Category Archive for 'physicians'

Editor’s Note: At the National Student Conference on February 12, 2011, Howard Zucker was the first of the day’s speakers, with a speech entitled Is Serendipity the Elixir for Social Change? A Physician’s Personal Journey into the UnknownHe received his MD from George Washington University School of Medicine at age 22 and going on to become a specialist in pediatric critical care, cardiology, and anesthesiology. Dr. Zucker has also worked at the White House, the Department of Health and Human Services, the World Health Organization, and at the Harvard Kennedy School of Government; he is also an attorney. He is currently the Senior Advisor for the Division of Global Health and Human Rights at Massachusetts General Hospital in Boston where he is leading the team on development and implementation of a Community Peace Index for use worldwide.

After opening with a heartbreaking example of an egregious human rights violation, Dr. Zucker reminded us that “…as members of the health profession, we must work towards the betterment of people’s lives and never let anything cloud our judgment, wisdom, or passion to help our fellow human journeying with us on this planet Earth.” He continued:

Dr. Howard Zucker

To protect human rights is to guarantee that others are free from tyranny, from falsehoods that corrupt the mind and disintegrate into loss of the fundamental belief that all individuals are entitled to respect and dignity. We need look no further than our own backyards during Hurricane Katrina, or across the oceans to Myanmar, Tibet, Rwanda, Darfur, Iraq, or even China. Though the United Nations and other organizations of similar ilk seem to serve as an umbrella against the raining down of human rights violations, the reality is that no one single covering can serve to blanket us from the storm of human rights issues that we weather every year across nations on all continents.

So what role does the physician, the public health specialist, the nurse, and the entire health profession play in this? Shouldn’t the sounds we hear from the ends of a stethoscope be more than just the physiologic flow of blood through a beating heart? Shouldn’t it really be that we are also hearing the sounds of any heart in trouble from broken dreams, from shattered homes, from fractured lives?

So as doctors we must look at our role as healer in many ways. Think about this for a moment. The doctor of early 20th century America came into the patient’s room, white coat buttoned down the front, distinguished-looking, and asked specific medical questions, biologic in nature, tailored to disease. He (and invariably it was a he, back then) was rewarded for clinical acumen.

However, the doctor’s role expanded. We began asking questions about domestic violence, child abuse, and elder care. We inquired about drug and alcohol use and advised accordingly. Our duty entailed addressing car safety seats, or discussing diet and nutrition. We became involved with issues of privacy rights and our DNA; we spoke about issues of birth control, about access to medicines, and social history. The doctor at the end of the 20th century was interested in the entire patient, recognizing that our health involves more than physiology, pharmacology, or pathology.

And yet, the doctors of the 21st century, you, all of you, are no longer bound by the confines of a library of words in a textbook; your reach takes you into villages in Southern Sudan, into the igloos in remote Alaska, into the mountains in Bhutan — if not literally with your feet, then with the click of a mouse, the touch of a screen, the image on a cell phone. You are the global physician. And there is no turning back. In NYC alone, there are 170 languages spoken and 36% of its inhabitants are foreign born. Even in America you need not cross the great pond we call the Atlantic Ocean, or even the greater ocean called the Pacific to find cultures from foreign soils. If we are to become the consummate clinician, we need to be part of the shrinking world. And when we bear witness to those whose best interests aren’t being addressed we must respond accordingly.  Whether with the eyes that nature gave us or the eye that technology designed, we owe it to those victimized by inequities in quality care.

Because I had asked Dr. Zucker to speak about his experience in global health and medicine to the students at our National Conference, he also addressed how he came to be a leader in the field.

So perhaps I can take you on a journey to past experiences in my life that can serve as examples for all of you. You will see that serendipity only works when it’s wrapped in hard work and listening to the wisdom of elders.

