Footnotes
Readers are encouraged to respond to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu
letter . 2007 Jun 25;9(2):65.
letter MedGenMed. 2007 Jun 25;9(2):65.
To the Editor:
The commentary by Edward O'Neil was interesting and quite valid on a global basis.[1] But the larger tragedy is that over 40 million people, in a country that has one of the highest per capita incomes in the world and certainly the most awash in resources, still do not have ready access to routine medical care. The efforts for practitioners to provide care for the needy should be concentrated in the United States until such time as universal coverage is instituted when everyone can access healthcare without fear of financial burden, socioeconomic bias, or trepidation.
Reference
- 1.O'Neil E. Awakening Hippocrates: A call for health providers to serve where most needed. Medscape General Medicine. 2006;8(4):44. Available at: http://www.medscape.com/viewarticle/547955 Accessed June 15, 2007. [PMC free article] [PubMed] [Google Scholar]
MedGenMed. 2007 Jun 25;9(2):65.
Dear Mr. Lyman,
Thank you for your response. I've been writing and speaking about this topic for years and your question is the one I hear most often. You are correct that we live in the world's wealthiest nation – by far – and that it is a source of national shame that 47 million Americans have no health insurance, while the indigent in post-Katrina New Orleans continue to search for help that isn't coming.[1] Yet I must disagree with your central point that we must care for our own before helping those abroad for several reasons.
First, I reject the premise. I have never understood why so many share the view that either we help those at home or we help those abroad. As you correctly point out, we have the resources to do both. I think we should do so. The United States' federal budget last year was $2.6 trillion, and our national economy generated $13 trillion, roughly 28% of the world's total GDP in 2006.[2] We have the resources to help the less fortunate both at home and abroad; only the will is lacking. By helping those in the poorest countries, we fulfill a national mission that virtually all Americans share, and help ourselves in the process by shoring up the “failed states” that are the source of so many global threats: terrorism, infectious disease epidemics, refugee movements, environmental degradation, and drug trafficking, among others.[3]
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. We need far more among us to have similar experiences; we all benefit from the passion and energy that those who work abroad bring to problem-solving here at home.
Third, despite the myriad of problems in the United States, the problems confronting the poor in sub-Saharan Africa, Asia, Latin America, and elsewhere are orders of magnitude greater; there is simply no comparison. Life expectancy in several African countries is now in the mid-to-late thirties, and falling.[4] The global AIDS epidemic hits hardest those countries least able to confront it; while someone, somewhere dies of AIDS every 8 seconds, most often in Africa or Asia.[5] Nearly half a million women die in childbirth in developing countries at rates 10 to 100 times that of those in the rich countries, while life expectancy of nearly 30 years separates those in the richest countries from those in the poorest.[6] I have worked in inner-city and rural hospitals in poor areas throughout the United States. Yet nowhere here have I seen the same degree of suffering and deprivation that I have seen in sub-Saharan Africa.
Finally, as members of a healing profession, our obligations are to our patients, and there is no nationalistic component to the Hippocratic Oath, nor to the unspoken ethic of what we do. Albert Schweitzer said that we have an “ethical imperative” to care for all people, including those not in our traditional realm of concern. Yet history shows that we have not done so. Instead of sending our health providers abroad to meet the stark workforce needs of the poorest countries, we lure the best and brightest from those countries here. A full 20% of our physician workforce comes from other countries, many among the world's poorest, in desperate need of our help.[7] Far from our self-perceived role as the world's benefactors, we are actually draining much-needed resources from abroad to fill our own gaps in health provision.
Ultimately we reap what we sow, and continued inattention to the plight of the global poor will lead us all to a bitter harvest. We can and must care for our own, but our calling – and our most pressing challenge – compels us to turn our gaze outward.
References
- 1.Editorial. In divided New Orleans. New York Times. May 15, 2007.
- 2.CIA Factbook. Available at: https://www.cia.gov/library/publications/the-world-factbook. Accessed May 18, 2007.
- 3.Sachs J. The strategic significance of global inequality. Wash Q. 2001;24:187–198. [Google Scholar]
- 4.WHO. World Health Report 2006:, Working Together for Health. Geneva: WHO Press; 2006. pp. 168–177. [Google Scholar]
- 5.UNAIDS. Available at: http://www.unaids.org/en/ Accessed May 18, 2007.
- 6.United Nations Development Program (UNDP) Human Development Report, 2002. New York, NY: Oxford University Press; 2002. p. 152. [Google Scholar]
- 7.Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353:1810–1818. doi: 10.1056/NEJMsa050004. [DOI] [PubMed] [Google Scholar]
