Saturday, June 28, 2014

What Ramadan Can Teach Us in the Struggle for "Health for All"

"In 20 years from now, at the half century of Alma-Ata, we could see a different world, with basic health care reaching many of the poorest families.  However, to achieve this goal, we have to revitalize the original revolutionary principles of Alma-Ata, sticking consistently to the core values of universal access for care, equity, community participation, intersectoral collaboration, and appropriate use of resources."
—Lawn et al, Alma-Ata 30 years on: revolutionary, relevant, and time to revitalize
This Ramadan (the Islamic month of fasting), I find myself reflecting on the 1978 Declaration of Alma-Ata, a groundbreaking achievement in the history of public health.  Adopted at the International Conference on Primary Care in Almaty, Kazakhstan, the Alma-Ata Declaration defined a comprehensive approach for addressing poverty, ill health, and malnutrition that shifted the focus from biomedical interventions alone to the inclusion of social determinants, from hospitals alone to entire communities, in the struggle to attain equity and social justice in global health.

Alma-Ata and the Lessons of Ramadan

While the Alma-Ata Declaration most immediately resonates with the enshrining of health as a human right in Islam, I believe that its connection to Muslim ethics in general and Ramadan in particular extends even further, reaching toward the very heart of this month's teachings.  The ritual of fasting provides a means of not only cultivating God-consciousness but also encouraging collective empathy and the provision of basic necessities to the poor.  This is emphasized by the Qur'anic instruction for Muslims incapable of fasting to feed one indigent person for each day of Ramadan that is missed (Qur'an, 2:184).  The guidelines of the Alma-Ata Declaration, which establish a commitment to providing basic health services at the local level and rectifying gross inequities in health, are thus intimately related to these lessons of Ramadan.

I would argue, however, that fasting also offers to teach us something less obvious and more meaningful about the nature of social justice, something never explicitly mentioned in the Alma-Ata Declaration, and that is the need for sacrifice.  There exist many well-intentioned individuals who, in the words of physician-anthropologist Paul Farmer, "think all the world's problems can be fixed without any cost to themselves."  Central to the practice of fasting, beyond empathy and charity, is voluntary abstention for a time from what is otherwise accessible, without which the act of worship is incomplete.  For public health and medicine in an age of energy scarcity, similar discipline and sacrifice in the face of unsustainable practices of consumption may be the only means of making lasting progress toward the vision of the Alma-Ata Declaration.

Peak Oil, Health, and Healthcare

The reason for this is that the remarkable improvements in health achieved by low- and middle-income countries in recent decades are increasingly threatened by peak oil, or the predicted peak and decline in global production of petroleum products.  While many disagree on the timing and nature of the "peak," imminent changes in the price and availability of crude oil are predicted to severely affect the health and nutrition of poor communities, whose populations and health systems are extremely vulnerable to fluctuations in food and fuel prices.  Even without the additional implications of climate change and environmental degradation, the challenges of peak oil threaten to directly and indirectly exacerbate existing problems of poor governance, armed conflict, shortages of health workers, and dependence on foreign aid in the face of growing population size.

While generally absent from the lexicon of heath professionals, there is little doubt that peak oil is intimately tied to our modern healthcare system, which is largely built around the use of petroleum-based products or production methods.  Perhaps the most notable of these are plastic disposable products in the hospital waste stream, which continue to occupy limited landfill space and partly explain the contribution of healthcare costs to oil prices.  Moreover, overuse of various lab tests, high vehicle use among healthcare personnel, and the overall dependence of healthcare on the transportation sector add to the problem.  With declining availability of cheap oil, the healthcare system will inevitably need to adapt to survive by substantially curtailing energy consumption and resource waste.


As Muslims around the world refrain from consuming food or drink during the daylight hours this month, my thoughts are consumed by the relevance of fastingthe embodiment of sacrifice and moderationto the impending threat of peak oil to the health of all.  In this crisis of consumption where neither the blame nor cost is equally shared by all communities, empathy toward those in most need among us must be central to the future directions of our collective response.  For all of these reasons, I pray that the lessons of Ramadan can help guide us as we seek ways to adapt to the growing challenge of peak oil while preserving the vision and commitment of the Alma-Ata Declaration to equity, social justice, and health for all.

Sunday, June 15, 2014

The Eastern Medicine Revolution? Not Quite

"The Eastern Medicine Revolution?" These were the words emblazoned across the screen behind Dr. David L. Katz, founding director of the Yale-Griffin Prevention Research Center, as he discussed the growing popularity of holistic integrative medicine on a recent edition of the Katie Couric Show. The conversation centered on the opening of Cleveland Clinic's Chinese herb therapy ward in January of this year, the first of its kind at a major US hospital. Dr. Katz argued—convincingly, I might add—that some instances where "alternative" medicines are criticized for lack of sufficient supporting evidence are more attributable to the profit motive driving drug development than to any lack of efficacy. Citing the case of coenzyme Q10, Dr. Katz explained that financial incentives drastically bias medical research against alternative medicines, which often cannot easily be patented for marketing and thus less often receive sufficient funding for extensive research and regulatory approval.

Not all "eastern medicines," however, are created equal in the eyes of many, and while Dr. Katz's argument lands a powerful blow to the general portrayal of holistic medicine as quackery, it would be a mistake to conclude that money can tell us the whole story.  This is especially true in the case of traditional Islamic medicine.  On the rare occasion that Islam can be discussed independent of the political rhetoric surrounding Muslims, terrorism, and immigration in Europe and the United States, Islamic medicine rarely exists in popular media without the word "medieval" preceding it.  While describing the study of Islamic medicine or even defining the concept of holistic medicine are challenging and important topics, the question I hope to explore here is whether the conventional medical establishments of the United States and Europe are ready to begin embracing even the possibility of traditional Islamic medicine representing an alternative treatment option, as they increasingly have for traditional Chinese therapies.  My answer is no, they are not quite prepared for such a step.

