim foreign medical personnel bring to clinical settings.  

I believe that health workers can successfully make people better in any setting regardless of cultural background. We have put so much emphasis on liberalized health goals like local capacity building, development initiatives and training programs that we have forgotten the brutal arithmetic of human suffering that is daily putting more patients in the hands of fewer doctors. Our enormous capacity to help through physical resources, health personnel and medical training is being handicapped by an ostensibly righteous drive to avoid (vague) concepts of medical colonization and imperialism.  This rhetoric is perpetuating inaction and diverting crucial resources to peripheral efforts. Are we so misguided that we think a sick patient in
Harare would prefer no doctor to a Western doctor?

A recent WHO report noted a deficit of 4.3 million health workers in developing countries. According to some estimates, there are almost 4 million health workers in the US and millions more in
Europe. If even a fraction of this highly trained, highly resourced workforce were to spend a few months or a year abroad, we could make a huge difference in the lives of many sick people. While perhaps they wouldn’t be able to perform many specialized procedures, simple interventions against diseases like pneumonia, diarrhea, malaria and the measles would drastically reduce the number of deaths in developing countries. In addition to contributing positively abroad, I anticipate that upon their return, these physicians would be better equipped to deal with patients from culturally disadvantaged backgrounds. Indeed a win-win situation.

Do not mistake this essay as anti-development. We are all aware of the need for local governments to arrange a successful and self sustained infrastructure. However, in the interim, we must shun our facile philosophical leaning towards inaction and don our personal and collective responsibility for making sick people healthy again.

Æ Beacon

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7 Comments

  1. amanb said,

    Hello,

    Great blog and effort. It looks like you started your blog about the same time as a group of students and former students from Berkeley and Boston U who are focused on global health solutions with a bias towards innovation and technology. You can visit us over at: thdblog.wordpress.com.

    We have a recent post that will be of interest to Brown Students on upcoming conferences:
    http://thdblog.wordpress.com/2006/11/09/upcoming-international-health-conferences-deadlines/

    Its great to see others discussing these issues. It would be great to partner up, we can be reached at: thdblog@gmail.com.

    Aman

  2. misarita said,

    You mention the brutal arithmatic of human lives. It seems to me that a lot of time and money is often spent by foreign medical personnel to visit a place for a short period, do medical work and go back. While these people are to be commended for their interest and dedication, there is a large part of the work that is making the donors feel good about the work that they are doing. I’ve experienced a lot of this through Rotary, the organization that is sponsoring me to be in India. Lots of people want to get involved in National Immunization Days for polio. Hopefully, we’ll soon be making these opportunities obsolete by eradicating polio. I’ve heard lots of folks mention that they want to go to India or Nigeria and do an NID before there is no more opportunity. That sort of language makes me wonder who is being helped the most. I’ve seen tremendously capable community women who don’t pay for a $1500 plane ticket who are able to administer oral polio vaccine. At the risk of sounding harsh, many of these opportunities are “feel good” opportunities for the people who pursue them.

    I think that medical exchanges are wonderful opportunities. They make physicians more sensitive to cultural differences, whatever their normal setting. More importantly, they signal that there are people who care and are willing to come great distances to help people.

    Perhaps it is different with long term posts. There is a dearth of public health people in India, and I think it would be better to have people doing the work than nobody at all. I just don’t think that the option is often others coming in OR having local folks doing the work. I think that the focus needs to be on building the capacity (I know, ambiguous development term) of the people in a country to do the work needed.

    I’ve seen a really heartening trend in India where there is a big push for people to go abroad, get training and then come back. As opportunities come up here, people are more likely to want to stay. But they go to learn professionalism and to bring it back here. One of the most popular Bollywood movies of the last few years, Swades, is about a NASA engineer who eventually opts to come back to India out of patriotism and love for his country. When it was in the theaters, people would stand up and clap or cry or cheer… it evoked a very powerful sentiment.

    I may have strayed from the original point, but my main thought is that I think it is superbly important to focus on how to build health systems that can be sustained by trained locals instead of depending on outsiders.

  3. acoria said,

    There are a lot of things I want to say about this post, but I’m going to stick with one, because it really riles me.

    This attitude that a “few months or a year” is enough of a commitment from industrialized-world doctors is one of the huge problems in global health. Adjustment to living in a foreign culture, with all its norms, values, and traditions, is not an easy thing, and is only just beginning to occur at the end of a year. If Western doctors come in and come out, they don’t have the opportunity to know or understand their patients’ needs and concerns. And, especially when working in rural communities that may have had only sporadic modern health care, but lots of exposure to traditional medicine, the key is to get the traditional healers involved. But that involves financing, culturally appropriate training and organizational commitment, not a doctor here and there who’s going to de-worm some kids as part of his summer jaunt abroad.

