According to the old Chinese proverb when the ruler of the underworld’s daughter falls sick he sends his servants out to find the doctor who is followed by the least ghosts. The one with the fewest ghosts is the best doctor as when patients die, their ghosts haunt the doctor. Over the course of the twentieth century China witnessed some of the most devastating humane tragedies, both during the Second World War and in its aftermath, with the ascent of Mao and his imposition of the Cultural Revolution. The ghosts of the dead follow not the doctors but the politicians. Despite the worst excesses of Maoist practices, novel approaches to the development of a health system emerged, including that of the Barefoot Doctor. After the war China had a large poor rural population that lacked access to Western health care, whose suffering was compounded by the recent ravages of war and food shortages. Into this mix came the Barefoot Doctor – a minimally trained health care worker who had access to the most remote populations.

The effectiveness of Barefoot Doctors is, and continues to be, much debated. A combination of poor statistics, confounding factors and conflicting political ideologies make it hard for a clear picture to emerge. Though quantitative evidence may be lacking, Barefoot Doctors have influenced many other health movements in developing and deprived communities and they were also one of the main inspirations behind the Alma-Ata declaration in 1978[1]. The declaration of Alma-Ata is particularly important because of the infusion of medicine, human rights and public health that were enshrined within its framework. Its contents can be divided into two sections: the principle themes that it enshrines, and public health interventions that it considers essential[2].

• Principal themes

o The importance of equity

o The need for community participation

o The need for a multi-sectoral approach to health problems

o The need for effective planning

o The importance of integrated referral systems

o An emphasis on health-promotional activities

o The crucial role of suitably trained human resources

o The importance of international cooperation

• Essential health interventions

o Education concerning prevailing health problems

o Promotion of food supply and proper nutrition

o Adequate supply of safe water and basic sanitation

o Maternal and child health care, including family planning

o Immunisation against major infectious diseases

o Prevention and control of locally endemic diseases

o Appropriate treatment of common diseases and injuries

o Provision of essential drugs

After the Second World War few developing nations were meeting these ambitions. In 1949, China was a country where the life expectancy was only 35 years. The main causes of death where from infectious disease and malnutrition[3]. By the 1970s, China’s life expectancy was approaching 60 years[4]. Clearly something had changed.

The Need for Another Way

In the late 1940s Dr Chen Zi Qian of the Dingxian health centre calculated that an average person in the rural community could afford to pay 10 cents a year for medical services[5]. At a time when a day’s stay in hospital would cost US$3, modern medicine was beyond the reach of an ordinary worker. Such a situation is made all the more poignant by the fact that 70% of mortality was caused by easily preventable disease⁵. Infant mortality in pre-revolutionary China was at 160/1000 live births, 34,000 died of cholera a year (although this figure is likely to be a gross under-estimation) and tuberculosis caused between 10-15% of annual mortality[6].

Medical care in China before the revolution was sparse. In a country of 540 million people there were only 10,000 doctors trained in Western medicine (though there existed 500,000 trained in traditional medicine)⁷. Additionally most of the doctors were situated in the cities to serve the urban elite whereas 80% of the general population resided in the countryside[7]. The transformation of China’s health care would require a new solution.

The Work and Impact of the Barefoot Doctor

The poor have always been served less well by the medical profession. In England physicians tended to practise only within the circles of the rich, those that could not afford a doctor used the services of the barber-surgeons. With Mao’s proclamation of taking health to the countryside, the Barefoot Doctor was created. The Barefoot Doctors get their name from working part time in rice paddy fields without shoes. Over time their health responsibilities increased and they were re-branded into paramedics or rural doctors[8].

Upon their inception Barefoot Doctors were given just five months of training (though this was later to be increased). According to Dr Joshua Horn, an English physician who migrated to be part of the people’s revolution and was involved in the training of Barefoot Doctors, the trainees studied anatomy and physiology and were introduced to pathology and bacteriology. Practical skills were taught early and, according to the Maoist mantra of learning through work, the trainees shadowed doctors and held their own pre-assessment clinics. The teaching focused on common diseases that were likely to be encountered and they learned the use and formulary of 40 drugs. Their studies were not just confined to the Western school of medicine – they also had to learn 50 acupuncture points[9]. There were also illustrations of common herbs and their uses in the manual that the Barefoot Doctors were provided with[10]. More than just treating disease, a large part of the work of Barefoot Doctors was preventative. In her account of her time as a peasant doctor, Li Qunying describes of how the first thing she would do upon entering a village would be purify the well water[11] and Dr Horn gives several examples of the public health measures undertaken by the local Barefoot Doctors.

Public health and promotion

Assessing the impact that Barefoot Doctors had is hard. Few statistics exist and the accounts that emerge tend to be heavily influenced by political bias. While there were a number of significant achievements within the public health arena, there were also some notable failures. For example, Mao’s initial campaign against the four pests had variable success. Whilst the fight against rats, flies and mosquitoes had improved the health situation, the battle against sparrows may have inadvertently precipitated a famine in the following year by allowing plagues of locusts to ravage crops unchecked[12]. The campaign against the snails (not initially regarded as one of the four pests) was altogether more of a triumph.

