I have a global interest in health. In this era of a return from specialization toward primary care, I have the ultimate wholistic approach to health care: when asked my specialty, I have been tempted to say ÏI am a skiin doctor: I take care of the skin and its contents, in its environment.Ó I can practice globally in multiple meanings of that term with interests, qualifications and certifications in medical, surgical and preventive services with an international interest in health promotion and health care education . It is the right time to be looking to global health information networking and medical education, following a career in the biomedical research track and as a classically trained academic surgeon.
I was enlisted early in the post-Sputnik generation of catch-up science and the rush to develop technology targetted to solve problem goals. I enjoyed the two science majors I had in college (along with special enrichment programs called HIFYS--Honors Institute For Young Scientists, once for a summer in physics and once again in chemistry), but never gave up a love for the humanities and the expressions of ideas. It was tempting to enjoy a life of letters, but that would be too much like "eating dessert all day", so I had set the ideal professional course for medical school to enter the scientific humanity, or the humane science, that would allow an application to benefit others in a challenging ever-expanding field. So, I graduated with an additional baccalaureate arts degree and the Philosophy and English Literature majors), an early chimera in this hybridity in the Golden Age of Biomedical Research. And I did a fair amount of bench research, also, with a special fondness for physiology: respiratory in the University of Chicago and endocrine/renal in the University of Michigan.MEDICAL:
My medical career was a wonderful time of rapid growth and expansion in all opportunities, when medical care and its advances were considered an unmitigated good, before the higher investment in curative medicine began to be suspect as part of the problem rather than the solution given the opportunity costs in foregone social and humanitarian goods that have been displaced. I enjoyed medical school when every day opened a new door without any sense of the limits of the possible, or that the next advance would be feared as unaffordable. I decided I liked the direct approach to patientĖs problems with a special flare for surgery and the complex processes of control systems, such as those balanced in endocirine surgery or those that went awry in disordered physiology after trauma or sepsis, and went completely amok in cancer. I never stopped looking beyond the borders of whatever barrier might be erected in social, economic, language, technology or cultural isolation, since I thought that anatomy and physiology were put together very much the same on either side of any artificial boundary that could be erected to separate men and women from each other from whom they might learn and help. The "third world" whether within or outside national boundaries fascinated me and I wanted to get into it and see what I could do with far fewer resources than I had lavished around me in the affluent USA. I started right after my freshman year in the Dominican Republic which broke out in civil war while I was there, complete with a US 82nd airborne invasion. My senior year was an exhilarating experience (see "Medical Adventures in the Nigerian Bush") which I have never forgotten; I have continued to repeat this kind of rewarding experience at least annually, and try to share that opportunity with each generation of medical students that comes along, undergraduate, graduate, or continuing.SURGICAL:
I have been very lucky. There had been a time magazine cover article under the title "If they can operate, you are lucky." The cover portrait was of Dr. Francis D. Moore, Moseley Professor of Surgery at HarvardĖs Peter Bent Brigham Hospital, who subsequently became my surgical chief. This was an era when transplantation was born, and I operated in the very room where the first kidney was transplanted, which had been the same room where Harvey Cushing had done his work before, and Dwight Harken was doing his cardiac valve work while I was there. Just crossing a bridge, I worked with Dr. Robert E. Gross, pioneer of both pediatric and cardiac surgery, as one of his last residents. And probably even more influential than my chiefs were my peers, all of us working in an era we were self-consciously aware was a rapid Renaissance, and nearly every one of my colleagues (with whom I have stayed in close contact as only buddies who have survived trench warfare together might understand) have played leadership roles in the medical and surgical advances that seemed endlessly promising.
I continued in this mode into a unique institution, when I was selected to enter the National Institutes of Health (NIH) in the Surgery Branch of the National Cancer Institute. There I partiipated in very major operations for salvage of cancer patients with recurrent disease or prior failed therapy, and also pursued independent research in a number of studies related to my earlier clinical and basic science research. I especially liked the endocrine surgical patients, and interesting metabloic and immunologic problems that patients experienced following severe injury (like a big operation) or major disease such as cancer.
