confluence of many related circumstances. My hope is that we will take advantage of this unique opportunity to benefit the clinical training of our
Surgery March 2013
surgery residents and to contribute to capacity building in surgical education and care in developing countries.
Commentary: Charity begins at home William P. Schecter, MD, San Francisco, CA
From the Department of Surgery, University of California, San Francisco General Hospital, San Francisco, CA
THE PLIGHT OF THE ONE BILLION IMPOVERISHED SOULS in the developing world is unimaginable, but the poor health of the 46.2 million Americans living in penury1 is a national disgrace and unacceptable. Lifestyle decisions have obvious health consequences, but poverty in and of itself affects health adversely irrespective of discretionary healthrelated behavior.2 Low-income Americans are sicker and use 2 to 4 times the health care resources compared with affluent patients (Cooper RA. Health, Poverty and Healthcare Spending. Geographic differences in health status and health care spending reflect geographic differences in wealth and poverty. Personal communication, August 23, 2010). Even residence in an economically depressed neighborhood is associated with poor health after other variables are controlled, including income.3,4 The adverse health effects span the spectrum of human disease, including cardiovascular,5 pulmonary,6 metabolic,7 and malignant disorders.8 Poor people also have an increased risk of both intentional and nonintentional injury.9 The epidemic incidence of gunshot wounds among poor urban minority youth is especially disturbing.10 An increasing number of impoverished Americans seek care in resource-constrained urban safety net hospitals stressed already to the limit.11 Access to care for the rural poor is even worse. In 2006, 925 (30%) of the 3,107 counties in the United States lacked a single surgeon, and nearly 9.5 Accepted for publication September 13, 2013. Reprint requests: William P. Schecter, MD, Department of Surgery, San Francisco General Hospital, 1001 Potrero Avenue, Ward 3A17, San Francisco, CA 94110. E-mail: [email protected]
sfghsurg.ucsf.edu. Surgery 2013;153:326-7. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.09.013
million Americans lived in those counties.12 Lack of access to operative care has a direct association with the greater rates of mortality after trauma in these ‘‘surgical deserts.’’13 Community health centers are an important component of the safety net but are usually limited to primary care. Low-income, uninsured patients who require operative care usually rely on ad hoc, pro bono services by a community surgeon or seek treatment in an emergency room. Surgical volunteer networks in the San Francisco Bay Area,14 Orange County, and North Carolina15 have made an organized response to this challenge. Operation Giving Back, a program of the American College of Surgeons, serves as a clearing house for both efforts by global and local volunteers. Although thousands of patients have been helped by these efforts, the overall health of our nation has not changed. The major determinant of life expectancy above a minimum level of household income is equity of income distribution.16 The greater the inequality of income distribution, the greater the rate of mortality. This is true when one compares life expectancies among different countries17 and among the different states of the Union.16 Unless the increasing inequity in income distribution is addressed through investment in education and social infrastructure, the health of our nation will continue to compare unfavorably with other industrialized countries. The current focus on global health is a positive development, but much work is also required at home. One thing is clear---despite the emphasis on ‘‘the broken health care system,’’ the overall health of our nation, like the health of the world, is a question of political economy, not medicine. Good policy is based on accurate information derived from research. Academic surgery, in collaboration with the American College of Surgeons, should also vigorously engage ‘‘the Surgery of Poverty’’ right here at home in the United States; this may be the most pressing domestic health issue of our time.
