The Draw of Dermatology?

March 20, 2008

This piece in the New York Times focuses on a married couple, both Harvard Medical School students, who are in their fourth year and waiting to find out about their residency placements. Like many medical students around the nation, they’re competing for competitive placements in specialty fields instead of going into less lucrative (and possibly less intellectually stimulating?) fields such as family practice and internal medicine.

And the competition is expensive:

Already saddled with about $330,000 in education loans, they borrowed $20,000 more so they could fly around the country this winter for about two dozen residency interviews each. All told, each applied to 90 such training programs.

The article makes me a little sad in general. I had a conversation at CGI U with a med school student who warned me about the “vortex” of med school. Paraphrased: “Everyone’s the same. You get to med school all idealistic, wanting to help people and stuff. Then you spend years and years studying and working, and you see the people ahead of you getting money. You see the doctors with the nice cars and comfortable lives, and you start to wonder when you’re getting yours? And you get into so much debt that you realize you have to practice, and practice well if you want to get out of that hole.”

I’m certainly idealistic about why I want to go to medical school. In fact, the struggle for me is deciding between larger scale health policy work–doing research, designing disease control programs, advocacy, etc.–and traditional clinical work, or how to balance both. I’ve never seen myself as one to get into private practice, or really even treating patients full-time as a traditional clinician. But the vortex sucks many people in.

The problem is ultimately not with the medical students who are drawn to dermatology and plastic surgery for the better pay. Medical students will inevitably be drawn toward the specialties that combine interesting work with the highest pay. From the NYTimes again:

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.

The market simply isn’t working here. We need more (many more!) primary care physicians. There’s a lot more demand for services there. But people who have the money to pay more for cosmetic treatments and surgery skew the demand away from those who don’t have the money to get adequate treatment for more life-threatening conditions like diabetes and high blood pressure.

I’m not sure what the solution is either. I know it would need to be a large-scale systemic change; merely getting pre-med students to read about Paul Farmer isn’t going to change everyone. Maybe having a single-payer system where doctors are compensated as much or more for basic services as they are for cosmetic services? Or maybe a loan-repayment situation where medical school is even more expensive, but all loans are automatically repaid by the government for those not going into specialties. Who knows. Suggestions?


If You Don’t Like to Think About AIDS, Don’t Read This.

June 10, 2007

Nicholas Kristof wrote a piece recently entitled “Save the Darfur Puppy.” I think he was going for getting a reaction with the title, and it worked, at least with me. You’ve probably notice that the media loves stories about endangered species–always cute, cuddly ones, never rodents–because people are moved by these stories. On the other hand, a crisis like the genocide in Darfur is unlikely to get airplay commensurate with its magnitude. And likewise with AIDS, which despite being of tragic scale–two or three flaming World Trade Centers full of people dying every day–rarely hits the news, in part because it’s the same old, depressing story, every day.

So, when I saw that Truthdig had an interview called “Stop Ignoring AIDS and Africa,” I gravitated light-wards. The piece is an interview of Stephanie Nolen, the author of a new book called “28: Stories of AIDS in Africa” which tells one narrative of a (real, actual, living and breathing) human being with HIV in Africa for every one million of the estimated 28 million living with the virus. I certainly plan on reading this book, but here’s what really caught my eye–this picture:

And its caption:

Bongos, an 8-year-old HIV-positive boy, waits in a hallway at the Sparrow Rainbow Village medical clinic in Johannesburg, South Africa, in November 2005.

This really hits home, because I volunteered at Sparrow back in 2005. They do incredible work, and my few weeks there were extremely moving. Sparrow is an orphanage and adult hospice–a “village”–where those with HIV are cared for. The corridor in the background is the central part of Sparrow’s administrative center, which connects some of the hospital rooms (for the sickest patients), a kitchen, administrative offices, and even a makeshift morgue. Because most of the patients there receive some level of antiretroviral treatment Sparrow is really, sadly, one of the best places to be in Johannesburg if you’re a kid with HIV.

Here are some compelling quotes from Nolen’s interview on Truthdig:

You show people a picture of one sad-looking puppy and everyone runs for their wallet, and you tell them that 30,000 children die a day of diseases that can be prevented for less than a buck and nobody gives a rat’s ass. I don’t know what it is, what that says about us as a species, but I certainly know from a long time reporting about HIV in Africa that it’s true.

