By Joseph Reardon
Working on the ground in a global health field position is a special chance to observe the collisions of world views, and Georgetown, Guyana is one of the most spectacular melting pots to do so. I am fortunate to work with resident physicians, nurses and students who are supremely passionate about providing the best emergency care for everyone who comes through our doors. We have great and powerful motivations from our faiths, families, friends and life stories. But as is always the case, an army of do-gooders cannot meet the needs of a whole population. How do we move from the cottage industry of global health into a world of systemic change?
Jim Kim identified it perfectly: we have little in the way of implementation science. Or to put it in another way, we have not translated our internal motivations into the language of the world economy to effect change. Jim Kim’s solution? We need MBA’s to run the field of global health.
As a young budding medical student in Farmer and Kim’s Social Medicine course, I was skeptical that “selling my soul” to the business world could actually make me a more effective global health practitioner. Yet, every day in the field, I become more convinced that Kim was right all along.
Economic considerations in global health aren’t a matter of “selling out” good intentions. In my hospital, we make economic decisions all the time, which in the words of Michael Porter are really framed around the value of care. We decide that we won’t CT scan a patient with a critical brain injury because the hospital’s charity fund for CT scans is nearly exhausted and the prognosis is already poor. We decide that we can’t intubate a moribund elderly patient because our one ventilator is occupied and we can’t afford to lose a highly trained nurse to hand ventilating with a bag valve mask. We use ethanol instead of chlorhexidine. We don’t measure bicarbonate on our metabolic lab panel. We use gloves instead of tourniquets.
But we can do better. Oftentimes an up-front investment in resources will yield far more benefits in the long term than continuing to work with nothing. But we have to make the case to funding agencies, administrators, ministries of health and even our colleagues. The common language we can use is cost-effectiveness: weighing the life-years or quality of life on one hand (expressed often in disability- or quality-adjusted life years or QALYs) and the cost we pay up front on the other hand. What is affordable in Canada may not be affordable in Guyana, and what is affordable in Guyana is likely not affordable in Tanzania.
Only a few studies in emergency and acute care have begun to look at cost-effectiveness and value of care initiatives. In the US, I don’t often consider cost in making patient care decisions because I know that the patient and the insurance company, but in Guyana we discuss these decisions daily on rounds. Moving my residents from the bedside decision (who gets a CT?) to the population decision (how are our criteria for CT different from European guidelines?) requires incredible granularity of thought. And therein lies one of greatest benefits of global health: we bring our hearts to the table, we sharpen our minds, and we make the best decisions we can to help the most patients.