Schistosomiasis affected millions of people in China. The “disease causes its ill effects when larval forms of a parasites are released by freshwater snails which then go on to penetrate the skin of people” bathing in the water. Schistosomiasis can damage the bladder, ureters, kidneys, intestine, liver, spleen and abdominal blood vessels[13]. To prevent the disease the snails had to be completely eliminated from the river banks. Such an implausible task was given credence by Mao’s parable of the man who removed the mountains; the tale tells of an old man whose view was blocked by an enormous mountain, so he, with the help of his two sons began to scrape the mountain away. A passer by remarked at the implausibility of the task to which he replied “when I die my sons will carry on, when they die there will be grandsons…and so on till infinity. High as they are the mountains can never grow higher. Every bit we dig away will make them that much lower. Why can’t we clear them away?6” The snails were eradicated from the river banks through a combination of peasants wielding flame throwers and the systematic combing of the river beds. According to some reports cases of schistosomiasis were reduced from 10 million to 2.4 million with most remaining cases being mild[14].

Syphilis was another disease where great strides were made. Before the revolution it was very prevalent and much of it was undiagnosed. A questionnaire was drawn up and given to the villagers. After much education and coercion the questionnaires were filled in and patients started to arrive. Barefoot Doctors carried out the necessary blood work to confirm the diagnosis (only one in twenty patients turned out to have syphilis) and they were then treated. The slightly biased Dr Horn estimated that in some districts 90% of all syphilis sufferers were being detected[15]. Parallels with the HIV epidemic in modern day China can be seen not only in the scale of undiagnosed sufferers but also in the solution that government provides. Entitled “Four Frees and One Care” the government policy is to give free ARVs, free counselling, free drugs to prevent maternal transmission, free schooling for AIDS orphans and care in the form of economic assistance to those affected by AIDS[16]. Whilst the reality on the ground may yet prove different to the political promises, the official line seems to embrace the principle of medicine as a means of social justice.

Preventative work (including health education and family planning) accounted for only 10% of the Barefoot Doctor’s time8. The majority of their time was spent in outpatient consultation (46%). Study and administration took up 10% and home visits took up a further 22% of their time⁸. The most common complaint faced by the Barefoot Doctor was the common cold (10%). Abdominal and musculoskeletal pains came next (9 and 8% respectively)[17]. In theory Barefoot Doctors were trained to deal with 70% of the population’s medical need18. Mobile medical teams (groups of doctors from urban hospitals doing tours of duty in the countryside) were the first port of call for referral from the Barefoot Doctors. The next level of care was the hospital, although this was often an impractical solution due to the distances involved in travelling there.

At its peak the Barefoot Doctor programme had almost two million[18] trained health workers out in the fields. Rural Chinese are however now suffering. With the failure of the Cultural Revolution, the Barefoot Doctor programme declined. This was due to the changing urban/rural demographics and the fact that the Barefoot Doctors carried some of the negative stigma that came with the Cultural Revolution18. Mao’s system of Barefoot Doctors has collapsed and China has gone from a state where nine out of ten people were able to access subsidised health care to a situation where 90% of people are now uninsured and out-of-pocket health care costs are rising fast[19]. Even towards the early 1970s when Barefoot Doctors were trained for longer periods and were devoting more time to going on courses the programme was only costing the average worker nine cents a month (average monthly salary at the time was US$30)[20].

China and Beyond

Allowing the rural poor large scale access to health workers was a remarkable step at the time, given all the problems China faced. Barefoot doctors were often able to treat and at other times they served as a useful step in allowing the patients to access secondary health care. Beyond the medical they also had important roles in sanitation, hygiene and public health. But the mantra of the Barefoot Doctors extended beyond Mao’s China Many health development projects now base themselves on using workers from the community to help achieve their aims. That the Barefoot Doctors worked side by side in the rice paddy fields with their potential patients certainly helped them to be accepted and to understand the perspective of the villagers. In Pakistan, Lady Health Workers have been pioneered to great effect to help reduce post-natal depression and infant mortality[21]. Modern day equivalents of Barefoot Doctors appear not just in the field of health but also in other areas of development. The National Institute of Adult Continuing Education (NIACE) has recently launched a scheme of “barefoot workers” who will help improve literacy amongst female ethnic minority groups in the most deprived areas of London. Similar to the health practitioners in China these barefoot workers will consist of women who work with other women of the same ethnicity to support and help endow them with literacy skills[22].

Mao had many faults. It is hard to envisage that China is now better off due to his Cultural Revolution, however it would also be hard to argue against the fact that health care improved dramatically under his rule. Undoubtedly the health of the Chinese would have improved much further were it not for the arbitrary killings of some of their more experienced doctors and forcing skilled medical personnel to work in the fields as farmers. Policies were not planned properly in advance and unintended consequences, as can be seen with the killing of the sparrows, could be devastating. Part of the problem was that Barefoot Doctors were there not only to serve health needs, but also political ones.