Surgery Volume 153, Number 3
REFERENCES 1. DeNavas-Walt C, Proctor BD, Smith JC. Income, Poverty, and Health Insurance Coverage in the United States: 2008. In: U.S. Census Bureau CPR, editor. . Washington, DC: U.S. Government Printing Office; 2009:60-236. 2. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;279:1703-8. 3. Yen IH, Kaplan GA. Neighborhood social environment and risk of death: multilevel evidence from the Alameda County Study. Am J Epidemiol 1999;149:898-907. 4. Waitzman NJ, Smith KR. Phantom of the area: poverty-area residence and mortality in the United States. Am J Public Health 1998;88:973-6. 5. Kucharska-Newton AM, Harald K, Rosamond WD, Rose KM, Rea TD, Salomaa V. Socioeconomic indicators and the risk of acute coronary heart disease events: comparison of population-based data from the United States and Finland. Ann Epidemiol 2011;21:572-9. 6. Strunk RC, Ford JG, Taggart V. Reducing disparities in asthma care: priorities for research---National Heart, Lung, and Blood Institute workshop report. J Allergy Clin Immunol 2002;109:229-37. 7. Lee H, Harris KM, Gordon-Larsen P. Life Course Perspectives on the Links Between Poverty and Obesity During the Transition to Young Adulthood. Popul Res Policy Rev 2009;28:505-32. 8. Greenlee RT, Howe HL. County-level poverty and distant stage cancer in the United States. Cancer Causes Control 2009;20:989-1000.
9. Gillespie CF, Bradley B, Mercer K, Smith AK, Conneely K, Gapen M, et al. Trauma exposure and stress-related disorders in inner city primary care patients. Gen Hosp Psychiatry 2009;31:505-14. 10. Murnan J, Dake JA, Price JH. Association of selected risk factors with variation in child and adolescent firearm mortality by state. J Sch Health 2004;74:335-40. 11. Gusmano MK, Fairbrother G, Park H. Exploring the limits of the safety net: community health centers and care for the uninsured. Health Aff (Millwood) 2002;21:188-94. 12. Belsky D, Ricketts T, Poley S, Gaul K, Fraher E, G. S. American College of Surgeons Health Policy Research Institute. Surgical Deserts in the US: Places without Surgeons. Chapel Hill, NC: American College of Surgeons Health Policy Science Research Institute; 2009; July(2). 13. Schecter WP, Charles AG, Cornwell EE 3rd, Edelman P, Scarborough JE. The surgery of poverty. Curr Probl Surg 2011;48:228-80. 14. Matula SR, Beers J, Errante J, Grey D, Hofmann PB, Schecter WP. Operation Access: a proven model for providing volunteer surgical services to the uninsured in the United States. J Am Coll Surg 2009;209:769-76. 15. Baker GK, McKenzie AT, Harrison PB. Local physicians caring for their communities: an innovative model to meeting the needs of the uninsured. N C Med J 2005;66:130-3. 16. Lynch JW, Kaplan GA. Understanding how inequality in the distribution of income affects health. J Health Psychol 1997: 297-314. 17. Rodgers GB. Income and inequality as determinants of mortality: a international cross section analysis. Population Studies 1979(29):231-48.
Commentary: The role of global surgery electives during residency training: Relevance, realities, and regulations Jason Axt, MD, MPH,a Peter M. Nthumba, MBChB, MMed (Surgery),a,b Kamene Mwanzia, MBBS,b Erik Hansen, MD, MPH,a,b Margaret J. Tarpley, MLS,a Sanjay Krishnaswami, MD,c Benedict C. Nwomeh, MD, MPH,d Ai-xuan Holterman, MD,e Evan P. Nadler, MD,f Diane Simeone, MD,g Susan Orloff, MD,c John L. Tarpley, MD,a and Nipun B. Merchant, MD,a Nashville, TN, and Kijabe, Kenya
From Vanderbilt University Medical Center,a Nashville, TN; AIC Kijabe Hospital,b Kijabe, Kenya; Oregon Health & Science University,c Portland, OR; Nationwide Children’s Hospital,d Columbus, OH; University of Illinois,e Peoria, IL; Children’s National Medical Center,f Washington, DC; University of Michigan Health System,g Ann Arbor, MI Accepted for publication September 13, 2012. Reprint requests: Nipun B. Merchant, MD, Professor of Surgery and Cancer Biology, Vanderbilt University Medical Center, 2220 Pierce Avenue, 597 Preston Research Building, Nashville, TN 37232. E-mail: [email protected]
Surgery 2013;153:327-32. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2012.09.014
TECHNOLOGY has made the world smaller. Worldwide communication is instantaneous, and those with little or no access to safety, food, and health care realize the inequalities within which they live. Surgery residents recognize the inevitability of globalization and want to address health care access and disparities under which many people live and thereby many of our residents want