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WORLD KIDNEY FORUM
Who We Are and Might Be: In Global Health, ExcellenceDemands Equity
Edward O’Neil Jr, MD
by th
World Kidney ForumAdvisory Board
Rashad S. BarsoumCairo, Egypt
Christopher R. BlaggMercer Island, Washington
John BoletisAthens, Greece
Garabed EknoyanHouston, Texas
John T. HarringtonBoston, Massachusetts
On October 8, 2005, in theremote mountainous ar-
eas of northeast Pakistan, theearth shook. Houses and build-ings crumbled all over the re-gion, crushing people by thethousands. The quake measured7.6 on the Richter scale, makingit nearly comparable in force tothe one that devastated San Fran-cisco in 1906.1 By the time theviolent shaking had ceased, largeareas of the Kashmir region ofPakistan, along with neighbor-ing areas in India and Afghani-stan, lay in ruins. Reports ofmass casualties spread quickly,and soon the United Nationswas reporting that roughly 3.5million people were affectedwith 100,000 wounded or dead.Given the remoteness and diffi-cult, mountainous terrain of the
involved areas, thousands ofAmerican Journal of Kidney Diseases, Vol
people waited in vain for helpthat would never come.
Within hours of the firsttremors in Asia, the first medi-cal response teams began toassemble, coordinating sup-plies and personnel.2 As inmany complex humanitarianemergencies, one of the firstassessment teams to arrive wasfrom Médecins Sans Frontieres(Doctors Without Borders), thestoried “smoke jumpers” of thehealth professions. Among itsmembers were a nephrologist/intensivist and a renal nurse.Both were members of the Re-nal Disaster Relief Task Force,developed by the InternationalSociety of Nephrology in 1989after thousands succumbed tocrush-induced acute kidney in-juries (AKI) in the 1988 earth-quake in Spitak, Armenia.
Fortunately for some vic-
About the Author: Dr Edward O’NGeorge Washington University, and cin internal medicine at Boston MedicKellogg National Leadership Programopment, and politics. In 1998, he foun(www.omnimed.org), which focuses oship. To date, over 120 physiciansinnovative, cooperatively designed pOmni Med also compiles data on gloeasier for anyone so interested to spublished by the American Medicapocrates: A Primer on Health, PoveGuide to Global Health Service. In 2Brookings Institution Taskforce on Hea practicing emergency physician atBoston, an assistant professor of eSchool of Medicine, and Adjunct FSchool of Medicine.Am J Kidney Dis 51:145-154. © 2007
tims of the Kashmir quake, the
51, No 1 (January), 2008: pp 145-154
response mechanisms hadevolved considerably since Spi-tak. The first dialysis performedon an AKI patient occurredwithin the first day of thequake. Over the next 22 days,2 “rescue teams” consisting of8 nurses, 5 doctors, and 2 dialy-sis technicians from 5 coun-tries (France, Turkey, UnitedKingdom, The Netherlands,and Belgium) dialyzed 55 pa-tients of the 88 referred to themain treatment centers of Is-lamabad.
On the surface, the renal in-terventions in the Kashmir
Address correspondence to EdwardO’Neil Jr, MD, Omni Med, 81 WymanStreet, #1, Waban, MA 02468. E-mail:[email protected]
© 2007 by the National KidneyFoundation, Inc.
0272-6386/07/5101-0019$34.00/0
r earned his medical degree frometed a residency and chief residencynter. Dr O’Neil completed the 3-yearying leadership, international devel-
the nonprofit organization Omni Medalth volunteerism and ethical leader-gone abroad through Omni Med’sms in Belize, Guyana, and Kenya.alth service opportunities, making itDr O’Neil is the author of 2 booksociation in 2006, Awakening Hip-nd Global Service and A PracticalDr O’Neil was appointed Chair of a
Service in Sub-Saharan Africa. He isas St. Elizabeth’s Medical Center inency medicine at Tufts Universityat George Washington University
e National Kidney Foundation, Inc.