Let me begin with how change can occur through helping one single individual life. Remember the saying that a pebble in the ocean or a breeze from the butterfly’s flapping wings can alter subsequent events. Many years ago I had a patient who we will call Jessica (to protect her real name). She was only five years old but had already had several open-heart operations and now needed another one. Adorable, funny, and smart, Jessica had congenital heart disease. The insurance company did not want to cover the operation at my hospital but wanted her surgery at another facility where they really didn’t have a talented pediatric cardiac surgeon nor did they understand the complexity of her case. So what is a doctor to do? Turn a blind eye knowing that she’ll die? Of course not! I tried the usual avenues with the insurance company but to no avail. And so I finally asked the parents for some photos of their daughter. I sent another letter to the insurance company. This time it said, “I know that you are very busy and that you might not know the patient that you are denying coverage to so I thought I would send a few pictures of her.” The first one was a picture of her in the swimming pool – and I wrote the following funny caption: “This is Jessica swimming — Olympic Gold — 2020?” and then there was a picture of her spinning a baton — and the caption read “This is Jessica showing off her talent — possibly a Dallas Cowboys cheerleader” and then there was a picture of her all dressed up holding a trophy — and the funny caption I wrote said “This is Jessica at the Dorothy Chandler Pavilion — ‘I’d like to thank the Academy for this Best Actress Award.’” And then I sent a picture that had a caption that read, “This is Jessica when you deny her insurance coverage for this operation at our hospital.” And the picture I sent for that caption was that of a coffin. Within days, I received a call and ultimately she had the surgery at the hospital I worked at. Today she is a nursing student with the same spirit, energy and passion that she had at age five. One doctor, any one of you, can change a life if you truly believe you can. Do not stop when the challenge gets too difficult. Do not let any injustice occur to any patient.

It is possible to challenge the hospital administration when you believe that it is in the best interest of your patients. I could tell you many stories like that of Jessica, from getting a child on Medicare transferred from NYC to a hospital right here in Boston because I knew that the cardiologist here could do the procedure that would save her life, to other stories that caused controversies amongst the leadership. Don’t turn away from a challenge. I would sooner be fired than have to lose my integrity. You must be willing to step into unforeseen territories, figuratively and literally.

Yes, you can fight city hall! In fact, as an aside – when I was around 13 or 14 years old, I designed a recycling program for the state that I lived in at the time and sent the entire proposal to the Governor recommending that we institute this concept into all counties. The reply letter read something to the effect that the people of the state are not ready for a recycling program. That was not an acceptable response! And so I wrote back “how do you know what the people of this state are ready for until you ask them? Ask the public and maybe they are ready.” Within 5 or so years, there was a recycling program.

Remember, you are in this profession to help others. Keep that your focus. Never forget why the medical school or public health school admissions committee offered you the seat you now occupy. They believe, as do I, that you will do well for your fellow human whether it is one individual patient in a major medical center or a village of patients in a developing world. It’s not about blind ambition. As I often have said: blind ambition is when one’s ego stands in the way of one’s intelligence and casts a shadow on the brightness of all the great things that one could do for others.

We must all seize this moment to help our fellow human who inhabits this fragile Earth, for I can assure you that there will never come a time when your to-do list — personal or professional — will be completely checked off. No education, no matter the price, is worth it if you fail to generate twice as many questions to the number of answers you have received. And on the subject of failure, expect to fail, we all do, and when it happens, do not wonder what others did to you, wonder what you didn’t do yourself. I’ve had so many ups and downs in my career that if it were a rollercoaster I would have motion sickness.

Perhaps I can now turn to an example at the national level. It was my sixth day of work in Washington when the September 11th terrorist attacks occurred. My medical colleagues in New York City asked how they could help and I started wondering what citizens did the last time America was attacked — Pearl Harbor. And I went to the Library of Congress and looked through books and went online and searched files. And realized that communities came together to help out in many ways. And from that I thought — maybe we should create a volunteer group of doctors, nurses, respiratory therapists, physical and occupational therapists, and others, to serve as a backup for the public health service. Maybe there are health professionals who aren’t working full time and would express an interest in joining such a group. And maybe if they spent enough time working together on public health projects from diabetes detection and anti-smoking campaigns to combating childhood obesity, they would easily work together in the event of a catastrophe in their community.

I believed that long before another terrorist attack occurred there would be a hurricane, snowstorm, tornado, flood, fire, or epidemic that would affect many communities and that we needed a volunteer group to help out. And so I called it the Medical Reserve Corps (MRC), wrote it up and showed it to my boss, Tommy Thompson, the Secretary of Health & Human Services. He liked the idea but I think he believed it was a bit too idealistic — though he never actually said that to me. Tommy Thompson is excellent in inspiring those who want to do well for the world! And so he said, “Howard, I like you so I’m going to show it to the President.” And the President of the United States embraced the idea. And momentum took hold and the idea was announced at the State of the Union in January 2002, as part of the President’s vision for volunteerism. The Medical Reserve Corps was born. It started out as 10 programs in 10 states with a few million dollars in federal funds and several hundred volunteers. And yet today, the Medical Reserve Corps has 900 programs, is in all fifty states, has close to a quarter of a million volunteers across the nation, with national seminars and credentialing systems. The MRC was written into the bioterrorism bill in 2005 and is considered a key component of national vaccination programs. One idea — one dream and the willingness to just try. And a tremendous amount of hard work day after day, month after month, year after year — and taking the risk of stepping onto uncharted paths, entering unknown highways of thought.

