Why global health matters to US primary care physicians.

Abstract

In 1991, New York City was besieged by an outbreak of multidrug-resistant tuberculosis. Before it was over, more than 500 people had died because the isolates of Mycobacterium tuberculosis were resistant to 1 or more of the standard therapeutic “cocktail” of isoniazid, rifampin (rifampicin), streptomycin sulfate, and ethambutol hydrochloride. The direct cost likely exceeded $1 billion; the indirect social costs of fear, anxiety, and isolation were immeasurable.1 We undeniably live in a global environment. Every year more than 500 million people cross borders in planes.2 With them travel latent tuberculosis, subclinical infections of influenza, and more exotic infections such as West Nile fever. Microbes crossing borders are worrisome, and the emergence of multidrug-resistant strains of Yersinia pestis in eastern Europe is cause for alarm.3 Primary care physicians work in this global context. They need the skills to offer health advice and prophylaxis to patients who travel abroad and to confront a malady in a recent immigrant to America. In 1997, for example, 1 in 4 Californians was born outside the United States—half of these were from Central and South America, and a third were from Asia.4 In the United States as a whole, 39% of all tuberculosis cases are in foreign-born individuals; in California, this proportion is 69%.5 But our interest in international health should go beyond infectious maladies. International health also is about cross-cultural health. Physicians who work with immigrants quickly realize that their East Asian patients prefer injections to pills. But how many are aware that Germans commonly worry about Herzinsuffuzienz (heart failure)? Even therapy has a cultural dimension. The French use suppository medication 7 times more often than their North American relatives.6 Cultural translations of vague symptoms are important in determining the level of care that a patient needs. For example, third-generation fully acculturated immigrants may complain simply of fatigue, but their first-generation Filipino grandparents describe the same symptom in terms of dizziness and other neurologic symptoms. Understanding the meaning of these symptoms requires cultural competence among physicians. The origin of resistant infectious diseases and the need for cross-cultural competency are examples of direct links between primary care and international health that affect the daily practice of medicine. The indirect lessons also are compelling reasons for primary care physicians to be globally attuned. Drug formularies, universal insurance coverage, and shared public or private hospital services all have their genesis overseas. Indeed, US primary care medicine can learn much from other countries when it comes to health services and policy. Why, for example, is life expectancy in Sri Lanka (73.4 years for women), one of the poorest nations in the world, close to that of the United States (79.7 years for women)?7 The rest of the world's health care systems, like ours, are experimenting with innovative ways to lower costs and raise quality. Specialist care, such as triage care for trauma and newborns, or integrated electronic medical records have been exported from the United States with great success. However, importation has been slower. For example, in many parts of the world, myomectomy has replaced total hysterectomy for treating menorrhagia due to fibroid tumors because it can spare a woman's fertility.8 But the use of myomectomy has been slower to catch on in the United States. Some physicians are (at last) doing these more routinely. One reason that primary care physicians should be interested in global health transcends all others—compassion. The global AIDS epidemic is the greatest public health catastrophe in recorded human history. Today, 13.2 million children have been orphaned by the human immunodeficiency virus.9 Malaria eradication, if it could be achieved, would spare the lives of the children who today die of the disease at the rate of 1 every 30 seconds. Physicians are ideally placed to be role models of compassion. Helping those who suffer from illness, regardless of the patient's country of origin or disease, is central to the healing profession. If primary care physicians show concern about global health, others both inside and outside the medical profession will follow suit. The results of this concern could prove dramatic—mobilizing all involved in health, from the basic scientists to health policy makers, to create a world where there is a vaccine for tuberculosis and the threat of drug-resistant tuberculosis is a thing of the past.