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Edward O’Neil Jr146
earthquake were a success. Of88 victims with crush-relatedAKI, only 15 died, a mortalityrate of 19%. This remains com-parable to mortality rates fol-lowing the earthquakes in Mar-mara (Turkey) in 1999 (15%),Jiji (Taiwan) in 1999 (17%),and Bam (Iran) in 2003 (13%).This success derives at least inpart to the efforts of those whocreated the Renal Disaster Re-lief Task Force and to thosebrave souls, both local and for-eign, who responded directlyto each of these disasters.
A BROADER VIEW
In the larger Kashmir re-gion, at least 73,000 peopledied, most after their homes orworkplaces collapsed on top ofthem.3 No one knows howmany succumbed to treatableinjuries, or more specifically,to AKI and other injuries ame-nable to interventions by neph-rologists. While the Renal Di-saster Relief Task Force,Médecins Sans Frontieres, andother groups’ heroic efforts re-flect the best our professioncan offer, there is a soberingreality underlying the dialysisrates per number of peoplekilled in the large-scale disas-ters since Spitak. In order tocompare “renal” response ratesin various disasters, the ratioof the number of AKI casesreceiving dialysis to the over-all number of deaths is calcu-lated and then multiplied by1,000. When disaster struckKobe, Japan in 1995, this ratiowas nearly 25. After the devas-tating earthquake in Marmara,the ratio was over 27.
Yet when disaster struck theKashmir region of Pakistan in
2005, the ratio of those receiv-ing dialysis to the number ofdeaths (� 1,000) was a mere0.8. Despite the heroic effortsof the many local and few vis-iting health personnel involved,just 55 people received life-saving dialysis during an earth-quake that claimed 73,000lives. Presumably, many suf-fered AKI from crush injuriesthat would have been ame-nable to treatment by dialysis.Yet only a small fraction re-ceived it, which leaves us witha rather disquieting question.For all of the scientific ad-vances of our age and our mi-raculous ability to heal, whydid so many have to die?
Certainly, local factors playeda major role. The Kashmir re-gion of Pakistan is mountain-ous, and the few roads leadingin were significantly damagedduring the initial quake, makingtransportation particularly ardu-ous. The lack of local infrastruc-ture, hospitals, and equipmentmeant that supplies and peoplehad to be imported, delaying po-tentially life-saving interven-tions. Additionally, the terrainand climate made helicopter res-cue difficult. Helicopters werescarce at the outset, and 2 crashesearly on further delayed victimtransport to treatment centers.
Yet, the local terrain and dif-ficult rescue conditions pro-vide us with only a part of theanswer. The rest comes throughthe larger structural issues thatdefined life for the local popu-lace long before the quakestruck. The truth is that peopleof the region have been dyingfar younger and suffering theravages of treatable illness farmore than their counterparts inJapan and Turkey for genera-
tions. But not solely becauseof weather and local geogra-phy. The underlying factors thatcontribute to these prematuredeaths and unnecessary suffer-ing derive less from the lawsof nature than from the choicesof people. Just as dialysis ratesfor disaster victims are fargreater in places like Japan thanPakistan, there are parallels inlife expectancy, infant mortal-ity, and other morbidity data inthe different regions of ourworld. Dialysis rates are but anallegory of a much darker tale,best explained by the conceptof structural violence.