And then one day after running the program for several years I walked into the HHS Chief of Staff’s office and I said that I wanted to move the Medical Reserve Corps out of my office and give it to the Surgeon General to run. And his face turned questioning and he said, “you want to give the program to someone else. No one gives up power in Washington.” And I said, that one day I would leave DC and if the MRC didn’t have a real home that it might be lost as result of inertia. I was told to think it over during the weekend and if I was really serious then he would make the move. I was serious and the MRC was moved and it continues to grow. One must always know that ideas you conceive of and then give birth to will only grow if you give them the freedom that is needed and a new place for them to venture forth from. The New York Times wrote on the front page a year ago, that if swine flu becomes a true pandemic then the NYC health department will deploy its 8700 Medical Reserve Corps volunteers in the city to supplement the health professionals already in place. I will confess that a chill ran down my spine when I realized how valuable the program had become.

It is your duty not only to receive education by others but to send it out there as well. No time is riper for this than now. With the Internet, the ether provides the breeze to carry the ethos of medicine, public health, and human rights to others across the globe.  Quite frequently many students ask how my career navigated about. It seems to be a common inquiry. So maybe I can show you how life takes unusual turns. And how I have traveled into the unknown and came out with great surprises. In truth, many things are, as the title of this speech says, serendipity. But, as I’ve said, serendipity must be wrapped in hard work and listening to the wisdom of elders. Perhaps I can share an example of what I mean. I was working at HHS and there was an international meeting of all the countries in the western hemisphere on Health & the Environment for Children. The Secretary at that time could not go, the Acting Assistant Secretary did not want to go because there was a strong likelihood that the US position might be criticized and so I was asked if I would make the journey to Mar de Plata, Argentina for 2 days. Long trip to get yelled at, I thought. But then I thought about it more and said it would be an interesting experience even if it would require a great deal of preparatory work.

While noodling over whether I wanted to go, I turned to my ultimate confidante, my mom — wisdom of elders — and said that the government wants to send me to Argentina for all of 2 days. And my mother’s reply had nothing to do with public policy, international health, politics: her reasoning was simple and practical. “Howard” she said, “you need a new leather jacket, they have great deals in Argentina and you can get one and even some new shoes for half the cost of DC or NY.” Any doubt I had was gone. I prepared for all eventualities and when I got there I was confronted by the criticism voiced by health ministers of many nations. But my preparation paid off and I fielded the questions. Then during a break in the meeting a quiet and distinguished man walked up to me and said, “you did a fine job handling the Ministers of Health that were challenging you.” We spoke for a little while. He didn’t introduce himself until after our conversation was just about over. He then handed me his card and said, “I’m J.W. Lee, Director-General of the World Health Organization. You should come visit us in Geneva one day.” I thanked him for the invitation and said I would enjoy that. Six weeks later his senior advisor contacted me and said that the Director-General wanted to know whether I would consider the position of an Assistant Director-General at WHO. And so my path turned yet again.  And no… I never did get the leather jacket!

But let’s return to what can be done to help people on an international level. The health literacy project that I spearheaded in Afghanistan is a great example of how a few people gathered around an old table in an office can generate a talking book tool that can improve public health for those in need. In the interest of time, let me just say that when everyone was questioning whether we could convince men in Afghanistan to let their wives learn about issues of health, I simply replied – it’s the “Yentl factor.” Yentl was a movie made in 1983 – long before any of you were born – where Barbra Streisand dresses up as an early 20th century Yeshiva boy so she can learn the Talmud. Her father lets her learn as long as she doesn’t go out into the public square. Drawing from that concept, I was convinced that every man in Afghanistan would want their wife and children to be healthy and that they would be accepting of this approach – even if it meant that they would learn in private. Over 6 million women in that war-torn nation have now used the health literacy tool, the talking book that we developed. No woman should ever have her health compromised for any reason in any nation. And guess what? The men are now the ones who are asking for more books for their families to use, in private as well as public. Believe in yourself, believe that anything can happen.

I am now working as part of the Division of Global Health & Human Rights at Massachusetts General Hospital on a project to psychometrically measure peace in communities in the world. By measuring peace through a definitive index, a foundation for an entire new field of study can be laid; a domain in which a scientific approach captures the essence of what fosters and what retards peace in communities. A peace index could translate subjective assessments into objective measurements and provide a paradigm shift in how we view our efforts in improving the human conditions. It’s another door into the unknown that I feel is worth opening.