On narrating an issue where the statistics are numbing:

Their lives could not look more different in some ways than the lives of an American or a Canadian. But when you sit down in the little counselor’s booth in Malawi or Lusaka and they say to you, “You have AIDS, you’re going to die,” that doesn’t feel different than it would if you were in America. And it’s getting people to realize that those people had all—sure, they’re Africans—but they had all those same expectations around their lives. They want to graduate from high school, they want to start a little business, they want to, you know, persuade that really cute girl they’ve been eyeing for a long time to go out with them. It isn’t any different. You’ve really got to go, go really micro to make people understand that story, to get them past the numbers.

On finding stories of progress:

You know, I think we get very often this perception of it being a grim story where not very much changes…We also don’t hear that huge progress has been made in responding. There were, for example, when I started reporting on this full-time, there were fewer than 100,000 people on treatments and today there are 1.5 million in Africa. And everybody said, “You can’t do it, there’s no way you can treat in Africa.” Well, that’s a 13-fold increase in four years, and those people have better survival rates on treatment than most Americans on treatment do. So lots of victories.

On money and broken promises and the real roadblock to widespread treatment programs (trained health care professionals):

And there’s a lot more money available than there was….They need about $6.8 billion to meet those proposals, and they have, you know, like, $1.85 in change. Constantly, countries promise money and don’t deliver or don’t promise anything like what’s needed to respond. So we need money. I think, even more than money, these days we’re realizing that there are some more intractable problems that are going to need more creative solutions. So you can use that money to fly in boxes and boxes of pills. You can’t fly in nurses, doctors, pharmacists. I mean, you can fly in a few, but not enough to meet the needs of a whole, continent-wide healthcare program, right?

On the underlying economic inequalities that drive the epidemic:

You know, I meet lots of young women who’ve been given information about HIV but who are selling sex down at truck stops because their parents have died, they’re raising their siblings and that’s the only option that they have. So, you know, they say, “Fine, we’ve been told about HIV in the safe-sex textbooks, but HIV might kill me in five years or 10 years and we’re all going to starve to death next week if I don’t do this.” So, you can address some of the obvious things around prevention, but unless you change the factors that drive people into risky behavior, then you haven’t achieved very much.

And, a bit further afield, but still in Africa, on Darfur and the war in Uganda:

And, you know, it’s also interesting to talk about Darfur because, yeah, there are probably 300, 350,000 dead there and a lot of people displaced, but it is in fact a far smaller conflict than the war in northern Uganda which has been going on for 21 years. You have four times as many people displaced in northern Uganda. You have four times as many people dead. Well, when did we last hear about that one, right? I mean, Darfur is suddenly sexy because George Clooney goes there and, meanwhile, the war in northern Uganda that relies almost entirely on child soldiers … you don’t hear about that one.

On Bush’s PEPFAR program (providing treatment for AIDS in Africa):

Well, you know, I’ve done a lot of call-in radio lately where people call up and are yelling about the Bush administration letting people die, and here they are, spending all these billions of dollars in Iraq. Why don’t they do something in Africa? So I say to people, “Well, guess what? Actually the $15-billion, five-year program to intervene for AIDS in Africa, that the Bush administration dreamed up, has been the single greatest response to the pandemic ever.” And then there’s kind of silence on the end of the phone, you know?

And its problems:

…They’re saying a group that’s going to get U.S. funds to distribute condoms or put AIDS programs in schools or care for sick people, has to sign a piece of paper condemning sex work. And that’s like crazy moral language that just has no place in a place where people are selling sex to eat.

I like Stephanie Nolen. And I like Truthdig.

(If you’d like to learn more about or donate to Sparrow, please do so!)


Shooting the Messenger

January 20, 2007

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Turkish journalist Hrant Dink was shot and killed in broad daylight on a street in Istanbul. Dink had been outspoken about the Ottoman genocide of Armenians at the start of the 20th century. While this may seem like ancient history to present-minded Americans, it plays heavily into regional politics in Turkey and Armenia. Many Turks think the killings were a justifiable part of a civil war, while Armenians see it as genocide (most non-Turkish sources I’ve read agree with the latter).