THE WORLD AT LARGE:STRUCTURAL VIOLENCE
A cursory look at our worldreveals the profound differ-ences in life quality and dura-tion between different coun-tries and regions. A comparisonof morbidity and mortality databetween just 2 of the above-cited countries is illustrative,and that between the wealthpoles of the world even moreso.4 According to the WorldHealth Organization, life ex-pectancy in 2004 was 20 yearslonger in Japan than in Paki-stan (82 years versus 62 years).On a per capita basis, Japanhas nearly 3 times as manyphysicians and 17 times asmany nurses. Fertility (the av-erage number of children awoman will bear in her life-time) is over 3 times higher inPakistan (4.1 versus 1.3); typi-cally, fertility rates are in-versely proportional to a na-tion’s wealth. High fertilitycompounds the problem of en-demic poverty, spreading littleamong many. It also fuels envi-ronmental degradation, spawns
regional conflicts,5 and in-
World Kidney Forum 147
creases the vulnerability ofwomen and children. A childgrowing up in Pakistan has a25 times higher likelihood ofdying before age 5 than a childgrowing up in Japan.6 One canonly assume these differentialswould be far greater if region-ally disaggregated data werefactored in, given the severepoverty that characterizes theKashmir region. Given theabove, it is easy to see whysomeone living in Kobe wasfar more likely to receive life-saving dialysis after an earth-quake than someone living inthe Kashmir region of Paki-stan. Even the most heroic in-terventions from abroad can-not begin to make up thedifferences.
Regional comparisons illu-minate these disparities moreclearly still. The global polesof health and wealth lie be-tween the club of the wealthi-est nations (members of theOrganization of Economic Co-operation and Development),and the poorest region, sub-Saharan Africa. Life expect-ancy between the 2 differs byover 30 years, and is increas-ing, largely due to AIDS, whichclaims a life every 8 seconds.7,8
A trip from Boston to Nairobirepresents a step back in time;people in Africa now liveroughly as long as Americansdid in 1900, before modernpublic health measures, antibi-otics, and Abraham Flexner. InAfrica, infant mortality is 18times higher, while under-5mortality is nearly 30 timeshigher. The continent with theworld’s greatest concentrationof AIDS, the birthplace of HIV,remains the least able to con-
front it. The health care workershortage in sub-Saharan Africaremains one of the world’sgreatest challenges, where just3% of the world’s health work-force, using 1% of world healthcare spending, attempts to treat24% of the global burden ofdisease.9 By comparison, theregion of the Americas has 37%of the world’s health work-force and uses over half ofglobal health care dollars tofight just 10% of the globalburden of disease. It is far morelikely that an American willreceive inappropriate antibiot-ics for a cold than an Africanwill receive life-saving anti-parasitics for malaria.
While physicians and nursesflock toward the United Statesand other wealthy nations, Af-rica and many poor countriesremain decimated, more suppli-ers of health care talent thansupplied.10 One-fifth of the USphysician workforce comesfrom other countries, includ-ing many developing nationsunable to meet the demands oftheir own people.11 Compara-tive data abound. During thelate 1990s, while there was 1physician for every 362 peoplein the United States, there wasjust 1 physician for every100,000 in Burundi, and 1 forevery 33,333 in Ethiopia.12
Five African countries nowhave fewer than 1 physicianfor every 20,000 people. Somehave blamed the exodus fromconcentrated centers of pov-erty on the frustrations of work-ing with meager supplies andoverwhelming burdens of ill-ness. Those who aspire to savelives find it difficult to functionas “morgue attendants,” a rolethat many health providers in
the AIDS belt now play.13The fact that poor peoplearound the world have shorterand harder lives is the result ofhuman design, a phenomenoncalled “structural violence.”The increased rates of deathand disability among those whooccupy the lowest rungs of theclass systems in unequal soci-eties result from the choicesmade both by individual coun-tries and the world communityregarding allocation of re-sources. The forces that con-tribute to structural violenceare complex and largely invis-ible. As such, they receive onlya smattering of attention fromworld leaders, the Americanpress corps, and our rather un-discerning populace.
Many researchers have triedto assess the damage inflictedby structural violence. In 1993,the World Bank developed astandardized system, used eversince, called DALYs, or dis-ability-adjusted life-years, totrack national and regional dis-ease burdens that trace directlyback to structural violence.14
In 1976, researchers Kohler andAlcock postulated that if allthe world’s countries had simi-lar resources and allocatedthem in similar fashion, struc-tural violence—and its result-ing higher mortality for thepoor —would disappear.15 Tak-ing the year 1965 as a model,the researchers used Swedenand its 75-year life expectancyas the society closest to idealresource allocation and com-pared it with one of the world’spoorest countries, Guinea, withits average life expectancy ofjust 27 years. The authors con-cluded that 83,000 deaths inGuinea could have been
avoided if life expectancies
Edward O’Neil Jr148
were identical in the 2 coun-tries.
