Thursday, December 9, 2010

Jeffersonian Insights on Public Health

I recently gave a presentation to medical students and faculty at the University of Virginia organized by their Center for Global Health. UVA has a strong tradition in tropical infectious disease work in developing countries, with groundbreaking research addressing diseases such as leishmaniasis. However, like many other institutions, UVA has recently seen a broad swell of interest on a range of global health issues amongst its student population and I had been asked to address the medical school on thinking at Columbia about emerging challenges in the field.

I had anticipated that my slides arguing that chronic, rather than infectious disease stands to be the focus of greatest preventable mortality in the coming years to be the most controversial. But it was one of my slides in the section talking about globalization and the broader political and economic changes that are shaping the landscape of global health that drew the strongest reaction. Squeezed between slides depicting Chinese investment in health infrastructure in sub-Saharan Africa and material outlining development in communications technology was – for me – a ‘commonplace’ graphic. It depicted the decline in the health workforce across Africa since the year 2000, with international migration to the developed world one of the major factors contributing to a declining available capacity to address escalating needs.

Touched on briefly during Q&A, a moving email on the topic hit my inbox shortly after the lecture. It asked for a copy of this slide so that the writer – a medical student with experience of working in Uganda – could share this evidence with friends and family of the ‘north’ drawing resources from a ‘south’ that could so ill-afford such hemorrhage. I was touched by her commitment to advocacy and, if truth be told, a little envious of the clarity with which she saw a moral issue on which I have become somewhat jaded by complexity and pragmatism.

Coincidence makes bad science. But it can valuably fertilize the imagination. The following day I was touring the Monticello estate on the outskirts of Charlottesville, which has been restored to the condition in which Thomas Jefferson spent his retirement years. The house and gardens were wonderful, but it was the ‘Plantation Community Tour’ – visiting the remains of the homes and workshops of the slaves on whose labor the estate depended until the time of Jefferson’s death – that was most compelling. We had noted in the house how Jefferson had seen slavery as an "abominable crime" and a "moral depravity”. But he continued to hold slaves to the end of his life, with the crucial economic role they played in the operation of his estate and his deep indebtedness (which saw slaves sold on his death to pay creditors), clearly a major barrier to translating his moral conviction to economic practice.

There was much complexity and pragmatism operating in Jefferson’s 18th century calculus on the issue of slavery. 250 years later we recognize his moral impulse to be profoundly correct and his economic compromise to be profoundly indefensible. The voluntary movement of doctors and nurses from Africa to the developed world is a radically different phenomenon from the forced movement of Africans centuries before. But there are enough parallels in the hegemony of a political and economic order to cause one to wonder at the casual acceptance of gross inequality in the human experience. When visitors to a futuristic museum of global health in the 21st century learn that movement of doctors from settings where there is one physician for 50,000 people to settings where there is one for every 500 was seen as an inevitable consequence of our global economic system, how will they judge us? I fear my own rationalizations on the issue sound rather too like Jefferson’s on slavery. My hope lies in the passion of that medical student and thousands like her that see global health not as a career specialization but as a moral quest.

Alastair Ager is Professor of Clinical Population and Family Health at the Mailman School of Public Health, working with the Program on Forced Migration & Health. He serves of Executive Director of the Global Health Initiative.