To reject Barefoot Doctors simply because they are tainted by the politics of Mao would be unfortunate. Barefoot Doctors are one of the few positive legacies that stem from Mao’s revolution. They embrace the principles of Alma-Ata long before it was written and were one of the inspiring factors behind the declaration[23]. The concept of healthcare needing to be delivered locally and provided for by culturally competent practitioners was ahead of its time. That Barefoot Doctors also provided a developing nation with universal health coverage to all its population, no matter how remote or how deprived, is no less than remarkable.

Acknowledgments
With many thanks to Dr Jeannette Naish for all her help

---

 

[1] Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978

 

[2] G Backman et al, Health systems and the right to health: an assessment of 194 countries, Lancet 2008; 372: 2047–85 (categorisation taken from the article)

 

[3] Bu Explores Use of Posters in Chinese Public Health, National Institute of Health Newslestter, 06/10/06

 

[4] Patterns of literacy in the People’s Republic of China, A Jowett, GeoJournal 1989 Vol 18 No 4

 

[5] S Hillier and J Jewell, The Development of Chinese Health Care 1911-49, p52, Health Care and Traditional Medicine in China 1800-1982,

 

[6] M Liang et al, Chinese Health Care: Determinants of the system, AJPH 1973 Col 63 No 2

 

[7] Health for the Masses: China’s ‘Barefoot Doctors’, National Public Radio, URL: http://www.npr.org/templates/story/story.php?storyId=4990242, Date Accessed: 04/01/09

 

[8] G Long and C Min, The Role of Barefoot Doctors, AJPH 1982 Vol 2 Supplement

 

[9] J Horn, Away With All Pests- p136, the Hamlyn Publishing Group Ltd, 1969

 

[10] A Barefoot Doctors Manual (translation), Running Press, 1977

 

[11] L Qunying, The Doctor Who Was Followed by Ghosts – p217, ECW Press, 2007

 

[12] The Loneliness of the Chinese Birdwatcher, the Economist, 18/12/08

 

[13] WHO Schistosomiasis, URL: http://www.who.int/topics/schistosomiasis/en/, Date accessed: 04/01/08

 

[14] Health for the Masses: China’s ‘Barefoot Doctors’, National Public Radio, URL: http://www.npr.org/templates/story/story.php?storyId=4990242, Date Accessed: 04/01/09

 

[15] J Horn, Away With All Pests- p92, the Hamlyn Publishing Group Ltd, 1969

 

[16] The history of AIDS from 2003-2006, AVERT, URL: http://www.avert.org/aidshistory.htm, Date Accessed: 21/01/09

 

[17] D Mechanic and A Kleinman, Ambulatory Medical Care in the People’s Republic of China, AJPH 1980 Vol 70 No 1

 

[18] S Hillier and J Jewell, The Cultural Revolution and after – p129, Health Care and Traditional Medicine in China 1800-1982

 

[19] China’s collapsing health care, the Economist, 19/08/04

 

[20] The Prescriptions of Chairman Mao, Time Magazine, 10/01/72

 

[21] Mother and Child, URL: http://www.wellcome.ac.uk/News/2004/Features/WTD006153.htm, Date Accessed: 04/01/08

 

[22] A Woman’s Place, NAICE, 2008

 

[23] To promote the spirit of Alma Ata, conditions are better than ever, People’s Health Movement, URL: http://www.phmovement.org/cms/en/node/934, Date Accessed: 04/01/09

Diane Wu reflects on her summer in Bosnia-Herzegovina.

The bus is destined for another area of town, but I’m getting off at Brcko. The bus rides an N-shaped route from Sarajevo north into Croatia and winds through much of Bosnia’s hilly terrain in the northern part of the Federation. Everyone is sleeping. Some poorly-oiled section of the bus frame squeaks as we round the turns. A cell phone rings. The bus attendant makes a clinking noise as he counts his change. It dawns on me that everything I own is either bouncing across Bosnia on a bus or creeping across North America with Canada Post. It’s a bit surreal.

The topography looks like bubble-wrap – hills are everywhere, blanked by a layer of fluffy-looking trees. Frequently, we see hillsides covered by a shock of brick-coloured houses. Children walk to school. A woman threshes some grass while sheep graze the landscape; the scene is almost bucolic enough to make you forget that anything bad had ever happened here. (more…)

Ashley Neils writes on her experience with the Maasai in Tanzania.

I’ve always loved running. But running with a Maasai warrior changes everything. In fact, being in Africa changes everything. It has certainly changed me.