By expanding the model toall countries, the authors con-cluded that 18 million peopledied as the result of structuralviolence in 1965, more than allof World War II’s battlefield ca-sualties and 150 times more thanin all of 1965’s armed conflicts.Two other researchers found thatduring the years 1948 to 1967,structural violence claimed over300 times the number of liveslost to “civil conflict.” Althoughsuch studies have their limita-tions, their chief points are bothcompelling and correct. Pov-erty—and the structural vio-lence that perpetuates it—killsand it does so relentlessly, invis-ibly (at least to those of us on thewealthier side of the equation),and in far greater numbers thanthe armed conflicts that under-standably command our atten-tion. I should add that discus-sions like this one aboutstructural violence are not veiledattacks on capitalism or sublimi-nal appeals for socialism. Rather,the concept of structural vio-lence should force us to re-examine the structure of theworld around us. Given the in-equality and suffering that de-fines our world order, shouldn’tthe healers’ quest be to betterunderstand why?
WHY THINGS ARE ASTHEY ARE
In the larger world order,few of us see the true extent ofsuffering, or fully understandthe underlying forces thatpropagate extreme poverty.Perhaps a quick review of thenormative is in order. Todayalone, some 28,000 children
under age 5 will die of treat-able illness, while 10,000 Afri-cans will die from AIDS, TB,and malaria, infectious dis-eases for which we have treat-ments.16,17 Over the course ofthis year, some half a millionwomen will die in childbirth inpoor countries at rates 10 to100 times that of their wealthiercounterparts.7 As recently as2001, more than 1.1 billionpeople lived on less than $1per day, while another 1.5 bil-lion lived on less than $2 perday.18
Those interested in explana-tions for the current world or-der, in which unimaginablewealth for some is matched byunimaginable suffering ofmany others, need only turn ontheir television sets or pick upthe daily papers. There is noshortage of people who pro-fess knowledge of the causesof global poverty and inequal-ity, theses which Paul Farmerhas rightly called “immodestclaims of causality.”19 Whilethe list is long, some of themore common explanations in-clude: immorality or lazinesson the part of the poor; culturalor racial explanations (“That’sjust the way they’ve alwaysdone things in Africa”); or, oneof the favorites, corruption.Such explanations serve an im-portant function in our world,reducing the dissonant, at timesintrusive, notions that we livein abundance while over a bil-lion of our neighbors live onless than $1 per day—andnearly half their kids won’treach age 40. It is no surprisethat “we” collectively searchfor reasons to blame the poorfor their suffering, and the sickfor their illness. We conve-
niently ignore Job’s insight thatthe poor are those to whomfate has simply dealt a difficulthand; it makes it easier for usto get through the day.
Yet for us to truly under-stand the factors that driveglobal inequality we must un-dertake a far more arduousjourney. These “forces of dis-parity” are often invisible tothose of us accustomed to com-fort and relative affluence; yetreadily apparent to those livingin the slums and barrios of thedeveloping world. The list offorces is long, but includes thefollowing: trade imbalances,debt, racism, sexism, history,governance, militarism, AIDS,other infectious diseases, popu-lation growth, the environment,and the basic “trap” of pov-erty.20 While there are goodand bad in the global poor Di-aspora, the overwhelming ma-jority of poor are there becausethe sum of the forces alignedagainst them predeterminestheir fate at birth. Sure, corrup-tion is a problem in many de-veloping countries, far greaterthan the excesses seen in theUnited States in recent years.21
But it is not the problem.22
Many other forces play farlarger roles.