Rather than return to Boston as had been planned before family emergencies made it important for me to take care of what familiy remained to me, I extended my stay as Associate Clinical Director at the NCI, and then continued my appointment, salary, laboratory and office base at NIH when I moved down to complete the surgical residency at George Washington University under Dr. Paul Adkins.
For the two decades from 1970 to 1990, I worked in all aspects of surgical care, working in the start-up of the emergency trauma service early with colleague in residency and the staff, Dr. Joe Giordano; I founded and then was Director of the Transplantation Service for fifteen years; I participated in much of the surgical oncology, before it became parcelled out into colo-rectal and breast service; but, I steadily developed my primary surgical endocrinology service as a source of great satisfaction in curative surgical solutions to subtle and complex disordered metabolism in which I was privileged to be present as patient and problem parted company. I rose through the ranks to full professor with multiple clinical research protocols being supervised and the direction of the Surgical Research Laboratory, with a highly enjoyable close relationship with the students and resident staff. I regularly made visiting professor appearances at the institutions around the country where many of these good friends have set up their own practices. I continued my interests in international health and worked annually in all parts of the world as volunteer surgeon and teacher in many aspects of health.
Along with progress on many fronts with great promise for further breakthroughs, there were problems as well. Despite the promise, there was uneven delivery based on an increasingly tense socioeconomic condition put on medical care. People who could not pay for services directly (and almost no one can any more) or indirectly through federal or private insurance were not getting care. There were increasing numbers of specialists competing for an ever smaller referral base of patients able to be admitted, and something new was starting up, called managed care, in which the administrators were on the opposite side of the table from the doctors with ever more complex constraints. A new chairman, quite unlike the gentlemanly Paul Adkins, came to blows with me and quite a few other staff, probably symptomatic of the tensions of systemic contraction, in which obligations multiplied as opportunities disappeared. The medical-legal escalation seemed a product of the disillusionment in what was heard by the "consumer" as a promise of "health delivery" and institutions in their advertising come-ons were not about to disabuse the public of this misconception if it gave a competitive advantage in filling empty beds. There were turf struggles over sphere of influence and claims that sounded petty , such as who had seen the patient first. All of this seemed to me, with my background and exposure to third world medicine to be symptoms of surfeit, with an excess manpower chasing diminishing qualified patients with fewer patients who could still be qualified even in the US. If I did not solve a patientĖs problem in Washigton, DC, it would be only milliseconds later that patient would get the care they sought if insured by the right carrier, probably by someone trying to push me away from the trough anyway; and if I did not fix a petientĖs problem in Africa, it would be forever unfixed, since I was their first and last hope. Life is short to be frittered in gmaes of superfluity in situations of health care redundancy when there is an unmet world of need not far away.
And surgery itself seemed targetted, as an easy recourse to a curative service when everyday newspaper headlines trumpeting "what we can do today" relieved the privileged population of the pressures to live wisely. I looked around the remote areas of the world and asked the question my good friend, the late Denis Burkitt had urged upon me: do not look at the exotic diseases these people have so much as the diseases that are so comon among us at to fill three fourths of our hospital beds that these people DO NOT have. Maybe we should be learning from them, rather than transporting our unaffordable (even, or especially, for us) model of health care in "technology transfer," to people who are so backward that they have not yet developed our epidemic of acquired degenerative diseases.PREVENTIVE:
My career of extraordinary dedication of directed effort in "all the best places" had brought me to a paradoxical pass in health care history : never before could we do so much through near-miraculous techniques for such advanced disease to help so small a population sector who had never been less satisfied with their care! It was time for KountzĖs "paradigm shift".