It is often difficult for people in developed countries to fully comprehend the depth of poverty that grasps many people in developing countries. The majority of Americans are not worried about losing shelter, food, and water. For Africans, these basic needs are not guaranteed. Making it through the day is a struggle. (more…)

Joshua Schulman-Marcus writes on the challenges and opportunities of working in a hospital in Queens, New York. 

A Colombian carpenter with a forearm laceration. A young African-American woman with bedbug bites and a heart murmur of unknown etiology. This patient is from Ecuador, the one in the next bed grew up in Bangladesh. In the corner is a patient who had colonic tuberculosis when she was a child in Uttar Pradesh, while in the trauma bay the woman who fell on the street speaks only Greek (we don’t have Greek translators today). Another waiting patient thinks in Korean, and stutters that the discharge from his back lesion looks like tofu.

The panoply of origins is not just among the patients. My current attending physician is originally from Goa, the surgical consultant trained in China, and the medicine resident in Cairo. Many of the nurses are from various Caribbean islands, though others are from the Philippines and Russia. The clerk is a Korean-American woman and the friendly janitor was born in Mexico (I think). I am originally from the suburbs of New York, but I speak a reasonable Spanish and Hebrew as well. We are nominally a like-minded team of professionals, but at times cultural friction flares. For some of us were originally trained in health systems emphasizing hierarchy, while others learned in more egalitarian settings.

After a year of global health research in Boston, these chaotic emergency room vignettes have been my “welcome home” to New York. They happened at the Elmhurst Hospital Center, a large public hospital in an ultra-diverse neighborhood of Queens. Most tourists to New York never make it out to Queens, a borough with few parallels in the United States. Almost half the borough’s population is foreign born, with every continent amply represented. This immigrant melange, many of whom are poor or uninsured, presents to Elmhurst’s overcrowded emergency department.

The communication challenges of providing quality health care at Elmhurst are formidable. All of the hospital signs are in English and Spanish, and some are also in Chinese, Russian, and Hindi. Although many of us health providers are familiar with medical Spanish, I am sure that we frequently miss nuances or explain ideas poorly. Speakers of other languages are less fortunate; an occasionally available translation phone can provide only so much help. The consequent reliance on relatives to translate diminishes the privacy and personal autonomy afforded to patients.  Sometimes, a communication gap delays a diagnosis or results in an unnecessary admission.

Most of the patients present with common diagnoses. At Elmhurst, though, one’s differential must also include the disease burdens of various developing countries.  Patients frequently travel to their home countries or live with recently arrived relatives. It is not uncommon to see malaria, typhoid, or tuberculosis along with diabetes, pneumonia, and urinary tract infections. A comprehensive mindset is important, but also one mindful of resource constraints and the relative poverty of the patients.

In several ways, I find that my experience at Elmhurst mirrors the challenges and opportunities presented to medical students interested in global health. Enthusiastic about providing health care to the marginalized, we travel to clinics in distant countries. We see a sea of faces rushing by, and we often struggle to communicate across vast disparities in culture, language, and background. Sometimes we succeed, and other times we are left speechless. We are unlikely to see our patients again or develop a longitudinal relationship, as few students remain in one location for a very long while. This remains true if we look to careers in humanitarian relief or medical NGOs. In the end, the situation is not so different than working in an emergency ward.

On the other hand, it is invigorating to serve the marginalized with the best of medical knowledge and technology. As at Elmhurst, to be effective in global health requires a flexible approach, knowledge of the systems that sustain poverty, and a belief that the right to health transcends language or citizenship. In working to alleviate suffering among the destitute or marginalized, one becomes a more thorough practitioner and appreciator of humanity.

For a native New Yorker like me, though, Elmhurst presents a rare opportunity. It is a setting where I can have a sustained global health career without the difficulties of long-term relocation or the inadequacies of sporadic medical tourism. I can strive to provide the longitudinal doctor-patient relationship that is the backbone of a “preferential option for the poor.” I can work to be a better communicator, witness, and advocate for the marginalized of developing countries and of my city. And it’s only a short subway ride away.

Joshua Schulman-Marcus, 4th year medical student at Mount Sinai School of Medicine, New York, USA

jschumar@gmail.com

Over the last decade, the inequitable gap between rich and poor has widened both in the UK and globally.  Urbanisation has continued, most notably in industrialising countries as more people go in search of employment opportunities.  In fact, 2008 was the first year that more of the world’s populace lived in an urban rather than a rural setting (1).  Global travel and tourism has also grown due to relatively accessible and affordable air travel (2).

These above forces have led to an increasing number of tourists arriving in cities with a growing slum dwelling population.  While the majority of tourists still visit the most famous sites and attractions within a particular country, an increasing number are choosing to pay for poverty tourism, or “poorism”.

Tours have the potential to perpetuate the poor health and poverty cycle

These trips usually involve spending a day walking around a major slum with a local guide who was born and raised in that area.  Poorists will have the opportunity to visit local initiative programmes from health clinics and schools to sewing sweat shops, sewerage systems and wells.  The tour may even include a refreshment break in a slum house (3).