Those of us in the healthprofessions don’t routinelystudy these larger forces. Manymight rightly question why anacademic or clinical nephrolo-gist should be asked to careabout the latest decisions ofthe United Nations, or how ne-gotiations at the Doha Roundof the World Trade Organiza-tions are progressing. Yet evena quick glance at the realitiesof life for those in the develop-ing world should prod us to
probe more deeply. Anyone
World Kidney Forum 149
who has visited one of theslums that have become an in-extricable part of the large in-dustrial areas in the develop-ing world will meet slumdwellers that are displacedfarmers. Paul Farmer oncewrote that a poor Haitianfarmer told him, “I’m sick be-cause I lost my land.”Shouldn’t such comments prodhealth providers to try to de-velop at least a basic under-standing of the structures ofglobal trade or the impact ofour nation’s farm subsidies?There is a well-established con-nection between poverty andillness, both nationally andtransnationally.23 There areequally strong connections be-tween the decisions of govern-ments and governing bodieslike the World Trade Organiza-tion, and the health and lifequality of the global poor. Is itany surprise that those with nojobs, who are forced to pickthrough the refuse of others,have abysmal survival rates?And what of their children?
Oxfam has rightly termedglobal trade analogous to a hur-dler’s race in which the “weak-est athletes face the highesthurdles.”24 More than three-quarters of the world’s poorlive in rural areas and dependon farming for their basic sur-vival. Yet, farmers in theworld’s poorest countries can-not compete with the heavilysubsidized products of theircounterparts in rich countries,and the ensuing fight hascaused the virtual collapse ofthe most recent round of globaltrade talks, the Doha Round.25
Rich country subsidies give aclear advantage to rich country
farmers over their poor coun-terparts, who should have acompetitive advantage throughfar cheaper labor and landcosts. These subsidies are notsmall. The Farm Bill is, as ofthis writing, winding its waythrough Congress. At its lastinception in 2002, PresidentBush signed the $248.6 billionbill, of which 70% of the pay-ments went to the largest 10%of producers, forming, in thewords of New York Times re-porter Tina Rosenberg, a “hugecorporate welfare program.”26
Globally, annual rich countrysubsidies constitute a $300 to$350 billion obstacle that fartoo many poor farmers simplycan’t overcome. One UnitedNations official estimates thatsuch subsidies cost Africanfarmers over $50 billion annu-ally, while former World BankPresident James Wolfensohnsaid, “these subsidies are crip-pling Africa’s chance to exportits way out of poverty.”27 Theserealities are all the more diffi-cult for Africans to bear sincethey are repeatedly told theyshould trade their way out ofpoverty, not seek foreign aid.Trade is but one of many forcesconspiring to keep change fromthe global poor. Contrary toour self-view as the world’ssaviors, we are very much com-plicit in maintaining orders ofinequality in our world.
WHY SHOULD WE RESPOND?
When disaster strikes, as itdid in Kashmir, few questionwhether or not we should re-spond. From massive relief ef-forts following the IndianOcean tsunamis of 2004 to anynumber of hurricanes, earth-quakes, or other natural or man-
made disasters, the world hasresponded, and health profes-sionals have often been in theforefront. But what about ourresponse to the larger, struc-tural factors that drive so muchof the world’s suffering? Ourfirst step must be to broadenour understanding of thesecomplex issues. But what then?Once we know more, whyshould we respond at all? As apracticing clinician, dedicatedto enhancing the quality andduration of life, it is a difficultquestion to have to answer. Yetgiven the lack of resources withwhich we in the rich worldhave addressed this concernthus far, history demands thatwe answer.
We can view the answers towhy we should respondthrough 2 distinct lenses: moraland pragmatic. In the former,we can turn to one of the iconsof our profession, AlbertSchweitzer, who, in postulat-ing the ideal of Reverence forLife, challenged us to care forall of the life around us, includ-ing those people not in ourtraditional realm of concern.28
These sentiments resonate withthe core beliefs of most worldreligions, which refer either di-rectly or obliquely to socialjustice and compassion for thepoor.29 These views coursedthrough the writings of theframers of the Universal Decla-ration of Human Rights, cham-pioned by Eleanor Roosevelt,and brought to life in the after-math of World War II.30 Thehuman rights paradigm informsus that we all, by mere inclu-sion in the human race, areborn with certain undeniablerights, among which are life,health, education, and the
chance to lead a dignified exis-
Edward O’Neil Jr150
tence. The Universal Declara-tion of Human Rights may rep-resent the pinnacle of humanambition, yet stands in strikingcontrast to the lived experi-ence of most of the world’sextreme poor. More dream thanreality, yet possible if enoughbelieve and heed the calls forchange.
