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

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<ul><li><p>WORLD KIDNEY FORUM</p><p>M lth</p><p>Oea</p><p>ea</p><p>inggiotho7.6itthecisvioare</p><p>Paingstama</p><p>an</p><p>was reporting that roughly 3.5miwiGicu</p><p>inv</p><p>petha</p><p>trecaasplimaemassfro(DstohemeintBonadeSociety of Nephrology in 1989after thousands succumbed to</p><p>resevtak</p><p>Address correspondence to EdwardONeil Jr, MD, Omni Med, 81 Wyman</p><p>A il JrGe pletein i enteKe tudyiop d the(ww healtshi ve ginn gramOm l healea e. Dpu ssocpo , andGu 7, DrBro th Sea p ritasBo ergenSc lty aScAm the N</p><p>Amllion people were affectedth 100,000 wounded or dead.ven the remoteness and diffi-lt, mountainous terrain of theolved areas, thousands of</p><p>crush-induced acute kidney in-juries (AKI) in the 1988 earth-quake in Spitak, Armenia.</p><p>Fortunately for some vic-tims of the Kashmir quake, the</p><p>Street, #1, Waban, MA 02468. E-mail:ejoneil@comcast.net</p><p> 2007 by the National KidneyFoundation, Inc.</p><p>0272-6386/07/5101-0019$34.00/0doi:10.1053/j.ajkd.2007.11.005</p><p>erican Journal of Kidney Diseases, Vol 51, No 1 (January), 2008: pp 145-154 145Who We Are and</p><p>World Kidney ForumAdvisory Board</p><p>Rashad S. BarsoumCairo, EgyptChristopher R. BlaggMercer Island, WashingtonJohn BoletisAthens, GreeceGarabed EknoyanHouston, Texas</p><p>John T. HarringtonBoston, Massachusetts</p><p>n October 8, 2005, in theremote mountainous ar-</p><p>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</p><p>nearly comparable in force toone that devastated San Fran-</p><p>co in 1906.1 By the time thelent shaking had ceased, largeas of the Kashmir region ofkistan, along with neighbor-</p><p>areas in India and Afghani-n, lay in ruins. Reports ofss casualties spread quickly,</p><p>d soon the United Nationsight Be: In Global HeaDemands Equity</p><p>Edward ONeil Jr, MD</p><p>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</p><p>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</p><p>w.omnimed.org), which focuses onp. To date, over 120 physicians haovative, cooperatively designed proni Med also compiles data on globa</p><p>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.</p><p>J Kidney Dis 51:145-154. 2007 by, Excellence</p><p>ponse mechanisms hadolved considerably since Spi-. The first dialysis performedan AKI patient occurred</p><p>thin the first day of theake. Over the next 22 days,rescue teams consisting ofurses, 5 doctors, and 2 dialy-technicians from 5 coun-</p><p>es (France, Turkey, Unitedngdom, The Netherlands,d Belgium) dialyzed 55 pa-nts of the 88 referred to thein treatment centers of Is-abad.</p><p>On the surface, the renal in-ventions in the Kashmir</p><p>earned his medical degree fromd a residency and chief residencyr. Dr ONeil completed the 3-yearng leadership, international devel-nonprofit organization Omni Med</p><p>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</p><p>ONeil was appointed Chair of arvice in Sub-Saharan Africa. He isSt. Elizabeths Medical Center incy medicine at Tufts Universityt George Washington University</p><p>ational Kidney Foundation, Inc.onwiqu2 8 nsistriKiantiemalam</p><p>ter</p></li><li><p>ea88AKratpalowmaJijanThpacreliebraeigto</p><p>giodiewothemainjtonarolsaMothflecarearatkiltercoinofrecalllat1,0Kowatatthe</p><p>Ka20</p><p>ingde0.8ofitinjussavqulivferthanaYeceaFovaracdid</p><p>a mgioouindutraouturmehatentioancuscaeatra</p><p>ficvidanthedelacstroffarravmoJaptio</p><p>ofphcodeingofoffogrePalifitythewoallbeof</p><p>reventiotriofbecitanposoHepelonstaOnhaphmaerawotimPacavetiocodeamronreg</p><p>Edward ONeil Jr146rthquake were a success. Ofvictims with crush-relatedI, only 15 died, a mortality</p><p>e of 19%. This remains com-rable to mortality rates fol-</p><p>ing the earthquakes in Mar-ra (Turkey) in 1999 (15%),</p><p>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.</p><p>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-</p><p>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-</p><p>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.</p><p>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-</p><p>ake that claimed 73,000es. Presumably, many suf-ed AKI from crush injuriest would have been ame-</p><p>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?