I, myself, had been blessed by perfect health, no doubt an unmerited genetic gift, but I had not been taking responsibility for my own health promotion acitivities. I went out and ran my first mile, and within eight months ran my first marathon. I paid more attention to dietary balance, making active plans NOT TO take advantage of the health insurance for which I have been a life-long payer, without my first ever claim. I have worked closely with, and do not envy, those who have had maximum claims against the insurance I have been paying and see no need to collect. Personal and public responsibility in preventive practices have been responsible for the control of most epidemic diseases, quite apart from any curative advances. And I saw that the claims we had made to have great progress against killer diseases rang rather hollow: we can now find ever smaller and earlier breast cancers through expensive screening imaging techniques--and isnĖt that just wonderful, and just in time too, when 20,000 additional women each year are going to have that breast cancer found--double the annual incidence since I was the chief of the surgical breast oncology unit at the NCI! And we can do amazing things to diagnose coronary artery disease and get the patient to the single most frequently performed operation in the US today (and one of the biggest ticket numbers, to be sure) coronary bypass. No mammagram ever prevented breast cancer, and no coronary catherization ever prevented coronary artery disease. These are techniques designed for sick (and, not incidentally) affluent people, not methods of health promotion! Nike is one company tht has quite possibly done more health promotion than any such medical-industrial complex such as Siemens!
As I had continued my interest in international health, I completed a graduate degree in international affairs, and then went from Central Africa to London in what the University of London modestly labels "EuropeĖs premier school of public health", and completed the DTMH awarded by the Royal College of Physicians after studying in the London School of Hygiene and Tropical Medicine. I did not stop there, but completed the MPH in Epidemiology: Health Promotion/Disease Prevention. And then to help fill in my longing to kow more about the fascinating peoples I have met and worked with in a varied tapestry of cultures around the world, I completed the graduate degree in Anthropology in studying biologic and cultural anthropology, with a special refernce to the African field of my metabolic study. I am now completing the earlier start on my serioius interest in the humanities in my PhD in Human Sciences focussing in my thesis work on the cultural mitigation of the biologic limits to human adaptation and development. At each step in pursuit of health, it seems that health care has been a less than half way technologic solution that has left underlying human problems unresolved, which may be why there is so much disillusion among the recipients of such care.GLOBAL:
I tell my students that I am now involved in the biggest health care growth industry on earth today--I care for and operate on anyone who cannot pay; no one seems to be competing with me for this privilege, it is often done in facilities that would be called sub-standard, and it is often done with very little support services or consultation. But, it is not likely that you will pick out from the waiting throng the marginal candidates for the services, and you will make a decision in the interests of the patient, without the nagging thought that a yacht payment may be due, or that you will want to keep yor numbers up in a series you are collecting. But this may be the most rewarding form of health care, since the results are astounding. People who desperately need a drug or procedure typically thrive when their problem is treated. As my surgical chief Dr. Moore used to say "The sickest patients tolerate the biggest operations, but only if they pay immediate metabolic dividends." Selecting those patients who have the most to gain, already biases your results positively.
And, one can provide the full spectrum of services tailored to the patientĖs problem rather than the machine or expertise: for example, I can treat a patientĖs peptic ulcer medically or surgically according to what would be appropriate for the patient, as opposed to what my role should be and the referal source of the patient.
One thing that is a bonus that comes back to anyone working with colleagues in third world settings. All indications tell those of us working in the first world setting that we are going to have to do more treatment of greater numbers of patients with increasingly complex problems with fewer resources. Our colleagues around the world can help with that, since they have had that post-graduate course in how to do more with less for larger numbers all their professional lives! I am always amazed at ow resourceful they are and ingenious in devising methods within the withiering resource constraints. As I had once said to a student on her first day in Swaziland practice, "We have no money, therefore we must think." I did not learn that in America, although there are definite areas where it will have to work.
