Who We Are and Might Be: In Global Health, Excellence Demands Equity

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    Amllion people were affectedth 100,000 wounded or dead.ven the remoteness and diffi-lt, mountainous terrain of theolved areas, thousands of

    crush-induced acute kidney in-juries (AKI) in the 1988 earth-quake in Spitak, Armenia.

    Fortunately for some vic-tims of the Kashmir quake, the

    Street, #1, Waban, MA 02468. E-mail:ejoneil@comcast.net

    2007 by the National KidneyFoundation, Inc.


    erican Journal of Kidney Diseases, Vol 51, No 1 (January), 2008: pp 145-154 145Who We Are and

    World Kidney ForumAdvisory Board

    Rashad S. BarsoumCairo, EgyptChristopher R. BlaggMercer Island, WashingtonJohn BoletisAthens, GreeceGarabed EknoyanHouston, Texas

    John T. HarringtonBoston, Massachusetts

    n October 8, 2005, in theremote mountainous ar-

    s of northeast Pakistan, therth shook. Houses and build-s crumbled all over the re-n, crushing people by theusands. The quake measuredon the Richter scale, making

    nearly comparable in force toone that devastated San Fran-

    co in 1906.1 By the time thelent shaking had ceased, largeas of the Kashmir region ofkistan, along with neighbor-

    areas in India and Afghani-n, lay in ruins. Reports ofss casualties spread quickly,

    d soon the United Nationsight Be: In Global HeaDemands Equity

    Edward ONeil Jr, MD

    ople waited in vain for helpt would never come.Within hours of the firstmors in Asia, the first medi-l response teams began tosemble, coordinating sup-es and personnel.2 As inny complex humanitarianergencies, one of the firstessment teams to arrive wasm Mdecins Sans Frontieresoctors Without Borders), theried smoke jumpers of thealth professions. Among itsmbers were a nephrologist/ensivist and a renal nurse.th were members of the Re-l Disaster Relief Task Force,veloped by the International

    bout the Author: Dr Edward ONeorge Washington University, and comnternal medicine at Boston Medical Cllogg National Leadership Program, sment, and politics. In 1998, he founde

    w.omnimed.org), which focuses onp. To date, over 120 physicians haovative, cooperatively designed proni Med also compiles data on globa

    sier for anyone so interested to servblished by the American Medical Acrates: A Primer on Health, Povertyide to Global Health Service. In 200okings Institution Taskforce on Healracticing emergency physician at Caston, an assistant professor of emhool of Medicine, and Adjunct Facuhool of Medicine.

    J Kidney Dis 51:145-154. 2007 by, Excellence

    ponse mechanisms hadolved considerably since Spi-. The first dialysis performedan AKI patient occurred

    thin the first day of theake. Over the next 22 days,rescue teams consisting ofurses, 5 doctors, and 2 dialy-technicians from 5 coun-

    es (France, Turkey, Unitedngdom, The Netherlands,d Belgium) dialyzed 55 pa-nts of the 88 referred to thein treatment centers of Is-abad.

    On the surface, the renal in-ventions in the Kashmir

    earned his medical degree fromd a residency and chief residencyr. Dr ONeil completed the 3-yearng leadership, international devel-nonprofit organization Omni Med

    h volunteerism and ethical leader-one abroad through Omni Medss in Belize, Guyana, and Kenya.th service opportunities, making itr ONeil is the author of 2 booksiation in 2006, Awakening Hip-Global Service and A Practical

    ONeil was appointed Chair of arvice in Sub-Saharan Africa. He isSt. Elizabeths Medical Center incy medicine at Tufts Universityt George Washington University

    ational Kidney Foundation, Inc.onwiqu2 8 nsistriKiantiemalam


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    Edward ONeil Jr146rthquake were a success. Ofvictims with crush-relatedI, only 15 died, a mortality

    e of 19%. This remains com-rable to mortality rates fol-

    ing the earthquakes in Mar-ra (Turkey) in 1999 (15%),

    i (Taiwan) in 1999 (17%),d Bam (Iran) in 2003 (13%).is success derives at least inrt to the efforts of those whoated the Renal Disaster Re-f Task Force and to thoseve souls, both local and for-n, who responded directlyeach of these disasters.