Being a prominent journalist about an unpopular issue is never an easy task. But in some places the messenger is more likely to get shot than in others. For example, I don’t think Anderson Cooper has gotten many death threats lately. (However, this may be a symptom of how any prominent journalist–especially American ones–pander to the system. If you’re not getting death threats or hate mail, your work might not be that important…)

So how big of a deal is calling the killing of Armenians genocide in Turkey? Evidently it’s illegal to insult the Turkish state (in America it’s mostly legal, just unpopular). From CNN:

Described as a “well-known commentator on Armenian affairs,” Dink had been called into court a number of times on allegations of “insulting” the Turkish state in his writing.

And apparently Dink isn’t the first Turkish journalist to be targeted for unpopular beliefs:

Joel Campagna, Mideast program coordinator for the Committee to Protect Journalists, said, “Like dozens of other Turkish journalists, Hrant Dink has faced political persecution because of his work. Now it appears he’s paid the ultimate price for it.”

Campagna said that Turkey “must ensure that this crime does not go unpunished like other cases in the past and that those responsible for his murder are brought to justice.”

He said that over the last 15 years, 18 Turkish journalists have been killed — making the country the eighth deadliest in the world for journalists in that period. He said many of the deaths took place in the early 1990s, at the peak of the Kurdish separatist insurgency.

Unlike Anna Politkovskaya, who was likely assassinated by the Russian government itself (for criticism of atrocities in Russia’s war on Chechnya), Dink’s death is more likely that of an Islamist or Turkish ultra-nationalist extremist (the assassin reportedly shouted “I shot the infidel”), categories which can often become blurred, but the Turkish government is anything but blameless for the overall situation:

Aram Hamparian, executive director of the Armenian National Committee of America, told CNN that the case is the “product of the environment that the Turkish government has created” — its persistent denial that the killings of the Armenians last century did not amount to genocide.

How Turkey handles this event, along with its relations with the Kurds, will also inevitably tie into Turkey’s desire to join the European Union. But while this killing raises political questions, it also brings me to a more philosophical inquiry.

Is there really a right to free speech? Do people inherently have an inalienable right to life, liberty, and the pursuit of happiness? Where do any of these rights come from? In the idealistic sense the answer may be yes, we have these rights, but many authors on human rights (Farmer ‘s Pathologies of Power comes to mind) would be the first to admit that they can’t “prove” rights. Nobody truly possessed a right to freedom of speech or freedom of religion until people decided that they had those rights, declared them, and made them a reality.

A right can exist as an ideal that has no real correspondence to actual conditions, but over time the ideal may come closer to realization. Our freedom of speech is still imperfect, but there are arguably more people in the world today who can speak freely than ever before. There will always be people and governments who will shoot the messenger, but if we shed light on and punish those who violate the right to speech, we may move closer to the ideal, if only incrementally. In the same sense, I hold that people have a right to health care–a right that is inseparable from our right to life–but recognize that this right is less realized in America than any other wealthy nation. The act of smoothing over the edges between the ideal and the reality is the whole pursuit of social justice.

Update: A suspect has been arrested in the case.


Letter to a Christian Nation

November 29, 2006

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That’s Mahmoud Ahmadinejad’s letter, not Sam Harris’s.

So what would posess the President of Iran to write a letter to the American people? Maybe he knows enough about the American press to realize that he’ll get lots of media coverage. And maybe he’s deluded enough to think that coverage will be positive. Nevertheless, I think it’s worthwhile to read some of his letter and offer a little critique.

“Both our nations are God-fearing, truth loving and justice seeking, and both seek dignity, respect and perfection. Both greatly value and readily embrace the promotion of human ideals such as compassion, empathy, respect for the rights of human beings, securing justice and equity, and defending the innocent and the weak against oppressors and bullies.”

I’m not sure the U.S. is quite as God-fearing these days as Mr. Mahmoud thinks. A poll in 1999 showed that only 63% of Americans believe God is “very important” in their lives. And, as the actions of Ahmadinejad’s regime to lessen the rights of women in Iran have shown (undoing years of work by Iranian liberals), profession of ideals relating to human rights is no substitute for really defending them.

“You know well that the US administration has persistently provided blind and blanket support to the Zionist regime, has emboldened it to continue its crimes, and has prevented the UN Security Council from condemning it.”