Turning to look through thelens of pragmatism, we findequally compelling reasons tocare about the global poor.Many of the world’s problems,including terrorism, infectiousdisease epidemics, drug traf-ficking, refugee movements,environmental degradation,among others, arise in failedstates like Sudan, Somalia, andAfghanistan. By helping thepeople in these places develop,we help ourselves. The USCentral Intelligence Agencydocumented as much in a 1994study, and the Bush Adminis-tration rightly elevated devel-opment as the “third pillar” ofthe 2002 National SecurityStrategy, along with defenseand diplomacy.31 The merits ofdevelopment are borne out bythe rapidly rising economies ofIndia and China, which havepulled millions out of povertyin recent decades. Such is thegoal of development every-where. While we will neverstop the next infectious diseaseepidemic from arising, we canlimit the amplification that oc-curs in areas of concentratedpoverty, where hordes ofpeople, immunologically de-pleted by starvation, pose averitable nirvana for emergingpathogens.32 Those interestedin the environment shouldknow that the United Nations
projects human populationgrowth to reach 9.5 billion by2050, with 8 billion in develop-ing countries, where 98% ofthe annual population growthnow occurs.33,34 Imagine anadditional 3 billion people, allclimbing the ladder of develop-ment, all using carbon-basedfuels and greatly speeding upthe process of global warming.Will we really be able to re-spond in time?35 Jeffrey Sachsis no doubt correct, that devel-opment, with larger invest-ments in health and educationin poor countries, is the bestweapon to curb populationgrowth; as incomes and ser-vices rise, fertility rates plum-met.36 Considering each of theabove in turn, it is clear thatour historic paradigm of largelyignoring the developing worldwill have to change.
There are many who rightlyask, “Why should we respondto problems overseas when wehave so many problemshere?”37 First, we should re-ject the premise. Why do somany people share the viewthat either we help those athome or we help those abroad?We have the resources to doboth and should do so. The USfederal budget in 2006 was $2.6trillion, and our nationaleconomy generated $13 tril-lion, roughly 28% of theworld’s total gross domesticproduct.38 Yet we remain nearthe bottom of foreign aid do-nors at just 0.22% of grossdomestic product, the thirdsmallest allocation of theworld’s wealthiest 22 coun-tries (the Organization of Eco-nomic Cooperation and Devel-opment), behind Portugal andGreece in dollars given per size
of gross domestic product.39(And that includes the $12.1billion in reconstruction ef-forts in Iraq and Afghanistan.)We have the resources to helpthe less fortunate both at homeand abroad; only the will islacking. Second, those whoserve overseas tend to be thesame people who care for themarginalized and poor in theUnited States. That’s no acci-dent. Most who work abroadhave transforming experiencesthat help them see more clearlythe problems at home, and theirreturning passion and energyhelps us all. Third, despite themyriad of problems in theUnited States, the problemsconfronting the poor in sub-Saharan Africa, Asia, and LatinAmerica are orders of magni-tude greater; there is simply nocomparison. As members of ahealing profession, our obliga-tions are to our patients, andthere is no nationalistic compo-nent to the Hippocratic Oath,or to the unspoken ethic ofwhat we do. Our professionhas an honorable heritage thatshould incite the better angelswithin us.
