What Physicians Can Do to Reduce Inequity in Global Health

Early in his keynote address, James Orbinski, MD, Senior Fellow at the University of Toronto and one of the world’s leading scholars and scientists in global health, complimented the United States on the recent passage of its health care bill, a “seminal achievement” that he said brought the US “just a hair’s breadth away” from achieving universal health care. But he was quick to point out that Canadians enacted universal health care 45 years earlier.

Canadians, he said, have an abiding concern for equity. If he is right, then Dr Orbinski represents what is greatest in Canadian medicine. His career has been dedicated to the promotion of equity in global health-and his address was devoted to providing examples of the great good physicians can do when they set their sights on reducing health care inequity. He exhorted his audience to join in such efforts.

Equity in health care, he pointed out, is a deeply political question, not just a humanitarian one. He quoted Disraeli: “The health of the people is the foundation on which all their happiness in the state depends.” However, the fact that health care equity is a political issue by no means rules out a role for physicians.

Speaking out. “The first political act is to speak,” Hannah Arendt famously said. Dr Orbinski offered an example from his own career of the great good that can be accomplished by simply speaking out. He was the head of the Doctors Without Borders mission in Kigali during the Rwandan genocide of 1994. Doctors cannot undo genocide, Orbinski noted, but he added that doctors have a responsibility to speak out against this horrific crime. During the Rwandan genocide, Doctors Without Borders did speak out-with a clear voice. In response to what “nonpolitical people” such as Doctors Without Borders were saying, courageous politicians created the ICC. Eventually (in 2003) the leader of the genocide was arrested and accused by the new ICC of genocide. (For his leadership in Rwanda during the genocide, Dr Orbinski was awarded the Meritorious Service Cross, Canada’s highest civilian award.)

Taking effective action. Another essential element in the promotion of equity is effective action. Kindness is not enough, Dr Orbinski said. Nor does the answer lie in ideas: ideas must be acted on by engaged citizens. Dr Orbinski’s career is replete with examples of just this kind of engaged action.

Deeply disturbed to see the numbers of people who were dying of HIV/AIDS in South Africa because they had no access to antiretroviral medicines, he launched Doctors Without Borders’ Access to Essential Medicines Campaign. By pooling purchasing power to buy generic versions of antiretrovirals, the organization has reduced the cost of a course of treatment that once cost South Africans $13,000 to a price of less than $88. The same year that Dr Orbinski began the Access to Essential Medicines Campaign, he accepted the Nobel Peace Prize on behalf of Doctors Without Borders for its pioneering approach to medical humanitarianism.

In 2003, Dr Orbinski inaugurated the Doctors Without Borders Drugs for Neglected Diseases initiative. The aim of this initiative was to develop drugs for illnesses to which pharmaceutical companies have not devoted resources because of the confinement of these diseases to the developing world. To date, the program has developed two new antimalarials and a new treatment for African Sleeping Sickness.

Dr Orbinski’s latest effort is the establishment of Dignitas International, an organization he started after seeing the need for communities in the developing world to be able to confront their health care needs on their own – especially the needs of people with HIV/AIDS. Dignitas fosters community-based care by training nurses and community health workers and by developing simplified algorithms that can be more easily implemented by these non-physician health care personnel. By the end of this year, as many as 3 million persons in Malawi will be receiving services through Dignitas’ efforts.

Addressing health inequity at home. Lest his listeners be discouraged and go away feeling that endeavors of this sort were not feasible for them, Dr Orbinski pointed out another facet of the problem of global health inequity that could-and perhaps must-be addressed closer to home: this is the problem of the brain drain in the developing world. Between 24% and 28% of physicians in the United States and Canada are foreign-born. Dr Orbinski emphasized the need to develop effective recruitment and training policies here in the United States and Canada that can satisfy our need for doctors with native physicians and thus reduce the reliance on foreign physicians that perpetuates the brain drain.

Despite the magnitude of the inequity in global health care, Dr Orbinski struck an emphatically optimistic note in his address. “We are capable of extraordinary things,” he said, citing the example of Barack Obama’s election to the presidency of the United States, something that could not have been imagined when Dr Martin Luther King, Jr. gave his “I have a dream” speech 40 years earlier. “We can get there with the right kind of engagement, the right kind of politics, the right kind of doing,”he concluded.