    And, as far as the de-worming, malaria treatment, TB treatment if they’ve got enough time, prenatal care, etc…These things are ineffective if not provided consistently and over a long period of time. Some doctor coming in for three months who treats some kids for malaria and shows moms how to concoct an ORT solution is not going to be effective unless the doctor can somehow overcome the population’s biases toward traditional remedies, and at the same time get parents and community leaders to implement follow-up programs on their own.

    Yes, maybe a few months a year from a few hundred thousand doctors would make a difference. But it’s the difference a band-aid makes; it just stops the hurt, it doesn’t stop you from getting cut again.

  4. misarita said,

    I can’t disagree with your points, but I do know that there are some of these organizations that are doing their best to be culturally appropriate. I went to Guatemala with this organization as a translator. ( http://gfmmf.org/ ) While they are clearly not perfect, they go to the same area two times a year and offer ten days of medical care. Each time, they do local trainings for healthcare workers, meet with community leaders and bring supplies and equipment that will help in the interim. I think that there are ways to do this sort of thing that are helpful. The fact is that nobody is stepping in to fill the void. Without these folks, nobody is offering care. I loathe the sort of “‘feel good about myself for what I’m doing here” attitude that can come with short term jaunts into developing countries. But, I do agree with Mr. Beacon that there are some places where the option is no/inadequate care versus people coming in who may not be as culturally aware. Can’t say that I’d pick no care.

  5. acoria said,

    I agree with you in principle, but the fact is (and I’m sorry I didn’t include this in my original comment) that there are finite resources available for medical programming. I wouldn’t pick no care either, but from a public health perspective, I’d pick an investment in long-term, sustainable care over a month of intensive and high-quality, but ultimately unsustainable interventions.

    The organization like the one you were with in Guatemala is clearly the happy medium – so, I would argue for more happy mediums.

  6. msoule said,

    So to weigh in briefly on one of the first things Beacon touched on, I think that there is really not a problem with Westerners (or Northerners) working in the East (or South). I don’t feel that there is a bias or problem with it. We may not be as culturally effective because we may not understand some of the cultural issues that drive health in some places, but we can try and we can study. And maybe that ignorance allows us to try things that doctors there won’t. I think the same is true for foreigners working in the US.
    I also want to gape for a moment at the figre that Beacon posted. There are almost as many health workers in the US as in the whole developing world? HOLY F-ING CRAP! We have an obligation to share the wealth, obviously. The question on the table is how to do it.
    And I’m ideologically with you, Beacon. Experientially, I’m with Sarah. It’s “impressive” and people coo and ooh and aah when you go abroad for a week out of every two years to work in the Poor Places. Such a big heart! I couldn’t do that! Well, it’s something but it’s not what we really need the very most. It’s like my post on the PRODUCT (RED) campaign.
    I think that funneling just a little bit of the time from many Northern doctors to the global South would work wonders. Sarah, did you look into WHY there is no one providing care in the area of Guatemala you went to? The donation of Northern doctors’ time in inventive and effective capacities should be explored with health providers in the South. If it is most practical to physically go abroad and practice, so be it. But that ought to be assessed with the help of locals. Have we asked them what they need?
    Maybe they really need funds. So our time might be best spent fundraising. Or training for community health workers if that’s a sustainable thing (Sarah?). Or maybe they have all the people and training they need but we could channel physical medical goods and resources (clean syringes are rare in Africa, I hear. That also may be ignorant. Correct me if I am off base). So there may be other ways we can contribute our time that would be of greatest impact. First, we need to figure out how to do really good community needs-assessments, though. Cross-cultural and deep ones. From there, we can donate our time site-specifically.

    Also, this word “sustainable” is driving me nuts lately. You guys need to say exactly what you mean by sustainable. It’s a buzzword. Buzzwords don’t mean anything after a certain point. It’s like “globalization” or “the information superhighway.” Matt Groening used to do a Life in Hell cartoon at the end of each year packed with the burned out phrases that he felt were past their life of use. Sustainable is getting there, in my opinion. I believe in what it stands for in my mind, but I want to know exactly what you mean by it. Sorry to rant, but it’s one of those things these days. 🙂

  7. acoria said,

    I think in a health context, sustainable means locally sustainable without depending on non-locally produced or trade-derived resources. So basically, if all the charitable giving was taken away, being able to sustain a comparable level of health.

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