Third World Health: Hostage to First World Wealth
http://www.100md.com
《新英格兰医药杂志》
What would the state of your health be if you had to live on less than $1 a day? Théodore MacDonald does not ask this question directly, yet it haunts his book, which documents how 1.9 billion people deal with the issue daily.
MacDonald's well-written account of the plight of too many people stirs outrage, as it should, in any conscientious physician. Its purpose, like that of any creditable clinical report, is reasoned engagement, not the venting of emotion. The book reads like a bedside chart, with accurate detail on the patient's condition leading to a clear sense of cause and effect. With the exception of the distracting use of many "in-house" abbreviations (the bane of many medical charts), it makes for fine reading.
For its chief complaint, the book offers a list of current widespread health problems, including severe malnutrition, malaria, AIDS, tobacco-related diseases, and tuberculosis — all of them treatable or preventable, but out of control. MacDonald's review of systems locates the nidus of these health problems in the international economic system, in particular the overbearing debt that developing nations owe to developed nations. Certain health problems appeared after World War II, as a result of the ill-fated good intentions of wealthy nations toward less fortunate nations. The World Bank and the International Monetary Fund (IMF) were created to lend money to poor nations to aid in dam construction, agriculture, lumber production, and mining. The IMF secured the cash to lend by selling the "paper" on world financial markets.
International bankers expect a return on their investment, but lending money to those who are too poor to pay interest turns out to be a financial non sequitur. New debt piled on old debt is not useful. To address this contradiction in logic, the World Bank along with the IMF stepped in with stipulations of change — a license to do what the borrower nation was considered unable to do: manage its country "profitably." Then, like a sheriff at a foreclosure sale, these financial organizations cleaned out the delinquent nation's assets — its natural resources — and the existing funding of health care and educational systems. And all of these difficulties have been aggravated by opening the borrower nation to exploitation by international corporations — what would be called "free trade" in the First World's subsidized markets.
For most of us physicians, this kind of money-lending may seem to be a bone-dry business routine, leading us to ask, "What has this got to do with the way I practice medicine?" Although MacDonald does not drive home how this situation in developing nations affects physicians in developed nations directly, a moment's challenge to our professional sensibilities makes the connection. Recollect, if you will, the number of physicians and nurses from the developing world who work within the scope of your practice. Then consider that number in relation to the number of local clinicians who have migrated from your area to practice in the developing world. What does the ratio tell you? Do I hear you explaining, as MacDonald would, how it makes economic sense for your local hospital to import nurses and doctors, albeit indirectly, since you pay them a better salary than sick people in their own countries can afford to pay? If you do, you are supporting the idea of our world as an open marketplace that belongs to those who can pay.
MacDonald describes this situation as a plague of institutionalized greed, using case histories of countries such as Brazil and Mexico, which have been brought to the edge of bankruptcy. He explains the strategies used by international corporations, including Nestlé, to convert women in developing countries from breast-feeding to the use of processed formula. In the area of education, the stipulations of change have eroded the funding of South Africa's school system. In health care, few instances of involvement in the profitable production of illness are more blatant than that of the British American Tobacco Corporation's planned development of China's market of 300 million cigarette smokers.
Conscientious clinician that he is, MacDonald does not leave the reader in despair. A ray of hope appeared after this book was published in the form of an attempt to reduce the atrocious exploitation of Third World debt. Welcome as this possibility may be, the author's recommendation is broader than only economic. The need is for those of us living in developed nations to grasp that our environment is the world, not a "gated" environment guarded by our national wealth. The disease and disorder in developing nations are spilling over into the parochial world of developed nations. MacDonald encourages everyone, including physicians, to define the world properly — not according to geography, but according to the immediacy of human suffering.
Read this excellent account of where you fit into the world of human suffering — read it as carefully as you would a textbook on human disease, and think deeply about the relationship between the message of this book and how you live your life. Start by asking yourself what the state of your family's health would be if each member were living on $1 a day. Then assert your professional will.