WHO WE ARE AND MIGHTBE: HOW WE
CAN RESPOND
We should first take stockon just what “we” have donethus far. One of the few studieson physicians and nurses work-ing overseas comes from JohnsHopkins’ Dr Timothy Baker,who found that just 1 in 300physicians and 1 in 1,000nurses had been active in globalhealth prior to the study’s pub-lication in the Journal of theAmerican Medical Associationin 1984.40 More recent data
from the Association of Ameri-
World Kidney Forum 151
can Medical Colleges providesome basis for optimism. In a2006 survey, the associationfound that 27% of US medicalstudents reported having takenelectives abroad, compared tojust 6% in 1984.41,42 Interestin global health is rising. Itseems that today’s medical stu-dents take their global healthresponsibilities far more seri-ously than we ever have be-fore. In so doing, they followin the footsteps of some iconsof our profession, like AlbertSchweitzer, Tom Dooley, andPaul Farmer. A host of nongov-ernmental organizations likeMédecins Sans Frontieres, Phy-sicians for Human Rights, Part-ners In Health, and many oth-ers remind us of all that we canbe as clinicians.
If we can agree that weshould respond, then how, ex-actly are we to do so? Our firststeps should be to enhance ourunderstanding of why thingsare as they are in our world,and then work toward change.The forces that maintain globaldisparities in health are bothpowerful and largely invisible.Many stem directly from deci-sions made by governments inthe United States and other in-dustrialized countries. Yet, doc-tors, administrators, nurses, andother health professionals re-main widely respected. Whenthey speak, the public usuallylistens. If more health provid-ers would take an active role inspeaking out against globalhealth inequalities, greatchange would result. A fo-cused effort to sway the lead-ers of the world’s most power-ful country may provide more
help to the global poor than anarmy of doctors serving over-seas. We should use the moralstrength of our profession toagitate for political change:fairer trade practices, a reduc-tion in farm subsidies, in-creased and more effective de-velopment aid, and legislativeefforts to develop a “US GlobalHealth Service,”43 to enhancehealth care capacity in sub-Saharan Africa (see44 to trackprogress of the The AfricanHealth Capacity InvestmentAct of 2007), and boost USvolunteerism through the cre-ation of a global service fellow-ship program.45 Perhaps moreof our medical societies coulddraft resolutions that supportsome of these larger, ambitiousinitiatives.
Certainly, we should honorand possibly join those whorespond to the complex hu-manitarian emergencies thatroutinely arise in our world,like the earthquake in Kash-mir. Thousands within themedical profession routinelytake extraordinary risks to savethe lives of those caught up inunspeakable tragedies. I was inTegucigalpa, Honduras follow-ing Hurricane Mitch in 1999when we got word that anMédecins Sans Frontieres heli-copter had crashed, claimingthe lives of everyone aboard,including the pilot, patient,nurse, and physician. Such arethe risks borne by these heroicindividuals, who elevate thestatus of the profession throughtheir work.
Yet, most of us simply don’thave the experience or trainingto parachute into a disaster areaand provide useful assistance.
In fact, many of the organiza-tions that do such workstrongly prefer those with con-siderable international experi-ence already. The untrained andpoorly prepared often takemore than they give in emer-gent situations, requiring helpwith language, logistics, cul-tural adjustments, disease enti-ties, etc. For many of us, thebest advice in disasters is theold adage, “Stay home; sendmoney.”
But there are ways that manymore of us can get involveddirectly, and I would urge allreaders to consider doing so.From the experience of havinggiven many talks on this sub-ject, I know that I can makepeople think, but can’t makethem feel. Only direct experi-ence can provide the latter. Oneshould heed the words ofGustavo Gutierrez, the fatherof liberation theology, whourges all of us to take a “foottrip” in lieu of a “head trip.”46
The difference between the 2is of enormous consequence;many who have worked over-seas are so moved by their ex-periences that they undergo apersonal transformation, andoften seek to better understandthe global order. The storiesare legion of lives irrevocablychanged by the sheer power ofthe experience. Many healthproviders who venture over-seas to work and serve findthemselves returning again andagain, experiencing what somany call the greatest experi-ence of their professional lives.
