In the past few decades, the pace of globalization—the phenomenon by which economies, as well as ideas, language, and culture become integrated worldwide—has drastically accelerated. Fueled by diminishing barriers to trade, greater ease of travel and transport, and widespread adoption of information technology including the Internet, the benefits and drawbacks of globalization continue to be debated on the international stage, with proponents and opponents clashing in ivory towers and on the streets. Despite the controversy, few dispute that globalization has had a major impact on both the health of populations and the systems that provide health care.
This issue of Virtual Mentor, titled Medicine in the Era of Globalization, explores issues faced by physicians, scientists, patients, students, and travelers in an increasingly globalized world. The global nature of this issue extends beyond its content to its contributing authors—many of whom work in countries around the world—Kenya (Jennifer Cohn), South Africa (Brook K. Baker), Ghana (Frank W. J. Anderson), Egypt (Sheldon Watts), Bangladesh (William Greenough), Australia (Mark Boyd), and Thailand (myself).
The spread of commercial aviation has allowed people, goods, and microbes to move quickly from one place to another, making it difficult to contain the spread of emerging infectious diseases such as SARS, which spread to 37 countries from Guangzhou Province, China, in 2003. In the medicine and society section, Dhrubajyoti Bhattacharya explores travel restrictions and transnational health threats in light of H1N1 (swine) flu, declared by the World Health Organization on June 19, 2009, to be the first global flu pandemic in the last 41 years. The case of cholera in British India is discussed by Sheldon Watts in the history of medical article, highlighting how those in power often attribute the origin and spread of deadly diseases to the “other,” despite ample scientific evidence to the contrary.
The theme of blaming the “other” has resurfaced in debates on immigration within the United States. Immigrants—especially undocumented immigrants—have been scapegoated by the media for skyrocketing medical costs and the collapse of state health care systems. Repatriation of immigrants—both legal and illegal—has become an option of last resort for hospitals around the country who find it more cost-effective to pay for a private aircraft to deport a chronically ill patient than to provide long-term uncompensated care. In a clinical commentary, William Greenough discusses a case of a physician confronted with the impending repatriation of a patient who depends on chronic ventilator support. The clinical pearl by Stephen C. Morris likewise focuses on the acute management of the polytrauma that landed the patient in the chronic ventilator support unit after a near-fatal car accident.
Medicines and medical technology that are unavailable or unaffordable in one country may be ordered from an Internet pharmacy operating in another country with the few strokes of a keyboard and a credit card. Faced with the high costs of pharmaceuticals and the lack of adequate public insurance in the United States, many patients are turning to the Internet to find cheaper or generic drug options. Legal and ethical issues surrounding parallel importation of drugs from outside the United States are explored by Jennifer Cohn in a clinical commentary about an uninsured patient with AIDS trying to buy generic antiretrovirals over the Internet. Kristin E. Schleiter touches on the subject in a health law piece about FDA regulation of drug importation. Patents, pricing, and the need for innovative intellectual property regimes to ensure access to medicines in both the developed and developing world are examined by Brook K. Baker in the policy forum.
With the Internet revolution, both patients and physicians now turn to their computers to garner knowledge about symptoms, diagnosis, and treatments. To practice evidence-based medicine, physicians must keep up with the continuing stream of published research. Unfortunately, many countries in the Global South do not have the financial resources necessary to purchase access to medical journals or databases online. During my time abroad as a medical student, I often was asked to pull articles that were unavailable through the local medical library in Thailand. The need for open-access publishing that makes up-to-date information available to health care professionals is the subject of an op-ed piece by Gavin Yamey.
As the world has become increasingly interconnected, medical education and research have developed across borders. “Brain drain,” a term used to describe the emigration of human capital from one country to another, has played a pivotal role in the health care worker crisis in sub-Saharan Africa and other countries, with many health care professionals from these areas migrating to high-income countries such as the European Union, United States, and Australia. The struggle for medical schools to keep trainees in-country to deliver health care to its people is explored by Scott Barnhart in a clinical commentary on an Indian medical school dean’s decision about whether or not to accept American students.
Multinational clinical trials have expanded to include sites in developing countries, many of which bear a disproportionate burden of disease. The journal discussion by Mark Boyd reviews a 2009 New England Journal of Medicine article by Glickman et al. on the ethical and scientific implications of the globalization of clinical research. Boyd offers an alternative viewpoint on how to develop both North-South and South-South research collaborations. Following in the same vein, the medical education piece by Frank W. J. Anderson and me emphasizes the importance of attempting to create sustainable partnerships and projects that benefit both parties, and offers advice to those who are planning to work abroad as medical students, residents, or attending physicians.
As physicians trained in the richest country in the world, we have special obligations to advocate for patients—locally, nationally, and internationally. Whether this means ensuring that informed consent is obtained in a medical clinic abroad or lobbying Congress on bills promoting increased access to medications for all patients regardless of their immigration status, physicians are in a unique position to make a difference. I hope this issue of Virtual Mentor helps you explore various aspects of medicine in this era of globalization—and inspires you to do something about it.