</p><p>Certainly, local factors playedajor role. The Kashmir re-</p><p>n of Pakistan is mountain-s, and the few roads leadingwere significantly damaged</p><p>ring the initial quake, makingnsportation particularly ardu-s. The lack of local infrastruc-e, hospitals, and equipmentant that supplies and people</p><p>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</p><p>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</p><p>swer. The rest comes throughlarger structural issues that</p><p>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-</p><p>ns. But not solely becauseweather and local geogra-y. The underlying factors thatntribute to these prematureaths and unnecessary suffer-</p><p>derive less from the lawsnature than from the choicespeople. Just as dialysis ratesr disaster victims are farater in places like Japan than</p><p>kistan, there are parallels ine expectancy, infant mortal-, and other morbidity data in</p><p>different regions of ourrld. Dialysis rates are but anegory of a much darker tale,st explained by the conceptstructural violence.</p><p>THE WORLD AT LARGE:STRUCTURAL VIOLENCEA cursory look at our worldeals the profound differ-</p><p>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).</p><p>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</p><p>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-</p></li><li><p>crewogro25dygroonwoallfacpoKaabsofarsavquthestaternodif</p><p>micleoftwestOropanSaanovingclaArepperoudidpuotiAftimmohigwoofremfro</p><p>shremgre3%forca24disregofforglofigbulikrecicswipa</p><p>floanricremerssuphfroingunthetivlatphinjus10evFihaforhacoertingovnelivasthathe</p><p>aroanhucaThanocclaetimatriregsotriareibla swopredis</p><p>tobythestasinabtraeabaInAlthelartheturingpoingtheanasrespapoitsjuscluGuav</p><p>World Kidney Forum 147ases the vulnerability ofmen and children. A childwing up in Pakistan has atimes higher likelihood of</p><p>ing before age 5 than a childwing up in Japan.6 One can</p><p>ly assume these differentialsuld be far greater if region-y disaggregated data weretored in, given the severeverty that characterizes theshmir region. Given the</p><p>ove, it is easy to see whymeone living in Kobe was</p><p>more likely to receive life-ing dialysis after an earth-</p><p>ake than someone living inKashmir region of Paki-</p><p>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-</p><p>een the club of the wealthi-nations (members of the</p><p>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;</p><p>ople in Africa now liveghly as long as Americans</p><p>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,</p><p>ains the least able to con-nt it. The health care workerortage in sub-Saharan Africaains one of the worlds</p><p>atest challenges, where justof the worlds health work-</p><p>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-</p><p>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</p><p>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</p><p>pplied.10 One-fifth of the USysician workforce comesm other countries, includ-</p><p>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</p><p>ve blamed the exodus fromncentrated centers of pov-y on the frustrations of work-</p><p>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</p><p>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-</p><p>es and the world communityarding allocation of re-</p><p>urces. The forces that con-bute to structural violence</p><p>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</p><p>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</p><p>m in similar fashion, struc-al violenceand its result-</p><p>higher mortality for theor would disappear.15 Tak-</p><p>the year 1965 as a model,researchers used Sweden</p><p>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</p><p>oided if life expectancies</p></li><li><p>wetri</p><p>allcludievioofsuinTwdustr30lossutiocoertlenaniblweanthestatiosiostrattnathelenexwoeqfintheun</p><p>fewsutheprPenoaloun</p><p>abcaaneamethiwopo10co20pepelioda</p><p>tiodeweunmathetheshfesofityhaclathemocluonorjusdoofSuporedintinliolesnereathaforforfonie</p><p>thefathato</p><p>staglodejoupathoforreaindeforfodegoothlatanertanaspjortheagthetiovethaUnBuMlar</p><p>prstumiacgisabthegooftioa qofingpr</p><p>Edward ONeil Jr148re identical in the 2 coun-es.By expanding the model tocountries, the authors con-</p><p>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</p><p>ring the years 1948 to 1967,uctural violence claimed over0 times the number of livest to civil conflict. Although</p><p>ch studies have their limita-ns, their chief points are bothmpelling and correct. Pov-yand the structural vio-ce that perpetuates itkills</p><p>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</p><p>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,</p><p>concept of structural vio-ce should force us to re-</p><p>amine the structure of therld around us. Given the in-</p><p>uality and suffering that de-es our world order, shouldnt</p><p>healers quest be to betterderstand why?</p><p>WHY THINGS ARE ASTHEY ARE</p><p>In the larger world order,of us see the true extent of</p><p>ffering, or fully understandunderlying forces that</p><p>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...</p></li></ul>


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