Martin Luther King, Jr oncesaid, “The racial problem inAmerica will be solved to thedegree that every American
considers himself personally
Edward O’Neil Jr152
confronted with it.”47 We canextend a similar analogy to theproblem of global health in-equality. This problem too willonly be solved to the degree towhich each of us feels person-ally confronted by it—particu-larly those of us in the healthprofession. That remains diffi-cult if the overwhelming major-ity of health providers remainsecluded away in the relativecomfort of the industrializedworld. It is only through anactive and direct engagementwith the global poor that ourperspectives can evolve. Pov-erty remains the most impor-tant killer in the world, and thebest way to understand it is towork with those who live un-der its yoke. Only then willenough of us be sufficientlymotivated to work for a morejust world.
When John F. Kennedyfounded the Peace Corps, hesaw the volunteers as playing afar greater role in the worldthan the direct service theywould provide. “Imagine,”Kennedy told a few PeaceCorps founders in its fledglingdays. “If we can send 100,000Americans overseas each year,by the end of the first decadethere will be over a millionAmericans with direct experi-ence in Africa, Asia, and LatinAmerica. What will that meanfor our foreign policy?” (per-sonal communication fromSenator Harris Wofford, formerspecial assistant to PresidentKennedy and a founder of theUS Peace Corps, October2007). Kennedy’s vision re-mains compelling all theseyears later. Two of the greatestobstacles facing the global poor
are our indifference and lackof understanding. We mistak-enly think that there is little wecan do, and that we are doingenough already. We who couldso readily change their livessimply must engage in fargreater numbers.
The good news is that thereare many ways to get involved.There are now more opportuni-ties in global health than everbefore, and funding for globalhealth has increased dramati-cally.48 A number of studentsand I spent years compilingorganizations that send healthprofessionals overseas; thereare hundreds of them. In APractical Guide to GlobalHealth Service, we listed over300 such organizations (includ-ing 50 organizations lookingfor nephrologists on page 321),along with many more work-ing on the political and advo-cacy side of global health.49 Itis easier now to serve than itever has been before. Severalorganizations, like Health Vol-unteers Overseas, the Interna-tional Medical Corps, and theorganization I founded and run,Omni Med, focus efforts ontraining, such that a volun-teer’s gifts remain long afterhe or she departs. While reliefefforts are of great importance,we should keep in mind thatmany more people around theworld will die of complica-tions of hypertension and dia-betes than from disaster-in-duced crush injuries. Wouldn’tit be of greater value for neph-rologists to teach colleagues indeveloping countries how tomanage these illnesses and pre-vent chronic renal failure thanto intervene after crisis strikes?There is an obvious need for
both long-term training andacute interventions in times ofcrisis. The bottom line is thatmore us of need to get in-volved.
CONCLUSION: A DEATHIN KASHMIR
Somewhere in a remote vil-lage in the Kashmir section ofPakistan on the night of Octo-ber 8, 2005 someone, perhapsa young woman trapped inrubble, cried out for help. Noone heard her, and she died inthe silence of history, her longmuted voice ringing out, punc-turing the stillness around her.She had no doubt witnessed, orat least heard rumors of, dra-matic scientific and technologi-cal advances in the worldaround her. Yet for her theseadvances held no personal sig-nificance; they might just aswell have occurred in anotherworld. Her cries, like those ofmillions of others like her inour unjust world, went unan-swered.
If the legacy of twentiethcentury medicine is excellence,then the legacy of the 21st cen-tury must be equity. Our sto-ried profession has an Achil-les’ heel: that our knowledgeand talents remain concentratedamong those who can affordthem. We, the inheritors of thelegacies of Schweitzer, Dooley,and Virchow simply must riseto the greatest challenge facingour profession and our world.If we choose to ignore the ris-ing storms around us—manycaused by the inequality thatdefines our world—we willtruly reap the whirlwind. Therewas a time when doctors weremen (and women) of the world,where to have scientific train-
ing meant that one also had an
World Kidney Forum 153
engagement in and concern forthe larger issues shaping theworld order.50 It is time thatwe again find our collectivevoice and venture forth intothe world, leading others in astruggle to bring social justiceand health equity to all people.We ignore this call—our call-ing as physicians—at our ownperil.
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