In Delhi, a city of 18 million, Western tourists can pay around $5 to spend a few hours watching the daily lives of Indian slum children – playing cricket around landfill sites, selling chewing gum to and polishing the shoes of passing commuters (4).  Similar excursions are offered in the Kibera district of Nairobi, Africa’s largest slum as well as Rio de Janeiro, Cairo and Soweto in Johannesburg.  Interestingly ‘ghetto’ tours can even be taken in New York (3).

Writing for the Observer, Amelia Gentleman argues that these trips are voyeuristic and exploitative (3).  Local people unfortunate enough to live in such conditions are gawked at and may be pressured by the tour organisers into acting up their impoverished situation (5).  This may include drinking stagnant water or glue sniffing to increase the sense of pity and subsequent donations to the ‘charity’ which has organised the tour.  How much money actually reaches the affected children and households and what difference this actually makes is unknown but certainly the tours have the potential to perpetuate the poor health and poverty cycle.  On the other hand, the international visitors and their foreign currency can demand change and small scale improvements, and it is better the tourists see beyond their 5-star hotels and safari jeeps (4).  Additionally, a charity organising poorism trips in Delhi have opened a day centre school which can provide some shelter and security to the street children (6).

Whichever view is taken, the tours demonstrate the inextricable gap and ignorance between the lives of the rich and poor.  There must also be something slightly perverse in enjoying a holiday observing profound misery.  To improve access to clean water, affective health care systems and to safeguard against the effects of climate change, the poor and the poorists alike should demand and will require much more investment than small initiatives and entrepreneurial start-ups.

Edward Armstrong
Foundation Year 1 Doctor
North West Thames Foundation School, UK
edward.armstrong02@imperial.ac.uk

(1) Population Reference Bureau (2007). World Population Highlights; 62: 3.

(2) Matsumoto (2004). International urban systems and air passenger and cargo flows: some calculations. Journal of Air Transport Management; 10; 4: 239-247.

(3) Gentleman A (2006). Slum tours: a day trip too far? The Observer. Accessed on-line http://www.guardian.co.uk/travel/2006/may/07/delhi.india.ethicalliving

(4) World Resources Institute (2006). Poorism in India. Accessed on-line http://www.nextbillion.net/blogs/2006/06/01/poorism-in-india-development-through-enterprise-or-lower-class-exploitation

(5) Lancaster J (2007). Next stop squalor. Accessed on-line http://www.smithsonianmag.com/people-places/squalor.html

(6) Salaam Baalak Trust (2008). Accessed on-line http://www.salaambaalaktrust.com/shelters.asp

Joshua Schulman-Marcus reports on the anthropological and psychological impact of chronic diseases in developing countries.

A Personal Reflection

Over the past year, I have written several articles for the Lancet Student on the growing prevalence of chronic noncommunicable diseases (CNDs) in developing countries. Major studies have indicated that diseases and risk factors such as hypertension, diabetes, tobacco use, and asthma are increasing in low- and middle-income countries in all regions of the world (1,2). Recognizing these trends, the World Health Organization (WHO) has recently begun to address this new global health priority (3,4). Researchers and advocates have pointed out that more investment in prevention, screening, and treatment will be needed to avert the resulting unnecessary disability and mortality (5,6). These reports indicate that CNDs will be a major item on the global health agenda for the duration of our careers.

Most of the research, including the recent series published by The Lancet (7), has been predicated on epidemiology, economic impact, health systems, and potential interventions. Less has been said about the non-technical implications of a transition to chronic disease in the developing world. This is unfortunate as “health” extends far beyond the biomedical realm; it is intertwined with sociological structures and culture. A shift from acute infections and traumas to chronic, often asymptomatic ailments, thus presents a paradigm shift in the notion of what it means to be a healthy person. This is a serious adjustment that deserves careful consideration. For how can we expect people to take medicines or alter lifestyles if they don’t believe that they are ill?

I personally saw the anthropological and cultural challenges of the epidemiologic transition when I worked with the Ethiopian Israeli community in 2005. Arriving in urban Israel from rural Ethiopia in the 1980s, the immigrants had a conception of health that largely revolved around the acute infections and malnutrition endemic to poor countries. Within ten years, though, the prevalence of Type 2 diabetes rose from 0.5% to 17% in some cities. Similarly, asthma, blood cholesterol levels, blood pressure, and red meat consumption soared.

The Ethiopian immigrants had no word in their common language for diabetes. I spoke with a man with longstanding diabetes who had never heard of the pancreas. He didn’t believe he was sick. As the deleterious elevation of blood glucose is often asymptomatic early in the disease course, it was exceedingly difficult to convince patients to adhere to therapy. Even worse, the language used to explain diabetes can be very confusing, as the notion of “high sugar” led some patients to believe that sugary foods were the cause of the condition. Miscommunication between the Israeli primary care providers and the Ethiopian patients, compounded by poverty and power disparities, led to distrust and very poor quality of care. And this was in a country with a well-financed health system designed to address chronic noncommunicable diseases.