    A BROADER VIEWIn the larger Kashmir re-n, at least 73,000 peopled, most after their homes orrkplaces collapsed on top ofm.3 No one knows howny succumbed to treatableuries, or more specifically,AKI and other injuries ame-ble to interventions by neph-ogists. While the Renal Di-ster Relief Task Force,decins Sans Frontieres, ander groups heroic efforts re-

    ct the best our professionn offer, there is a soberinglity underlying the dialysises per number of peopleled in the large-scale disas-s since Spitak. In order tompare renal response ratesvarious disasters, the ratiothe number of AKI caseseiving dialysis to the over-number of deaths is calcu-

    ed and then multiplied by00. When disaster struckbe, Japan in 1995, this ratios nearly 25. After the devas-ing earthquake in Marmara,ratio was over 27.

    Yet when disaster struck theshmir region of Pakistan in05, the ratio of those receiv-dialysis to the number ofaths ( 1,000) was a mere. Despite the heroic effortsthe many local and few vis-g health personnel involved,t 55 people received life-ing dialysis during an earth-

    ake that claimed 73,000es. Presumably, many suf-ed AKI from crush injuriest would have been ame-

    ble to treatment by dialysis.t only a small fraction re-ived it, which leaves us withrather disquieting question.r all of the scientific ad-nces of our age and our mi-ulous ability to heal, whyso many have to die?

    Certainly, local factors playedajor role. The Kashmir re-

    n of Pakistan is mountain-s, and the few roads leadingwere significantly damaged

    ring the initial quake, makingnsportation particularly ardu-s. The lack of local infrastruc-e, hospitals, and equipmentant that supplies and people

    d to be imported, delaying po-tially life-saving interven-ns. Additionally, the terraind climate made helicopter res-e difficult. Helicopters wererce at the outset, and 2 crashes

    rly on further delayed victimnsport to treatment centers.Yet, the local terrain and dif-ult rescue conditions pro-e us with only a part of the

    swer. The rest comes throughlarger structural issues that

    fined life for the local popu-e long before the quakeuck. The truth is that peoplethe region have been dyingyounger and suffering theages of treatable illness farre than their counterparts inan and Turkey for genera-

    ns. But not solely becauseweather and local geogra-y. The underlying factors thatntribute to these prematureaths and unnecessary suffer-

    derive less from the lawsnature than from the choicespeople. Just as dialysis ratesr disaster victims are farater in places like Japan than

    kistan, there are parallels ine expectancy, infant mortal-, and other morbidity data in

    different regions of ourrld. Dialysis rates are but anegory of a much darker tale,st explained by the conceptstructural violence.

    THE WORLD AT LARGE:STRUCTURAL VIOLENCEA cursory look at our worldeals the profound differ-

    ces in life quality and dura-n between different coun-es and regions. A comparisonmorbidity and mortality datatween just 2 of the above-ed countries is illustrative,d that between the wealthles of the world even more.4 According to the Worldalth Organization, life ex-ctancy in 2004 was 20 yearsger in Japan than in Paki-n (82 years versus 62 years).

    a per capita basis, Japans nearly 3 times as manyysicians and 17 times asny nurses. Fertility (the av-ge number of children aman will bear in her life-e) is over 3 times higher in

    kistan (4.1 versus 1.3); typi-lly, fertility rates are in-rsely proportional to a na-ns wealth. High fertilitympounds the problem of en-mic poverty, spreading littleong many. It also fuels envi-mental degradation, spawnsional conflicts,5 and in-

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    World Kidney Forum 147ases the vulnerability ofmen and children. A childwing up in Pakistan has atimes higher likelihood of

    ing before age 5 than a childwing up in Japan.6 One can

    ly assume these differentialsuld be far greater if region-y disaggregated data weretored in, given the severeverty that characterizes theshmir region. Given the

    ove, it is easy to see whymeone living in Kobe was

    more likely to receive life-ing dialysis after an earth-

    ake than someone living inKashmir region of Paki-

    n. Even the most heroic in-ventions from abroad can-t begin to make up theferences.Regional comparisons illu-nate these disparities morearly still. The global poleshealth and wealth lie be-

    een the club of the wealthi-nations (members of the

    ganization of Economic Co-eration and Development),d the poorest region, sub-haran Africa. Life expect-cy between the 2 differs byer 30 years, and is increas-, largely due to AIDS, whichims a life every 8 seconds.7,8trip from Boston to Nairobiresents a step back in time;

