Global health is plagued with dichotomies, even if most are false dichotomies. One persistent dichotomy is the emphasis on clinical care for individual patients versus interventions focused on public health & social determinants.
Years ago, I faced that dichotomy myself, when I had to decide on my residency training. I decided to give up practicing clinical medicine and made up my mind to dedicate my career to public health. I decided that I would focus all my energies on preventing problems rather than deal with sick individuals with problems. I wanted to turn off the tap, rather than mop up the floor, so to speak.
There are others who have spent their entire lives saving lives, one at a time. Why do they do that? What motivates them? What sustains them in their quest to make sure everyone should get the best medical care possible? What keeps them up at night?
ONE BY ONE BY ONE is a new book that provides valuable glimpses into these questions. The book is by Aaron Berkowitz, a Harvard-trained neurologist, currently Director of Global Health at Kaiser Permanente School of Medicine.
After reading the book, I could think of just one word to capture my impressions: honest. The book is brutally honest and reveals all the struggle and excitement involved in providing the best care possible to some of the most under-privileged patients. It will inspire many young medical students and health professionals.
Much of the book is focused on the journey of one patient, a young Haitian man named Janel. Berkowitz learns about Janel during his numerous visits to Haiti, during his time with Partners in Health (PIH).
Janel is diagnosed to have an enormous brain tumor, the largest PIH or Harvard docs had ever seen. Since the surgery would have been impossible in Haiti, Berkowitz decides to fly Janel to Brigham and Women's Hospital in Boston, where he worked as a young attending neurologist. Berkowitz thought Janel could be a 'big save.' Janel was young and if the tumor could be removed, he might have good prognosis and could perhaps go back to school.
After herculean efforts with incredible contributions from many individuals (especially Michelle Morse, Co-Director of EqualHealth and Assistant Program Director for the Internal Medicine Residency at Brigham and Women’s Hospital), Janel reaches Boston and gets operated by Ian Dunn, a neurosurgeon.
Contrary to expectations, Janel does not recover easily. Over a period of time, he ends up needing 5 surgeries, repeated hospitalizations, long-term rehabilitation, etc. Despite this disheartening progress, Berkowitz finds and helps many such patients in Haiti.
Why? Because Berkowitz truly believes in the philosophy that every person is a person (tout moun se moun, in Haitian Creole). It is a simple phrase, but a radical notion, he argues. "If every person truly believed that every other person was just like them, then how could anybody accept inequity, let alone racism, sexism, classism, and the conflicts that arises as a result of these individual views and societal forces?" he asks.
Not surprisingly, Berkowitz is inspired by Paul Farmer, whose is famous for this quote: "The idea that some lives matter less is the root of all that's wrong with the world."
Dr Aaron Berkowitz, the author, is Director of Global Health at Kaiser Permanente Bernard J. Tyson School of Medicine. Photo credit: Richard Howard.
In the end, months after Janel's first surgery, Berkowitz finds him walking, talking, eating, and singing. It was a long and painful road to recover.
Paul Farmer encourages Berkowitz to explore the possibility of getting such complex neurosurgeries done in Haiti, at the Hôpital Universitaire de Mirebalais, which PIH helped build after the devastating earthquake in Haiti. He reminds Berkowitz that what was once thought impossible 30 years ago (e.g. management of HIV and MDR-TB), is now routinely done in Haiti and other low-income countries by PIH and their partners.
Paul Farmer, Michelle Morse, Joia Mukherjee, and Aaron Berkowitz are all examples of clinicians from high-income countries who invest enormous energies living up to the principle that every person is a person. They are not alone. Global health today attracts many such doctors who are passionate about ensuring medical care for the most under-privileged. Their passion is reflected in the explosive growth of programs such as global surgery, global anesthesiology, global oncology, global child health, global mental health, global pathology, global neurology, global health nursing, global health rehabilitation, among others.
Indeed, global health today is not just about public health. It has opened a space for clinicians who aspire to live up to the notion of tout moun se moun. While I am not among such clinicians, I admire them for their commitment and passion, and greatly value their contributions in global health. They remind us that we need to do the best for every person who suffers, while simultaneously tackling the underlying social and public health determinants. In other words, there is no dichotomy here.
Note: for more such inspiring global health books, check out this crowd-sourced list of over 175 great books: https://naturemicrobiologycommunity.nature.com/posts/41300-if-you-had-to-read-one-book-on-global-health