In the beginning of his excellent article about cost effectiveness in global health, Leslie Roberts gives us this story of a resident physician on an international rotation who was inspired to save a child’s life.
Last year during his internship in a Thai refugee camp, he encountered a child suffering from a treatable form of cancer… He proposed to the director of his fellowship that she simply spend the fellow’s travel budget for the next year to pay for the boy’s treatment. When the director refused, he roped me in by e-mail, assuming I would support his position. I suspect he was more than a little stunned when I wrote back saying I thought that he as a doctor was a credit to the Hippocratic Oath, but that I considered his proposal to be public health malpractice.
This story is worth quoting in full because it illustrates a very interesting and contentious paradox in global health ethics: the conflict between a medical perspective and a public health perspective.
“Global health”, as a discipline, is a nexus between the fields of public health and medicine. As such, those working within the field often must wear multiple hats – or perhaps it would be more appropriate to use the metaphor of capes, with their overtones of heroism. As the old parable in public health circles goes, when a physician sees a man drowning in a river, he leaps in to pull the man ashore and save his life. As drowning victims continue to be swept downsteam, the physician continues to spring into the river to rescue them – but the public health practitioner begins to run upstream to investigate why so many people have fallen into the river in the first place. In the world of health, both types of heroes are necessary. So, what happens when the same hero is forced to don a new cape?
We can see this conflict in action each time a student, resident, or physician serves on their first international rotation in a resource-limited setting. These healthcare providers are trained within a system in which a patient can command the forces of the most advanced and expensive technologies be deployed for their health, simply by stating “I want heroic measures to be taken to preserve my life, at all costs.” How does one adapt when moving from such a system to a new system in which even the most elementary lifesaving interventions are denied routinely to patients on the basis of cost? Surely such an experience could be expected to induce post-traumatic stress disorder, as it can certainly be seen to consist of a series of traumatic events which, as the DSM-IV puts it, “involve actual or threatened death or injury…. [to] others.”
Being confronted by the reality of poverty and disease in a low income country forces a person to confront their helpless feelings at the magnitude of the problems. It removes one of the commonest barriers to action, which is the physical distance of those in need from the person who can provide aid. In Jonathan Glover’s essay, Poverty, Distance, and Two Dimensions of Ethics, he discusses distance as a source of paralysis for the public in regards to taking action to rescue those in poverty: “If any of us had to be in [a place where we witnessed the preventable deaths of children every day], we would be overwhelmed by the horror and sadness of it all, and overwhelmed by the moral urgency of putting a stop to these preventable deaths of children.” He also points out another source of paralysis that remains for travelers during their visit, which is the seeming vastness of the problems at hand. Visiting healthcare practitioners who provide clinical care are faced with a daily onslaught of humanity suffering from preventable diseases, and at the same time, must consider the fact that the same situation is playing itself out in countless clinics in villages and cities around the world. Denial is futile.
It is not unusual for the travelers in these circumstances to seize upon a single case – a case involving such a medical atrocity that it seems particularly impossible to ignore; for example, a horribly disfigured child – and then to set out to raise the funds to ensure that this case, at least, is treated. The idealist in question may even transport the patient to the United States for treatment, arranging flights and lodging and all the necessities. This is what I call the starfish effect. Why starfish? It all goes back to another parable. In this story, two people meet on a beach covered for miles with innumerable dying starfish. One of them is busy picking up the starfish and throwing them back in the water. The other one questions this, saying “There are so many starfish! You can’t possibly make a difference.” At which point the starfish rescuer smiles, throws another starfish back into the waves, and says “I made a difference for that one.” This parable is generally used to try to inspire those who may be feeling paralyzed by the scope and enormity of a problem.
The starfish approach to healthcare, in Dr. Roberts’ view, constitutes public health malpractice. After all, public health takes a step back from the individual patient to look at the population. At the population level, it is easy to see why spending $10,000 on a single child’s cancer treatment could be viewed as a crime. Funds that are spent on one patient’s treatment are funds that cannot be spent on others. Thousands of other children are dying for want of interventions costing much less – penicillin, vitamins, artemisinin. So what is it that drives the visiting students or physicians to ‘adopt’ a case, to passionately spend large amounts of energy, money, and time on a single patient? It appears impossible to morally justify this practice.
On the other hand, the starfish effect can motivate us to continue pushing in the Sisyphean effort that is the provision of healthcare. It can provide a focal point for our horror and hopelessness, and a shield against the crush of cynicism and apathy. Spending ten thousand dollars to save a life is the sort of grand gesture that can comfort an idealist wondering if their work really made a difference. Spending ten dollars each to help a thousand people forces one to acknowledge that there are many others suffering, and that what an individual can do to help is and will always be a drop in the bucket. I find myself morally opposed to adopting a starfish approach to global health work, having been fully indoctrinated at this point with a public health, utilitarian mindset. But if there is a way to keep oneself from tiring in an unwinnable battle without such motivation, I haven’t found it yet.
Alison Schroth Hayward, MD, is a board certified emergency medicine physician in Connecticut. In 2003, she co-founded a nonprofit called Uganda Village Project, and currently serves as the Executive Director. Any expertise she has in global health ethics has mainly resulted from making all the mistakes already herself, and trying to learn from them.
Glover, J. “Poverty, distance, and Two Dimensions of Ethics.” Global Health and Global Health Ethics. Eds. Solomon Benatar and Gillian Brock. Cambridge: Cambridge University Press, 2011. 311. Print.
Roberts, L. A plea for cost-effectiveness, or at least avoiding public health malpractice. Am J Public Health. 2009 September; 99(9): 1546–1548.