Why the United States and Europe are NOT ready to embrace the possibility of traditional Islamic medicine as an option:

In addition to the challenge of profit motive demonstrated by Dr. Katz, traditional Islamic medicine faces the same difficulty encountered by nearly all understandings of illness originating outside the conventional biomedical model: the patronizing categorization as "beliefs" as opposed to knowledge.  While anthropologists have generally understood knowledge and beliefs as complimentary, health professionals tend to view the terms as contrasting, with "beliefs" connoting ideas that are irrational, erroneous, and obstructive to health.  As such, the very terms used within public health discourse often exclude Islamic medicine from serious consideration, along with other traditional forms of holistic medicine.

There also exist obstacles that are unique to Islamic medicine, however, as the portrayal of Islam and Muslims by medical writers is hardly neutral.  A review of medical literature from 1966 to 2005 revealed recurring latent biases, including notions that Islamic tradition is a barrier to modernity, that being an observant Muslim poses health risks, and that "Islam" represents a problem for healthcare delivery.  Even historic examinations of Islamic medicine frequently reduce "positive" elements to mere transmissions of Greek, Jewish, or Christian thought.  Such messages build on a long history of orientalist representations of Muslim societies as deficient and dehumanized Others, a phenomenon famously examined by Edward Said, to which medical discourse is no exception.  Nowhere is this more apparent, perhaps, than in depictions of Arabs and Muslims in psychodynamic literature post-9/11, during an era of suspicion and hostility toward Muslims and of military interventions in Muslim-majority countries by Europe and the United States.

Thus, to fully comprehend Islamic medicine's exclusion from the conversation around alternative medicine in the West, let alone from the conventional medical establishment, we must look beyond questions of research funding and evidence-based medicine.  While important, these issues speak little of the relationship between knowledge production and geopolitical power that are behind persisting orientalist narratives around Muslims and Islam in medical literature.  Until American and European health professionals and academics are prepared to critically address these narratives, Islamic medicine is unlikely to be included in any "Eastern medicine revolution" that may be underway.

Wednesday, June 11, 2014

3 Reasons Premedical Students Need the Liberal Arts

In his commencement address at Sarah Lawrence College, international affairs journalist and author Fareed Zakaria defended the value of a liberal arts education.  "At its essence," explained Zakaria, "a liberal education is an education to free the mind from dogma, from controls, from constraints.  It is an exercise in freedom."  His speech, I imagine, was well received and much appreciated by the over 400 graduates earning liberal arts degrees that day in the midst of declining funding, popularity, and respect for their chosen field.

Premedical students, presumably destined for the prestige and pay scale of a medical career, might imagine themselves to be outsideor maybe even abovethe scope of Zakaria's message.  If you are among them, you are seriously mistaken, potentially to the detriment of both your higher education in general and your professional training as a future physician.  Rather than strategically choosing classes on the basis of how easily you can fulfill breadth requirements while completing the premedical curriculum, I would urge you to pay closer attention to your courses in the liberal arts, and here are the three most important reasons why:

1. The liberal arts teach you the power of words and language, which are the basis for communication and the relationship between doctor and patient.

Despite incredible advances in technology, modern medicine remains as much about communication as about any of the biomedical sciences.  In fact, with the leading causes of premature mortality being driven by behavioral and societal factors, better communicationwhether in counseling individual patients or informing the larger publicmay be the most important tool in addressing our greatest public health challenges today.  Conveying the importance of exercise, vaccination, or any other preventive action to another person, however, requires more than presenting cliché public health messages or statistics.  It also requires an understanding of the immense power of words and language to shape ideas and change people, hallmarks of a liberal arts education.  Moreover, such an understanding of language opens a window into the unique human experiences behind a person's words.  It allows you to learn empathy and make a genuine connection with the person in your care.

2. The liberal arts train you to be critical thinkers and lifelong learners, cornerstones of the medical profession.

While the scientific method provides a foundation for much of medical practice, empirical and quantitative methods have limits to the questions they can answer.  When it comes to the grayer areas of uncertainty, including many clinical decisions and ethical judgments faced by physicians every day, the critical thinking and analytic skills emphasized by a liberal arts education become essential.  They allow a physician to consider various perspectives, seek evidence, and construct an argument for specific action.  There can be no skill more vital to a doctor than this ability to take reasoned action in the face of uncertainty.  Furthermore, the open mind and inquiring attitude that this skill imparts lends itself to continued learning and adaptation, even as the available evidence and standard practices change with each passing year.

3. The liberal arts prepare you to tackle the more complex questions facing physicians, including what role they should play in society, politics, and promotion of social justice.

Contrary to what the progressive commercialization of medicine would have us believe, medicine continues to be "a calling, not a business," in the words of William Osler.  Physicians continue to bear a social obligation of service and integrity toward the patients and communities with whom they work.  In many ways, the liberal arts offer to elevate our level of discourse above the ever-changing market forces and administrative policies in medicine and to thereby ensure that these principles are never unwittingly compromised under external pressure.  Additionally, it provides a framework for beginning to address the larger social and political issues involved in promoting greater justice in the distribution of healthcare resources.  These represent priorities that deserve our greatest attention as future doctors and that require us to "free the mind from dogma, from controls, from constraints" and exercise the freedom of thought afforded to us by the liberal arts.