Ralph Crawshaw, M.D.
Oregon Health Sciences University
Portland, OR 97201
rckos@imagina.com(By Théodore H. MacDonald.)
MacDonald's well-written account of the plight of too many people stirs outrage, as it should, in any conscientious physician. Its purpose, like that of any creditable clinical report, is reasoned engagement, not the venting of emotion. The book reads like a bedside chart, with accurate detail on the patient's condition leading to a clear sense of cause and effect. With the exception of the distracting use of many "in-house" abbreviations (the bane of many medical charts), it makes for fine reading.
For its chief complaint, the book offers a list of current widespread health problems, including severe malnutrition, malaria, AIDS, tobacco-related diseases, and tuberculosis — all of them treatable or preventable, but out of control. MacDonald's review of systems locates the nidus of these health problems in the international economic system, in particular the overbearing debt that developing nations owe to developed nations. Certain health problems appeared after World War II, as a result of the ill-fated good intentions of wealthy nations toward less fortunate nations. The World Bank and the International Monetary Fund (IMF) were created to lend money to poor nations to aid in dam construction, agriculture, lumber production, and mining. The IMF secured the cash to lend by selling the "paper" on world financial markets.
International bankers expect a return on their investment, but lending money to those who are too poor to pay interest turns out to be a financial non sequitur. New debt piled on old debt is not useful. To address this contradiction in logic, the World Bank along with the IMF stepped in with stipulations of change — a license to do what the borrower nation was considered unable to do: manage its country "profitably." Then, like a sheriff at a foreclosure sale, these financial organizations cleaned out the delinquent nation's assets — its natural resources — and the existing funding of health care and educational systems. And all of these difficulties have been aggravated by opening the borrower nation to exploitation by international corporations — what would be called "free trade" in the First World's subsidized markets.
For most of us physicians, this kind of money-lending may seem to be a bone-dry business routine, leading us to ask, "What has this got to do with the way I practice medicine?" Although MacDonald does not drive home how this situation in developing nations affects physicians in developed nations directly, a moment's challenge to our professional sensibilities makes the connection. Recollect, if you will, the number of physicians and nurses from the developing world who work within the scope of your practice. Then consider that number in relation to the number of local clinicians who have migrated from your area to practice in the developing world. What does the ratio tell you? Do I hear you explaining, as MacDonald would, how it makes economic sense for your local hospital to import nurses and doctors, albeit indirectly, since you pay them a better salary than sick people in their own countries can afford to pay? If you do, you are supporting the idea of our world as an open marketplace that belongs to those who can pay.
MacDonald describes this situation as a plague of institutionalized greed, using case histories of countries such as Brazil and Mexico, which have been brought to the edge of bankruptcy. He explains the strategies used by international corporations, including Nestlé, to convert women in developing countries from breast-feeding to the use of processed formula. In the area of education, the stipulations of change have eroded the funding of South Africa's school system. In health care, few instances of involvement in the profitable production of illness are more blatant than that of the British American Tobacco Corporation's planned development of China's market of 300 million cigarette smokers.
Conscientious clinician that he is, MacDonald does not leave the reader in despair. A ray of hope appeared after this book was published in the form of an attempt to reduce the atrocious exploitation of Third World debt. Welcome as this possibility may be, the author's recommendation is broader than only economic. The need is for those of us living in developed nations to grasp that our environment is the world, not a "gated" environment guarded by our national wealth. The disease and disorder in developing nations are spilling over into the parochial world of developed nations. MacDonald encourages everyone, including physicians, to define the world properly — not according to geography, but according to the immediacy of human suffering.
Read this excellent account of where you fit into the world of human suffering — read it as carefully as you would a textbook on human disease, and think deeply about the relationship between the message of this book and how you live your life. Start by asking yourself what the state of your family's health would be if each member were living on $1 a day. Then assert your professional will.
Ralph Crawshaw, M.D.
Oregon Health Sciences University
Portland, OR 97201
rckos@imagina.com(By Théodore H. MacDonald.)