Sustainabilty vs. Solidarity

 

I am reading a book now written by Aaron Berkowitz entitled "One by One by One." 

Aaron is a young neurologist who has traveled to Haiti multiple times to teach young doctors and to examine patients in medical clinics. I have seen Aaron teach online and his teaching is just great in every way. 

At the beginning of the book, Aaron describes his plans to bring a young Haitian man to the United States who has a large brain tumor. (I don't actually know how this story plays out because I am not too far in the book.) 

Aaron writes about the concept of "sustainability versus solidarity" when caring for patients in Haiti. I have struggled with this concept for about 25 years. 

NeurologyToday states, "The book is a compelling account of the clashes between medical utility--making the most of limited resources to serve the greatest number of people in need of care--and the needs of an individual patient who is right in front of you."

"Would it be possible, I inquired in a follow-up email to the neurosurgeons, to consider bringing the patient to one of their hospitals for surgery? The neurosurgeons wrote back that they disagreed with trying to do this for several reasons. First, they felt that bringing this patient abroad for care would be unsustainable since there was no guarantee that this could be offered to the next brain tumor patient who might arrive at HUM. Second, they thought treating the patient wouldn’t be cost-effective—how could we justify hundreds of thousands of dollars’ worth of care for one patient when that money could be used to help so many other patients with lower-cost illnesses? Finally, they were concerned the surgery would be too high-risk, with the potential for the patient to worsen afterward, even if performed in an optimal high-resource setting. The neurosurgeons reiterated their recommendation to pursue a palliative approach by implanting a VP shunt, but not touching the tumor. 

"Sustainability. Cost-effectiveness. These considerations may be well-intentioned on a policy level, but they break down when faced with a patient in front of you. True, we likely wouldn’t be able to help every patient who needed brain surgery in Haiti. But why should that prevent us from trying to help Janel? True, for the potential hundreds of thousands of dollars that would go into this one patient’s treatment—surgery, intensive care, and radiation and chemotherapy if the tumor turned out to be malignant—we could vaccinate an entire region of Haiti against deadly childhood infections. We could probably even build a whole new hospital in Haiti. But try explaining that trade-off to Janel. What would be the point of building more hospitals if they would never be able to help him?

Berkowitz, Aaron. One by One by One (pp. 10-11). HarperOne. Kindle Edition. 

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Over the years, I have become very attached to my Haitian patients. When I examined Willie Fortune for the first time in the late 90s at Hopital Lumiere in southern Haiti, how could I look away from his playful face and his mother's worried face? The last thing I was thinking about was whether helping Willie was something "sustainable". 

Should I have told Willie and his mother that I could use Haitian Hearts money better by investing in food and feeding thousands of malnourished Haitian kids rather than investing in Willie's backward heart with many holes that had turned him blue?

I do not want to get trapped into a "false choice" with any of my patients.  The presentation of a false choice often reflects a deliberate attempt to eliminate several options that may occupy the middle ground on an issue. 

I should not have to choose between helping one patient in Haiti or helping the masses of people in Haiti. The infrastructure in Haiti needs to be strengthened so one does not have to choose who to help.  

And if one is confused, and one must choose, the default is choosing solidarity, like Aaron Berkowitz did. 

To be continued....