Necessary Angels

As I work towards entering a career in medicine I am sometimes overwhelmed by the incredible barriers to entry. Where, after working so hard to be trained to save lives and help people improve their health I can still only help one person at a time. I would like to think that I could get a better rate of return. Or more acurately, I would like to think that I could invest myself in a way that would have a profound ripple effect, helping to improve the lives of more people than the one person I can treat at a time.

I found this article while I was reading the December 2008 issue of National Geographic (NGS). I was left feeling very hopeful and inspired for the future of health-care in the world. I believe it is accurate that every country in the world has a shortage of providers, especially primary care providers. The idea of the world being short by 2.3 million physicians, nurses and midwives (according to this this WHO study) makes a prospective physician pretty sure that he'll have something to do in the future. Unfortunately, according to this same study, the economic demand for health care providers will be almost satisfied by 2015. Oh! don't get me wrong. We'll only be scratching the surface of those 2.3M needed providers. But even the providers who are trained in the countries that need them leave those under served areas to seek employment in wealthier areas that can provide them with a better comfort to skill ratio. The illustration below was pulled from this follow up article in NGS.


True, even the US has a need based shortage of providers right now, and we seem to have money to pay them - not only to pay them but to retain them. We have an amazing system set up to provide incentive to emerging physicians to focus on primary health care and to practice it (at least for a time) in an under served area of the U.S. This is fantastic. But what about say Ghana, or any of the other 30 odd countries that are predicted to still have major deficits in health care provision long into the foreseeable future. Illustrated above are 45 different physician producing nations, many of which still have major deficits in health-care provision. Doctors want to get paid!

I almost hate to say it. But it's unfortunate that physicians have to be paid so much. The financial barriers to entry, the ever ominous malpractice nightmare and the growing expense (in more developed countries) of technological standards in medicine drive the cost up and up. Not to mention that spending 11+ years after high school making zilch dough to endure what is un-arguably one of the most grueling secondary educational experiences in the world leaves many doctors with an overdeveloped sense of entitlement and very little energy or patience to do anything but maximize their comfort to skill ratio. Compound that with the growing case that most doctors and nurses (especially specialists) are trained to work in/with high tech developed facilities where even if they wanted to go work for pennies in a place that needed them more they would be up sh** creek without a paddle.

As a doctor there are a few key procedural skills that I would feel naked without in any country, any specialty, at any time of day: performing topical sutures, removing bullets, and delivering babies. Personally I have had more stitches than babies. But I hear babies are pretty common. Fortunately, delivering a baby is one medical procedure that it is not overly difficult to train a "lay person" how to do (including training them to know when they are in over their head). This brings me back to the hope. The example that was illustrated in the Necessary Angels article showed me that so SO much could be done for un(der) developed countries to fill in the need for much health care without having to export millions of physicians to those countries. In developed countries people are at risk to die from things that mostly take highly trained physicians/practitioners to remedy. In un(der) developed countries people die from things that could be reduced by education and sanitation. What Raj Arole demonstrated in Jamked was that: 1) a passionate lay person can be moderately trained to administer rudimentary primary care and to educate their community, and that 2) a little bit of attention from a moderately trained lay person can make a serious impact in improving the quality of life in underdeveloped areas. Instead of proposing that a way be found to educate doctors "for free," I would argue that it would not only be more efficient, but possibly even more effective to provide funding for and train a handful of the members in underdeveloped communities to provide the kind of care that we see in Jamked.

I like to get more than a 1:1 return on my investments. This story of passionate women and physicians in India gives me hope that as a doctor I will not just be buying into a great tragedy of the information age. I hope that one day in a world far from the one I live in now I may be helping to implement health-care for more than just one person at a time.