True, though I would have worded it a bit different (one can and should criticize Israel, but calling it “the Zionist regime” just turns off your American readers…). Our veto on the UN Security Council has been used more than any other coutntry’s, almost exclusively in protecting Israel from (sometimes legitimate) criticism.

“Who can deny such broken promises and grave injustices towards humanity by the US administration?”

Err.. American conservatives? Oh wait, that’s rhetorical.

“The legitimacy, power and influence of a government do not emanate from its arsenals of tanks, fighter aircrafts, missiles or nuclear weapons. Legitimacy and influence reside in sound logic, quest for justice and compassion and empathy for all humanity. The global position of the United States is in all probability weakened because the administration has continued to resort to force, to conceal the truth, and to mislead the American people about its policies and practices.”

He’s right about legitimacy- it stems from justice and compassion. But power and influence stem from military, economic, and cultural power, all of which we’ve been happy to employ in our commonly realpolitik international relations. The illusion of American exceptionalism may convince many American citizens that their country’s actions are for the good of the world just as Muslim fanatics in Iran are convinced that forcing their religion on others is really what’s best for them.

“We all condemn terrorism, because its victims are the innocent.”

But Mr. Ahmadinejad, you do a decidely poor job of condemning terrorism.

“What have the Zionists done for the American people that the US administration considers itself obliged to blindly support these infamous aggressors? Is it not because they have imposed themselves on a substantial portion of the banking, financial, cultural and media sectors?”

Uh oh.. Here comes the whole worldwide Jewish conspiracy again. Powerful Jewish lobby? Sure. Overzealous, scary premillenial dispensationalists? Definitely. But worldwide Jewish conspiracy? Definitely not. (My friend Mr. Steinman told me so.)

And to the Democrats:

“Now that you control an important branch of the US Government, you will also be held to account by the people and by history.”

Thanks buddy. Glad you’re watching out for us.

“It is possible to lead the world towards the aspired perfection by adhering to unity, monotheism, morality and spirituality and drawing upon the teachings of the Divine Prophets. Then, the American people, who are God-fearing and followers of Divine religions, will overcome every difficulty.”

I’m not sure if the religious zealots in both our countries would very well in agreeing on which Prophets to follow. Unity and monotheism sound great, but when people can’t decide what to be unified about (look at denominationalism in Christianity and Islam) or which monotheistic God (and which book He wrote) to follow, unity is often another way of saying “my way is the only perfect way.”

Aspiring to perfection gives me mixed feelings. Yes, we should always try to improve, but the illusion that real perfection is possible is dangerous. It reminds me of a quote from the introduction to Francois Bizot’s The Gate, a first-hand account of his captivity in the killing fields of Cambodia. Bizot writes,

“I detest the notion of a new dawn in which Homo sapiens would live in harmony. The hope this Utopia engenders has justified the bloodiest exterminations in history.”

I think there is a middle ground, a way to envision a world that is better- more just, more peaceful, more free, more prosperous, more equal- without knowing that it is possible within one’s lifetime. But we should always strive to move closer to that ideal, even if the ideal may never be realized. Don’t let visions of revolutionary change- religious or not- stand in the way of gradual steps up.

Or, as Paul Farmer says, “Don’t let perfect be the enemy of good.”


Quotes for Thought

October 18, 2006

Some quotes to ponder from two of my favorite doctors…

Dr. Jim Kim:

“There are more billionaires today than ever before. We are talking about wealth that we’ve never seen before. And the only time I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people.”

“Farmer got hold of a pamphlet about how to equip labs in third world places published by the World Health Organization. It made modest recommendations. You could make do with only one sink. If it wasn’t easy to arrange for electricity, you could rely on solar power. A homemade solar-powered microscope would serve for most purposes. He threw the booklet away. The first microscope [at Partners in Health’s medical clinic in] Cange was a real one, which he stole from Harvard Medical School. ‘Redistributive justice,’ he’d later say. ‘We were just helping them not to go to hell.'”

Paul Farmer:

“God gives us humans everything we need to flourish, but he’s not the one who’s supposed to divvy up the loot. That charge was laid on us”.

“I recommend the same therapies for all humans with HIV. There is no reason to believe that physiologic responses to therapy will vary across lines of class, culture, race or nationality.”