    ople in Africa now liveghly as long as Americans

    in 1900, before modernblic health measures, antibi-cs, and Abraham Flexner. Inrica, infant mortality is 18es higher, while under-5rtality is nearly 30 timesher. The continent with therlds greatest concentrationAIDS, the birthplace of HIV,

    ains the least able to con-nt it. The health care workerortage in sub-Saharan Africaains one of the worlds

    atest challenges, where justof the worlds health work-

    ce, using 1% of world healthre spending, attempts to treat% of the global burden ofease.9 By comparison, theion of the Americas has 37%the worlds health work-

    ce and uses over half ofbal health care dollars toht just 10% of the globalrden of disease. It is far moreely that an American willeive inappropriate antibiot-for a cold than an African

    ll receive life-saving anti-rasitics for malaria.While physicians and nursesck toward the United Statesd other wealthy nations, Af-a and many poor countriesain decimated, more suppli-of health care talent than

    pplied.10 One-fifth of the USysician workforce comesm other countries, includ-

    many developing nationsable to meet the demands ofir own people.11 Compara-e data abound. During thee 1990s, while there was 1ysician for every 362 peoplethe United States, there wast 1 physician for every0,000 in Burundi, and 1 forery 33,333 in Ethiopia.12ve African countries nowve fewer than 1 physicianevery 20,000 people. Some

    ve blamed the exodus fromncentrated centers of pov-y on the frustrations of work-

    with meager supplies anderwhelming burdens of ill-ss. Those who aspire to savees find it difficult to functionmorgue attendants, a rolet many health providers inAIDS belt now play.13The fact that poor peopleund the world have shorter

    d harder lives is the result ofman design, a phenomenonlled structural violence.e increased rates of deathd disability among those whocupy the lowest rungs of thess systems in unequal soci-es result from the choicesde both by individual coun-

    es and the world communityarding allocation of re-

    urces. The forces that con-bute to structural violence

    complex and largely invis-e. As such, they receive onlymattering of attention fromrld leaders, the Americanss corps, and our rather un-cerning populace.Many researchers have triedassess the damage inflictedstructural violence. In 1993,World Bank developed a

    ndardized system, used everce, called DALYs, or dis-ility-adjusted life-years, tock national and regional dis-se burdens that trace directlyck to structural violence.141976, researchers Kohler andcock postulated that if allworlds countries had simi-resources and allocated

    m in similar fashion, struc-al violenceand its result-

    higher mortality for theor would disappear.15 Tak-

    the year 1965 as a model,researchers used Sweden

    d its 75-year life expectancythe society closest to idealource allocation and com-red it with one of the worldsorest countries, Guinea, withaverage life expectancy oft 27 years. The authors con-ded that 83,000 deaths ininea could have been

    oided if life expectancies

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    Edward ONeil Jr148re identical in the 2 coun-es.By expanding the model tocountries, the authors con-

    ded that 18 million peopled as the result of structurallence in 1965, more than allWorld War IIs battlefield ca-alties and 150 times more thanall of 1965s armed conflicts.o other researchers found that

    ring the years 1948 to 1967,uctural violence claimed over0 times the number of livest to civil conflict. Although

    ch studies have their limita-ns, their chief points are bothmpelling and correct. Pov-yand the structural vio-ce that perpetuates itkills

    d it does so relentlessly, invis-y (at least to those of us on thealthier side of the equation),d in far greater numbers than

    armed conflicts that under-ndably command our atten-n. I should add that discus-ns like this one aboutuctural violence are not veiledacks on capitalism or sublimi-l appeals for socialism. Rather,

    concept of structural vio-ce should force us to re-

    amine the structure of therld around us. Given the in-

    uality and suffering that de-es our world order, shouldnt

    healers quest be to betterderstand why?


    In the larger world order,of us see the true extent of

    ffering, or fully understandunderlying forces that

    opagate extreme poverty.rhaps a quick review of thermative is in order. Todayne, some 28,000 childrender age 5 will die of treat-le illness, while 10,000 Afri-ns will die from AIDS, TB,d malaria, infectious dis-ses for which we have treat-nts.16,17 Over the course ofs year, some half a millionmen will die in childbirth inor countries at rates 10 to0 times that of their wealthierunterparts.7 As recently as01, more than 1.1 billionople lived on less than $1r day, while another 1.5 bil-n lived on less than $2 pery.18Those interested in explana-ns for the current world or-r, in which unimaginablealth for some is matched byimagina...


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