Indeed, the entire notion of chronic disease resulted in confusion and frustration for some Ethiopian immigrants. “Why can’t the doctor cure me? Why doesn’t he give me a shot?” asked one. “He must just be a bad doctor, or maybe he doesn’t treat me because I am Ethiopian.” I heard similar confusion about the concept of lifelong drug therapy. One mother, for example, refused to give her son an asthma inhaler, lest he become “addicted” to it like tobacco. Another, however, wanted constant steroids to treat his mild asthma, because “they make me feel good.”

My discussions with the Ethiopian immigrants and Israeli health workers also hinted at the complexity of advocating lifestyle changes to prevent chronic disease. Lifestyle is the product of thousands of choices, many of which are heavily influenced by economics, sociocultural norms, and status. People in developing countries may aspire to eat Western foods high in saturated fats and may choose to smoke American cigarettes to indicate their wealth. Being overweight or obese, even having some diabetes, may be lauded as a sign of success. These attitudes can be deeply ingrained, and modifying them will require interventions informed by a nuanced understanding of local culture and health beliefs. If chronic diseases are not presented in terms that make them believable, most people will be hesitant to significantly alter their lifestyles in order to “prevent” an abstraction.

Over the past few years, attention has been increasingly paid to the coming epidemic of chronic noncommunicable diseases in the developing world. These diseases can lead to devastating consequences, both physically and economically. It has thus been recognized that many disciplines will need to be rallied in order to adapt health systems for chronic care, re-train workers, ensure access to medicines, and design cities amenable to physical activity (2-7). Yet the barriers to the effective prevention and care of these diseases cannot be lowered through the technical expertise of biomedicine or policy alone. Rather, my experiences have taught me that it will require a more holistic understanding of how individuals adapt to a revolution in the conception of health, illness, and healing. To do so, I think we first will need to learn how to be better and more patient listeners.

Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York, USA

jschumar@gmail.com

(1) Lopez AD, Mathers CD, Ezzati M et al. Global and regional burden of risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57

(2) Jamison D, Breman J, Measham A, Alleyne G, Claeson M, Evans DB et al. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press and the World Bank, 2006.

(3) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002

(4) Preventing chronic diseases: a vital investment. Geneva: WHO, 2005

(5) Leeder S, Raymond S, Greenberg H, Liu H, and Esson K. A Race against Time: The Challenge of Cardiovascular Disease in Developing Countries. New York: Trustees of Columbia University, 2004.

(6) Yach D, Hawkes C, Gould CL, Hofman K. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004; 291:2616-2622.

(7) Horton R. Chronic disease: the case for urgent global action. Lancet 2007; 370:1881-82.

Amanda J. Redig, a student at the Feinberg School of Medicine in Chicago, has written an article on the challenges in biomedical research and the increased need – and opportunity – for translational knowledge sharing between physicians and scientists.

An Indian fable tells the tale of several blind men asked to describe an elephant.  The man who reaches the tail declares the unknown animal to be like a rope; the man who brushes past the leg asserts that what is in front of him must be like a tree; while the final man bumps into the tusk and concludes that the unseen creature resembles a spear.  In the end, those of us who can see the elephant know that each individual assessment is both right and wrong: what is missing is the vision required to put all of the pieces together into a comprehensive whole.  What I want to know, as an MD/PhD trainee during arguably the most exciting time to be a student in the history of both medicine and biology, is whether the biomedical community is now confronting a similar challenge.  Recent advances offer a tantalizing glimpse of what our future could be, but has the quest to integrate an ever-widening information pool and spectrum of disciplines become an exercise in describing the elephant?

Without doubt the 20th century’s remarkable achievements in clinical therapies and scientific discovery provide a solid foundation for the enthusiasm with which we can move forward into the 21st.  Yet for every shining success story-the 85% survival rate for pediatric leukemias or the technical achievements behind transplant surgery-we must still confront the published survival curves for a disease like lung cancer.  And here, as with far too many other diseases, despite decades of effort and millions of dollars, not much has changed.  The complexity of understanding human health and disease means that we must continue what is often a painstaking process of piecing together insights that move from structural biology and model organisms to targeted therapies that do have efficacy in the clinic.  From Watson and Crick to chromosomal translocations and the development of imatinib, the connection between scientific advancement and new medical therapies is undeniable.  However, what I can’t help but wonder as I move through the process of dual training as a physician-scientist is if the current trajectory of our research efforts-the overlap between basic science and clinical medicine-is one that in the end will achieve the greatest results.  The progression from lab to clinic might be self-evident, but unless our framework for biomedical progress moves to truly integrate not only the expertise of multiple clinical specialties but also a full spectrum of scientific investigators, 21st century advancement in medicine cannot live up to its potential. 