The future belongs to those who dream, it belongs to those whose heart yearns for a better tomorrow for people imprisoned by walls for non-conforming speech, or imprisoned in thought from ignorance. So for those fighting for human rights, whether in Uganda where David Kato, a gay rights activist was beaten to death for protesting a Ugandan bill promoting the death penalty for homosexuality, to those speaking out and rising up against rape and terror in the Congo, against “honor killings” in Pakistan, remember that it only takes a few people to tackle tough problems.

My dear friend, Rose Styron, was not much older than you when she helped found Amnesty International because of her convictions. Amnesty International works closely with PHR and I suggest you all learn more about their remarkable work as they now celebrate their 50th anniversary. No voice should be quieted when speaking for the rights of people who cannot speak for themselves. Torture and injustice is fueled by ignorance and insecurity. It is the responsibility of tomorrow’s leaders in medicine and policy, in education and the arts, in engineering and in politics, to pull back the curtain of bias and bigotry and let those whose lives are living in sheltered worlds of erroneousness and hearsay see the brightness of wisdom and fact.

Later, Dr. Zucker compared our potential to the innovation of the Renaissance:

I believe that our society is at a turning point. It is at a rebirth much like 15th century Renaissance Italy. That was a time when our search to perfect one’s worldly knowledge transcended obstacles and bridged intellectual divides. Students of creative thought — da Vinci, Michelangelo, Copernicus and Galileo — questioned conventional wisdom. At that moment in time the Earth was finally accepted as round and the concept of human genius was defined. Theories abound as to what caused the Renaissance. Some claim the bubonic plague of late 14th century brought thinkers to focus upon the human condition. Maybe our global economic meltdown is today’s plague, or perhaps our expanding carbon footprint, or a looming pandemic of our own. Whatever wrinkle in time that one attributes our state of affairs to, let’s capture the chance, the serendipity, and find opportunities to shape a better future. Just as Leonardo, the quintessential persona of the Florentine Renaissance, invented intricate pieces of engineering and explored the mysteries of human anatomy, so too walk visionaries who will shape our tomorrows in ways we only can dream, from human rights and medicine to technology and peace.

Could the modern era comprised of greed, famine, disease, and war be coming to a close? Are all of you the bright eyes that will take the world forward to the beginning of a new Renaissance; an era that I choose to call the rejuvenation epoch? – a time when we join hands for a better cause. The chance for greatness exists. It may be in Seattle or Beijing, Dubai or Bangalore, but it breathes the air of enthusiasm. And whoever it may be, he or she will build a new vehicle of thought that crosses allegorical oceans where the storms of uncertainty will lead to a better horizon, a new era for a new world order.

The foundation behind the Renaissance scholars was the belief in the power of human ingenuity. It was an era when anything was thought possible and hence everything became possible. The world yearns for inspirational Renaissance gurus. And though pragmatists claim that money is paramount to splendid achievements, the real currency for change requires more than dollars, euros, or yen. It requires a collective will to guarantee a paradigm shift — the vision to secure a better world for future generations.

Let us recognize that the new moment, this rejuvenation epoch, is happening now. Let this century show, when the world welcomes the year 2100, that the seed was planted by a cross-cultural society at the dawn of the millennium to cast away global trouble of poverty, inequity in human rights, a pandemic called AIDS, and a climate in upheaval. Just as the Renaissance masters cast away conventional concepts so too shall we discard friction that creates inertia in our thoughts. Let’s spawn a new generation, entrusting in you the ambitious objectives of securing a better planet.

The global populous desires 21st century Leonardos who dare to make the impossible happen in all social constructs. Let our renaissance fashion a new day for history when the world reached across societal divides and embraced a better tomorrow. The morning’s light has come and we are ready to cross the threshold into our own Florentine moment. Be that change, be tomorrow’s light for medicine and public health, for human rights, for your fellow human being. Thank you.

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To promote and protect the Right to Health, a health system must be of good quality, equitable, integrated, responsive, effective, and accessible to all. The capacities of health systems can be measured in many ways. No matter how they are measured, the disparities between countries’ health systems are tremendous, and these differences are a matter of human rights. It’s evident that these disparities have a significant – and at times, astonishing – impact on health outcomes:

Approximate number of Washington, DC residents: 600,000

Population size of Ethiopia: 80.7 million

Ratio of doctors in Washington, DC to doctors in Ethiopia: 2:1

Number of countries the World Health Organization identified as having severe shortages of health workers: 57

Number of times quarterback Jay Cutler spoke the phrase “you know” during a televised interview within five minutes: 57

Vehicles recalled by Toyota in October 2009 for faulty floor mats: 4.3 million

Number of missing health workers in 57 severe shortage nations: 4.3 million

Of the 57 shortage nations, percentage of which are in Africa with severe health worker shortages: 69

