Global health in Foriegn Affairs

Here's a very interesting piece in Foreign Affairs on some problems facing global health.

The take home point as I see it (from the eyes of someone new to this area) is that the health problems facing people in the developing world need to be addressed at local political and economic levels. One of the main reasons that NGOs, foreign aid, and teams of doctors and nurses have failed to provide sustainable public health results abroad is insufficient integration of these activities into long-term structures and policies that involve the local governments. More money is easy to come by (there has not been a lack of this in recent years), but political and economic reform is not. This view is iterated by some development experts (Nicholas Kristof has a good review).

I wonder what the role of doctors and nurses should be in global health. It is hard to know if one is part of the problem or part of the solution anymore. At any rate my training in medicine is fundamentally to diagnose and treat patients. However, I am also ethically compelled to wear two hats which often conflict with each other: one, being the advocate of my patients, the other being an advocate for public health. This conflict applies to any doctor in the US as well, but I think the difficult thing to recognize is that the public health hat is ultimately more important when it comes to providing health in developing countries. Treating HIV or Tb in impoverished Africa with fancy new drugs is all and good, but strikes me as an odd use of resources when these same patients - or their children - don't have access to clean drinking water or even sufficient daily nutrition.

An additional issue raised in the Foreign Affairs piece is the health care professional brain drain from developing areas is promoted, albeit unintentionally, from both

1. a failing US health care system that must recruit foreigners to meet the demand for primary care doctors and nurses.
2. NGOs that hire local doctors and nurses at salaries greater than those of local hospitals and clinics. Good for doctors, but not so good for the patients of those government clinics.
   

I also think that the criticism leveled at many American NGOs - that they focus too much on single diseases and miss the big public health picture - probably derives from our medical system in the US that itself focuses on treatment rather than prevention of diseases (or, as a professor of mine has said, on illness-care instead of health).

1. My training in medical school (7 years all told for an internal medicine physician) is aimed at treating the 1 patient in a 1000 that has the complicated syndrome. Nevertheless, the large majority of patients will be much less complicated and will not need to be admitted to the hospital or visit the ER if they have good access to a family doctor. And an even larger majority of patients would not need any medical intervention provided they have access to some form of preventative medicine.
2. Medicare, the national health insurance system for people over 65, will pay for your heart surgery once you have a heart attack, but provides very poor access to primary care, which with good, non-invasive, low-cost, medical management, would prevent the heart attack in the first place.