I have not limited my interest to the canon of what is acceptable since I have focussed on the problems of peoples of different settings and how they improvise or deal with difficulties taht still have us stymied. For example, I once was invited to the PeopleĖs Republic of China as visiting professor, and they had set up a thyroidectomy for me to do under acupuncture anesthesia. I was about to protest that I do not believe in it, when I might have been reminded that the only person for whom that belief is important is not the one standing up in the operating room. it worked amazingly well: I simply report this; I cannot explain it. I began collecting helath practices around the world that seemed interesting, in some cases harmless so long ast hey did not displace treatment that we know to be effective for serious diseases, but we in the western world have large lists of disorders, many of which are called functional, and still others glorified with some inflammatory or autoimmune sounding name as a cover for the fact that we just do not know and are hardly even descriptive in our avoidance of what it is that we cannot name or help. So, why not listen to "alternative medicine" when we have no effective alternatives? A number of these treatments come from China, india or Africa which simply sums to two thirds of the pasengers on this planet and we should not be so arrogant as to expect tht if they cannot explain themselves in our terms, they are irrational. The healing practices that have passed to us through prehistory included some that worked, long before the active ingredient was identifed (like James LynnĖs fresh produce and limes, that made "limeysĖ of the British seamen, and both treated and prevented scurvy, long before ascorbic acid had been found, named, or even thought of), and many of tem may work even if we do not have an active ingredient isoloated or synthesized in substitute for these natural substances found in healerĖs kits who have not graduated from all the same schools I have. But there are any number of big categories of disease for which I have no similar kit bag of effective treatments: most advanced cancers, much inflammatory disease, many neurologic and joint degenerative disorders. I had worked on a compilation of some herbal and other remedies to see particularly what preventive practices these remedies were said to useful for, and that list of the reports of others practices is available as Health Secrets from Around the World. The scientific method itself was a product of this human experience, and the tried an proven techniques we can count today as distillates of this approach to human problems has not yet resolved all these problems that remain and may not be the only way for human relief and coping with the problems of their everyday lives in settings and with resurces quite different from ours.
The relief of suffering, especially that inflicted on others, is one of the highest of humanitarian goals. A global approach to the science of suffering has been proposed, and an organization set up to study how the relief of inflicted suffering might be effected (The International Society of Panetics). This would raise the title of Global Health to legitimiacy and usher in a new era of the Humane Renaissance.
The new era has many neweer bridges across the bariers that have persisted too long. Appropriate technology does not mean only the lowest technology, since often a CD Rom readeer can cost-effectively replace the need for building and stocking a library in an environment where ther is an urgent and rapid need with few resources to repeat some of the mistakes made in development in the west. Radioimmunoassay plates, locally made, ae an effective and cheap substitute for a hightly developed laboratory science enterpriseif it is unavoidable. Technikos Cirurgikos may be the way to procede in areas such as Mozambique, wher no investment in new medical schools and residnencies will ever get any surgical pracitce out to the provinces within the lifetimes of the next rapidly expanding genertions of that nations of 18 million souls and two surgeons. The internet may be the biggest mega-university yet devised, and an example of its utility is already launched in the Epidemiology Super-Course addressed to the world from an international group of volunteer instructors of whom I am happy to be a member.
There is more than enough world to work on out there by any number of means that are found to work. The need is urgent. As it has been pointed out in print Mind the Gap -- during this Golden Age of Surgery, when I was in each of the major institutions in which I worked for two decades as a full-time surgeon, every major organ in the body had been successfully transplanted except the brain, major advanes were made in the understanding of the immune response, and multiple cancers, especially in children, became curablewith drug therapy or combined treatment modalities. There were ever less invasive methods of surgical treatment with image intensifiesr and remote operations; dissectioins of the living body could be done by computerized tomographic imaging. And a man with a strangulated hernia in sub-Saharan Africa had a less than one in 15 chance of being seen by any health care personnel for treatment. A woman at the same time and in the same place who needed a C-Section, had less thatn a one in 20 chance of having it done. And this is the Golden Age of Surger at fin de siecle and fin de millenium. It is time that the Golden Age goes global or it will be tarished with still futher disappointment, and the new investments made in the much more satisfying, more cost effective, and rewarding practice of prevention. This is something we may have to do more learning about than teaching, since many are well ahead of us now.