The foundation of this challenge is clear: much of the time, physicians and scientists simply do not understand one another.  Both parties ask questions, but the good physician arrives at the same diagnosis as any other good physician while the good scientist sees what no one else has and arrives at a new conclusion.  Unfortunately, the stark differences in training and perspective that make laboratory investigators or clinicians successful within their respective fields can and do inhibit the success of potential collaborations that are not exclusively one discipline or the other.  Speaking to this challenge, much has been made in the literature of late about the directions of academic medicine, biomedical research, and the future of so-called translational research.  Editorials and analyses discuss the role of the physician-scientist or clinical investigator as a go-between (1,2) as well as concern about funding mechanisms and the increasing age at which investigators secure independent grants (3-5).  However, even as initiatives such as the National Institutes of Health roadmap or the recommendations of the Cooksey review are exploring ways to bridge science and medicine (6,7), there is also controversy over whether this is even a good idea let alone a feasible goal (8-10).  In the end, much of the discussion falls back to the fundamental differences between how basic scientists and clinicians ask questions-investigator-driven mechanistic grants on the one hand and large-scale correlative studies on the other.  Yet in order to build on the promise of the last century, our challenge is not merely to discuss the possibility of a new paradigm for biomedical research but rather to implement it.

First, we face the task of integrating physicians and scientists when the barriers between them are constructed with each year of the extensive training process.  In most cases, physicians must complete medical school, residency, and often some fellowship training before they have the time to become involved in meaningful laboratory research.  During this same training period, their early-career scientific colleagues have been just as immersed in the no-less rigorous and time-consuming program of focused graduate school and post-doctoral research.  By the time their paths overlap, the boundaries are set: physicians are physicians and bench scientists are bench scientists.  From the perspective of a post-doc who has spent the last ten years dissecting the most intricate of molecular details, the physician who waltzes into the lab not knowing how to pipet but expecting multiple first author publications in less than two years will never be a scientist.  On the other hand, for the senior resident who has thirty seconds to respond to a coding patient in the throes of cardiac arrest, the scientist planning to spend a career elaborating a pathway in fruit flies is out of touch with the real world.  Is it any wonder that each field can view the other with more than a healthy dose of skepticism and sometimes even outright resentment?

Unfortunately, the separation between these fields continues past the early stages of training. By the time a junior scientist is ready to start his own lab or a junior attending moves into her own niche as a professional, the responsibilities of career development at this crucial juncture take priority over exploring the complex challenges that will likely require input and ideas from both physicians and scientists to solve.  Molecular science is emphasized in the very beginning of medical school, but after that, the details take a back seat to the pathophysiology that is the territory of the physician.  This works for training clinicians, but what about clinician-investigators? In turn, Drs. Kaushansky and Shattil encourage aspiring physician-scientists everywhere as they editorialize about supporting the development of biomedical investigators in hematology-oncology, but this very same op-ed also highlights a hole in the cross-disciplinary mentoring of junior scientists (11).  If physicians who move into the scientific arena need support and mentoring to tackle multidisciplinary problems, then the same is true of their scientific peers seeking to apply scientific training to clinical problems.  Yet there seem to be few, if any, organized opportunities for scientists to be introduced to the clinical problems that their technical skills and hypothesis-driven training could help solve.  Even more problematic, although biomedical research buildings are often adjacent to academic hospitals in an attempt to promote translational research, it is much less common to see such collaboration with scientists several steps further away from medicine; engineering, applied math, and computer science have yet to become as closely integrated with biomedical research as molecular biology and genetics.  It is true that the more conventional partnership has led to some success stories-understanding the role of a single gene or pathway in disease has allowed the development of new therapeutic options.  However, as the aftermath of the Human Genome Project has made clear, the majority of chronic diseases-like cancer-that continue to cause great suffering around the world are too complex for the approach of inhibiting a single pathway or kinase to work.  Indeed, the molecular biology-based success of a targeted drug like imatinib remains to be replicated in the mathematically more complex signaling milieu of solid tumors.

While it is easy to take sides in the pull between medicine and science, morbidity and mortality statistics make it clear that we cannot afford to maintain the status quo: we need to fix the culture gap.  In order to translate our leaps and bounds of information acquisition into leaps and bounds that make a tangible difference in patients’ lives, we must broaden not only the scale of our vision but also the connections we are willing to forge to get there.  If communication-or lack thereof-amongst early-career trainees is a barrier to future success, then an added dimension to the training process might produce physicians and scientists with enough common vocabulary to minimize the height of the walls.  For example, Duke University’s medical training program-and now a joint medical school started in collaboration with the government of Singapore-includes a mandatory year of independent scholarship (12).  While the range of chosen research projects is broad, each graduating MD does so not only with firsthand experience of biomedical investigation but also with a new set of skills and language that can be a bridge to future collaborations outside of strictly clinical medicine.  Many academic institutions have recognized the need to better integrate medicine and the life sciences; key to these efforts will be not only involving medical appointees but also providing opportunities for scientists of all stripes to learn more about the clinical challenges-metastasis, antibiotic resistance, microimaging-that practitioners of medicine cannot solve on their own (13-15).  While excellence in a specific discipline should be the goal of graduate training, the gradual acquisition of blinders that prevent recognition of excellence in an outside specialty is not. 