Ratio of physicians to total Liberian population (2007): 1:21,000

Ratio of physicians to total U.S. population (2009): 1:386

Percent increase in number of health workers required to address African nation shortages: 140

Temperature in Celsius degrees for the boiling point of aspirin: 140

Additional health workers (doctors, nurses, midwives) required to alleviate severe health workers shortage in South East Asia region: 1.2 million

Minimum number of new health workers the US government has committed to train and help retain in the 2008 PEPFAR legislation: 140,000

Number of applications currently available for Apple’s new iPad: 140,000

Number of health workers in Africa the Japanese government has promised to train by 2013: 100,000

Amount of funding G8 nations have jointly agreed to commit to addressing the health worker shortage: $0

Washington Director, John Bradshaw, was recently interviewed by PressTV about PHR’s new report, Aiding Torture: Health Professionals’ Ethics and Human Rights Violations Demonstrated in the May 2004 CIA Inspector General’s Report.

A team of PHR doctors authored the white paper, which details how the CIA relied on medical expertise to rationalize and carry out abusive and unlawful interrogations. It also refers to aggregate collection of data on detainees’ reaction to interrogation methods. Physicians for Human Rights is concerned that this data collection and analysis may amount to human experimentation and calls for more investigation on this point. If confirmed, the development of a research protocol to assess and refine the use of the waterboard or other techniques would likely constitute a new, previously unknown category of ethical violations committed by CIA physicians and psychologists.

A team of PHR doctors authored the new white paper, “Aiding Torture: Health Professionals’ Ethics and Human Rights Violations Demonstrated in the May 2004 Inspector General’s Report.”

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The report details how the CIA relied on medical expertise to rationalize and carry out abusive and unlawful interrogations. It also refers to aggregate collection of data on detainees’ reaction to interrogation methods. PHR is concerned that this data collection and analysis may amount to human experimentation and calls for more investigation on this point. If confirmed, the development of a research protocol to assess and refine the use of the waterboard or other techniques would likely constitute a new, previously unknown category of ethical violations committed by CIA physicians and psychologists.

In a statement today, Scott Allen, MD, PHR’s Medical Advsisor and lead author of the report, said:

Medical doctors and psychologists colluded with the CIA to keep observational records about waterboarding, which approaches unethical and unlawful human experimentation. Interrogators would place a cloth over a detainee’s face to block breathing and induce feelings of fear, helplessness, and a loss of control. A doctor would stand by to monitor and calibrate this physically and psychologically harmful act, which amounts to torture. It is profoundly unsettling to learn of the central role of health professionals in laying a foundation for US government lawyers to rationalize the CIA’s illegal torture program.

Steven Reisner, PhD, PHR’s Psychological Ethics Advisor and report co-author, said:

The required presence of health professionals did not make interrogation methods safer, but sanitized their use, escalated abuse, and placed doctors and psychologists in the untenable position of calibrating harm rather than serving as protectors and healers. The fact that psychologists went beyond monitoring, and actually designed and implemented these abuses — while simultaneously serving as ’safety monitors’ — reveals the ethical bankruptcy of the entire program.

The Inspector General’s report documents some practices — previously unknown or unconfirmed — that were used to bring about excruciating pain, terror, humiliation, and shame for months on end. These practices included:

  • Mock executions;
  • Brandishing guns and power drills;
  • Threats to sexually assault family members and murder children;
  • “Walling” — repeatedly slamming an unresponsive detainee’s head against a cell wall; and
  • Confinement in a box.

Co-author and PHR Senior Medical Advisor Vincent Iacopino, MD, PhD, said:

These unlawful, unethical, and ineffective interrogation tactics cause significant bodily and mental harm. The CIA Inspector General’s report confirms that torture escalates in severity and torturers frequently go beyond approved techniques.

Co-author Allen Keller, MD, Director of the Bellevue/NYU Program for Survivors of Torture, said:

That health professionals who swear to oaths of healing so abused the sacred trust society places in us by instigating, legitimizing and participating in torture, is an abomination. Health professionals who aided torture must be held accountable by professional associations, by state licensing boards, and by society.  Accountability is essential to maintain trust in our professions and to end torture, which scars bodies and minds, leaving survivors to endure debilitating injuries, humiliating memories and haunting nightmares.

PHR has called for full investigation and remedies, including accountability for war crimes, and reparation, such as compensation, medical care and psycho-social services. PHR also calls for health professionals who have violated ethical standards or the law to be held accountable through criminal prosecution, loss of license and loss of professional society membership where appropriate.