Guidance for the globally minded physician
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* Brodie Ramin, MPhil

*   © 2007 Canadian Medical Association

**Improving health for the world's poor: what can health professionals do?** Mike Rowson, David McCoy and Martin Carroll, eds. British Medical Association, International Department; 2007 70 pp. Free online at www.bma .org .uk /ap.nsf /Content/Improvinghealth

You've trained for years, it may seem like decades. You aspire to do good, but what use are the carefully honed skills and noble aspirations of Canadian health care workers in improving the health of the global poor? It's hard enough to get your own patients to quit smoking. What is a globally minded physician or nurse to do? This new guide from the British Medical Association provides some useful answers.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/177/9/1074/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/177/9/1074/F1)

Photo by: British Medical Association

The publication is arranged around 8 themes that must be addressed to improve the health of the global poor: health systems, water and sanitation, climate change, fair trade, malnutrition, tobacco control, patent law and global health leadership. Each of the 8 chapters provides a rich assessment of best practice in global health followed by a series of key recommendations.

The report opens by laying out the structural constraints facing health systems in poor countries where the average health expenditure is about US$30 per person annually. This figure is half of what the World Health Organization calculates is needed to run a minimally functioning health system. And while international donors contribute to health spending in poor countries, the aid is often given sporadically and inefficiently, for example, by focusing on 1 or 2 major diseases rather than on strengthening the entire framework of primary care.

A desperately neglected and increasingly crucial topic that the report touches upon is the link between climate change and health. The report argues that climate change will have an “overwhelmingly negative” impact on the health and livelihoods of the vast majority of the global population through an increase in heat waves, drought, hurricanes and flooding. The ethical imperative for rich countries to mitigate this harm is clear, because although poor populations have contributed relatively little to global warming emissions, they will experience the lion's share of the adverse consequences and be least able to cope with those effects. Health professionals can mitigate these harms by adopting and promoting low-carbon lifestyles that could also be healthier (for example, cycling rather than driving increases exercise and leads to less unhealthy air pollution).

The chapter on fair trade is centred around a well-documented case study of the surgical instrument industry in Sialkot, Pakistan, where 100 000 local workers produce two-thirds of the world's basic surgical instruments. Employees in Sialkot work in unsafe conditions, suffering from a high incidence of machine-related injuries, as well as exposure to toxic metal dust, noise, repetitive strain injuries and corrosive chemicals. The case study exposes the hypocrisy of a medical industry that markets life-saving devices whose very production costs lives. The report argues that the health care sector should demand that all medical goods be ethically produced, including such items as bed linen made from fair trade cotton and surgical gloves and urethral catheters manufactured from fair trade rubber.

Each of the 8 chapters concludes with a list of actions that health professionals and their associations can undertake to improve global health. The chapter on patent law asserts that health care workers can shape the terms of the debate through concerted education and lobbying. In Canada, the CMA should be firmly lobbying the Canadian government, including its representatives to World Trade Organization talks, to ensure a just international patent framework that enables the poor to access essential medicines. The chapter on health systems argues that health care professionals in rich countries should be encouraged to spend time abroad as part of their careers, and that medical students should be exposed to more international health teaching. For the truly committed, this report is packed with enough action points to keep one busy for a lifetime.

However, not every aspect of the report is necessarily best practice. The policy recommendations for improved water and sanitation reads like a menu for increased bureaucracy, emphasizing “monitoring and evaluation frameworks,” “global task forces” and “Global Action Plans.” This type of bureaucratic proliferation is often blamed for diverting resources from actual service delivery and allows critics to deride international aid work as an expensive talking shop, which is all too often true.

Nonetheless, overall this is an extremely high quality booklet that deserves to accomplish its important goal of inspiring and educating physicians, nurses, physiotherapists and others to make informed and effective contributions to global health. Canadian health care workers, equipped with this guide and armed with the desire to do good, can now tackle global health head-on.