What we are missing, it seems, is a greater focus on not only what our own skill set- whatever that might be-can bring to the table, but also what we stand to gain from the contributions of the others around us.  Although the initial steps of beginning an initiative that focuses on a problem, not a five-year grant project, can be daunting, the results of innovative collaboration are no less remarkable.  When the problem is that of infertility in young women who are cancer survivors, a reproductive biologist at Northwestern University chose to establish a partnership with an engineer to address the structural and biological challenge of ex vivo oocyte maturation.  The combined expertise of two divergent branches of science led to further expansion and a move towards the clinic.  Today, the Center for Families After Cancer encompasses the work of oncologists, surgeons, scientists, engineers, ethicists, and social scientists to move forward a new field that has been dubbed ‘oncofertility’ (16).  On their own, each member of this team held only part of the puzzle, but together their skills and uniquely valuable perspectives have combined to produce a vision that is both more extensive, more accurate, and ultimately more productive than anything they could have done on their own.  Within the time-span of a career, the members of this team will see a profound change-a giant step forward-in a clinical dilemma that until now had no solution.

And if this and similar advancements are slowly developing in some areas of medicine, then why not in one area after another?  As an aspiring oncologist, the challenges are clear-from lung cancer to pancreatic cancer, the list of malignancies for which there are very few options is still far too long.  Yet with the combined expertise of talented scientists and clinicians the world over, are we closer than we think to moving past the pieces of the elephant?  The mainstay of lung cancer therapy is some combination of surgical resection, radiation, and chemotherapy, which in the end most often delay, not prevent, the inexorable progression of the tumor.  But what if that picture changed?  Imagine a world that still started with thoracic surgery and the metastasis of lung cancer but then moved to a physical chemist and nanoscale visualization techniques implemented by an engineer and then data-mined by a mathematician using a program designed by a computer scientist who then together present a kinetic model of invasion to a molecular biologist who uses an animal model to uncover a mechanism and then collaborates with a pharmacologist to design an inhibitor cocktail which is prescribed by a medical oncologist working in tandem with a thoracic surgeon.  And in the end, the patient goes home to live, not to die. 

These changes have already begun and I know they will continue-but as baby steps or giant strides? The extent to which we can revolutionize both scientific inquiry and medical treatment is directly proportional to our ability to see beyond the walls that can-but only if we let them-separate us from our colleagues.  We owe it to ourselves, to each other, and most of all to the patients who are our family and friends and sometimes even ourselves, to work towards a future that is worthy of what we have already gained and what we stand to lose if we let our moment at this historic juncture slip away.  The men in the elephant fable are blindfolded, but we don’t have to be. 

Acknowledgements: I am grateful for the thought-provoking discussion and insightful commentary provided by Alan Hauser, MD, PhD and HG Munshi, MD during the preparation of this manuscript.

Amanda J. Redig

Feinberg School of Medicine, Northwestern University

a-redig@md.northwestern.edu

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(2)  Dickson D. UK plans to encourage physician scientists. Nat Med 2000;6:490.

(3)  Weinberg RA. A lost generation. Cell 2006;126:9-10.

(4)  Vastag B. Increasing R01 competition concerns researchers. J Natl Cancer Inst 2006;98:1436-8.

(5)  McNally N, Kerrison S, Pollock AM. Reforming clinical research and development in England. BMJ 2003;327:550-3.

(6)  Zerhouni EA. Clinical research at a crossroads: the NIH roadmap. J Investig Med 2006;54:171-3.

(7)  Black N. The Cooksey review of UK health research funding. BMJ 2006;333:1231-2.

(8)  Marks AR. Rescuing the NIH before it is too late. J Clin Invest 2006;116:844.

(9)  Marks AR. Rescuing the NIH: the response. J Clin Invest 2006;116:1460-1.

(10)  Crowley W, Courtney J, Jameson L et al. The Clinical Research Forum and the Association of American Physicians disagree with criticism of the NIH Roadmap. J Clin Invest 2006;116:2058-9.

(11)  Kaushansky K, Shattil SJ. Bloodlines: the importance of mentoring for the future of hematology. Blood 2007;109:1353-4.

(12)  O’Connor Grochowski C, Halperin EC, Buckley EG. A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum. Acad Med. 2007;82:375-82.

(13)  Humphrey JD, Coté GL, Walton JR, Meininger GA, Laine GA. A new paradigm for graduate research and training in the biomedical sciences and engineering. Adv Physiol Educ. 2005;29:98-102.

(14)  Tadmor B, Tidor B. Interdisciplinary research and education at the biology-engineering-computer science interface: a perspective. Drug Discov Today. 2005;10:1183-9.

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