InkLinks

InkLinks is a regular column for readers’ response. This month contributors, in company with Fred Gifford in his lead article, write about what they’ve learned from studying and working in other countries. If you would like to carry on this conversation, or start another, please drop us a line.

––JA

A Physician Ethicist in London: “We became Londoners each morning”

I have taught the London course in ethics and history of medicine three times since our first offering in 1986. I was privileged to be part of its inauguration, working in tandem with Peter Vinten-Johansen, who deserves credit for making it come about. The course has been one of our most successful undertakings; I am regularly gratified to speak to former “Londoners” and to hear from them uniformly high praise for the learning experience.

Peter made an important strategic decision when the course was first planned. He insisted that we use dormitory space at the University of London and classrooms at St. Bartholomew’s medical school a couple of miles away. In contrast to students in many MSU London summer programs, ours had to become London commuters each morning, using the tube or the bus to get to class. From Day One the students felt part of the life of the city. When they then had their experiences watching the National Health Service at work in physicians’ offices (“surgeries”) or in hospital wards, students had a better sense of the daily lives of the patients whom they observed. Seeing health care in another country is a way of learning things that no classroom lecture could convey. Because Costa Rica is considerably more different from the U.S. than is the U.K. (even if parts of London seem at times like parts of Bangladesh), the new course [described in Fred Gifford’s lead article] adds an important dimension to our Study Abroad efforts.

Howard Brody
Center for Ethics & Humanities in the Life Sciences
and Department of Family Practice

An Anthropologist in Mexico: “No ethical map is conceivable”

Conducting research in southern Mexican hospitals, I am regularly challenged in my notions about moral principles in health care, and reminded that medical practice must be assessed within its socio-economic and cultural context. The profound inequalities between rich and poor nations constitute a hard-edged frame within which hospital staff and patients must make terrible choices. I remember the weary sadness of a pediatrician who explained his criteria for deciding which babies would be placed in the hospital’s two incubators; the anguish of a surgeon as he futilely negotiated for anesthetics that were being diverted to a bigger hospital, forcing him to choose which desperately ill patients could have surgery. I remember the subsistence farmer who sold his family’s land and livestock to buy chemotherapy drugs, only to run out of assets before completing treatment. His death left his family with nothing.

Where is the right and wrong in any of this? How should one even frame the questions? Local circumstances must be central: local power structures affect who has decision-making authority; the appropriate unit of analysis may sometimes be a family or community, rather than an individual. While such reframing may be useful for specific cases, the bigger picture remains disturbing. True resolution to these ethical dilem-mas would require a more equitable distribution of medical resources world-wide. Without that no real ethical map even seems conceivable.

Linda Hunt
Department of Anthropology and
Julian Samora Research Institute

A Student in Nepal: “I saw problems and beauty from the front line.”

We spent approximately three weeks in Nepal studying health care. We visited Red Cross stations and hospitals, interviewed doctors and patients, and talked with ayurvedic doctors who are a large part of the culture and have many ties to religion. The way religion is tied to everything in the country is so unusual. In visiting hospitals I saw bribery, a chaotic lack of organization, unsanitary conditions, and primitive treatment methods. In contrast to this, many Nepalese had never had Western health care, but they showed amazing health even in old age. We visited their form of a hospice–a sacred community where elders go to live in a community together to find peace and not be a burden to their families.

It was the most amazing experience of my life. (It was also affordable, as Nepal is one of the cheapest countries to visit.) Living with a Nepali family, learning from native teachers, and grasping the language allowed me to see the problems and beauty from the front line. There were so many ways to attempt to make a difference–many non-governmantal organizations (NGOs) and countries tried to intervene but made things worse, while others really helped. It was a chance to see the masked problems that the world faces.

David Miller
Psychology Major

A Nurse Researcher in Zimbabwe: “Is it too late?”

In 1980 a newly independent Zimbabwe under a socialist government poured scarce resources into the well organized but impoverished health care system. For the first time it became possible for black Zimbabweans to use all health facilities, even if equipment and physician numbers were still inadequate. Childhood immunization numbers increased while water borne infectious diseases decreased. Life expectancy for men and women rose by 20 years.

In 1985 the World Bank began to loan the government funds for development, in exchange for promises of a capitalist economy. As a result of this and other factors the economy has been decimated, and the health care system has crumbled with it. The AIDS epidemic is devastating the working and middle classes. Now the country is in turmoil. Providers strike for realistic wages, or simply emigrate. Two tertiary hospitals have closed. Formal health care is now primarily available to the elite, black and white. President Mugabe governs despotically. The rule of law has vanished. Would different policies by the World Bank have avoided the economic collapse? Why are the world’s leaders willing to ignore catastrophes in Africa? Would enlightened intervention by more stable countries have helped avoid the decline of Zimbabwe? Is it too late?

Barbara Sparks
Dept. of Osteopathic Surgical Specialties
College of Osteopathic Medicine

A Physician in Zambia: “Nothing provides me as much perspective.”

Each year during Zambia’s rainy season, while malaria rages and the queue of outpatients seems never-ending and hospital wards burst to overflowing (two children to a bed –-siblings, if possible), and wails rise from the mortuary just outside the hospital, I arrive for a 3-month visit. I return looking haggard, tired, sleep-deprived, thin. Why this strange annual retreat?

Perhaps it is the vague look of relief on the faces of exhausted medical staff. Or the rush that comes with caring for truly sick patients in an environment with minimal resources. Or even the words of admiration from people at home (“Gee Dr. Birbeck, it’s really wonderful, that work you do over in Africa”). No––what I gain is deeper.

So often day-to-day annoyances overwhelm us––incompetent clerks, traffic jams, telemarketers, whining children. Nothing provides me as much perspective on this as my annual three months of reality: malnourished children carried for hours by growth-stunted mothers just to reach the clinic; running out of Tylenol just as another febrile seizure case arrives. Yesterday, here in Michigan, I found myself furious about some misplaced x-rays. Then I remembered that next month, in a TB ward in Zambia, I might not have developing solution for the chest films. My fury evaporated.

Gretchen Birbeck
Departments of Neurology & Epidemiology
College of Human Medicine