“In an era of failed development projects, and economic policies gone bad, I sometimes feel very lucky as a physician, since my experience in Haiti has shown me that direct services are not simply a refuge of the weak and visionless, but rather a response to demands for equity and dignity.”

“Shuttling back and forth between what is possible and what is likely to occur is instructive and a lot of what shapes our sentiment.”

“I critique market-based medicine not because I haven’t seen its heights but because I’ve seen its depths.”

“For me, an area of moral clarity is: you’re in front of someone who’s suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act.”


Partners in Health

October 18, 2006

Boston was amazing. I wrote a report for the group that funded my trip, and I realized it would make a decent blog post. And I got to meet Paul Farmer, who’s basically my hero/role model in many ways. I don’t think it quite qualifies as a “hero” because that implies you idolize the individual. Dr. Farmer is a figure worth looking up to because of his extraordinary work ethic, the good he’s been able to accomplish for global health, and the fact that he is an icon for like-minded individuals.

Partners in Health’s 13th Annual Thomas J. White Symposium was attended by approximately 1500 people–students, volunteers, admirers, and donors of all ages–at the Kresge Auditorium on the campus of MIT in Cambridge, MA. Partners in Health (PIH) is a non-profit organization that has grown over the past two decades to include 4000 employees in Boston, Haiti, Russia, Peru, Guatemala, Rwanda, Lesotho, and soon in Malawi, who last year provided health care to over 1 million people, including 1000 on antiretroviral treatment for HIV. PIH has had a significant impact on global health policy because of the personal dedication of its founders and the principles on which it is founded, which were expressed well by the 2000 People’s Health Assembly in Savar, Bangladesh; “The attainment of the highest possible level of health and well-being is a fundamental human right”.

The symposium, designed to summarize the past year’s activities, and to outline the policy and programmatic struggles to come, began with remarks by Ophelia Dahl, Executive Director of Partners in Health, on the last year’s expansion of PIH�s operations into Rwanda. A video was shown that highlighted the adaptation of clinical models developed in Haiti, incorporating HIV and TB treatment with community health workers and housing support, for Rwanda.

The keynote address was given by Dr. Jim Yong Kim, current head of Harvard’s Division of Social Medicine, and co-author of Women, Poverty, and AIDS. About ten years ago, Dr. Kim and Dr. Paul Farmer, cofounders of PIH, demonstrated the possibility of treating patients with HIV and Multi-drug-resistant Tuberculosis (MDR-TB) in resource-poor settings. Their research findings changed World Health Organization policy, which had previously recommended against treatment in impoverished countries. Dr. Kim recently spent three years in Geneva as the director of the World Health Organization’s AIDS program, where he pioneered a campaign to get 3 million poor patients on HIV treatment by 2005. He spoke of the triumphs and pitfalls of working within the WHO bureaucracy, of which he was previously a well-known critic. While lauding the continuing research into new cures, Dr. Kim also introduced a new program at Harvard Medical School in Global Health Effectiveness, helping to improve worldwide access to therapies currently available in high-income countries.

Dr. Paul Farmer, who has become a minor celebrity to students of international health and development after being featured in Tracy Kidder’s Mountains Beyond Mountains, spoke charismatically about the interconnection of social and economic factors with the health of the poor, and about the continued need for an equity plan to prevent and cure treatable diseases worldwide. He also praised donors like Thomas J. White, the millionaire who made PIH’s early work possible, and in whose honor the annual symposium is held.

Other presenters included Lucette Fetire, a Haitian HIV patient and advocate who told her story of how PIH first treated her, then empowered and employed her as a community health worker to help her HIV+ neighbors. Dr. Ludmilla Kashtanova, director of PIH�s Russian programs, talked of treating MDR-TB in Russian prisons, and changing the course of Russian policy to prevent further spread of the disease. Veronica Suarez Ayala and Jason Villarreal, community health workers for PIH in Peru and Boston respectively, shared stories of their patients, sometime succumbing to disease, and sometimes recovering to help others.

Personally, I found the event extremely affirming and encouraging. Meeting many likeminded undergraduate and medical students was uplifting, and being in a large crowd that affirmed a belief I strongly hold�that people should not die of treatable diseases regardless of their country of birth�only helped crystallize my goals.