Much that is good and too much that is disparately tragic

Synopsis of a long blog entry: The disparate socioeconomics of health
and healthcare are evident seemingly everywhere. And those who get
published and come to even international bioethics conferences may
represent only the better off. Many others of our int'l colleagues
labor, live, and die in relative obscurity due to disparity of income,
though not of intelligence or ability or educational level. In one
place, central Philippines, I was informed of typical clinical ethics
dilemmas almost exactly opposite from our own--due probably to
differences of culture, medical resources, and especially of income.

So...

I am writing--iPhone thumbing actually--from a sleepy picturesque
harbor village on Lantau Island of Hong Kong. A 40 min ferry ride
brings one to HK City and what must be the most architecturally
interesting and beautiful metro area in the world. Hi-tech, also. It
would be instructive to learn more of their healthcare system, visit a
hospital (or several--both for the rich and for the poor). Next time.

We notice many elderly people here, but mostly in the villages on
Lantau Island, where we are spending time this trip. In the fast-paced
city, it seems primarily to be able-bodied young people who are able
to negotiate the many stairs, steep grades, and crowds on public
transportation. From prior visits and local friends, I am inclined to
think the elders are there too, but up in their highrise apartments or
in densely populated older neighborhoods less accessible to tourists.

Prosperous 2010 Hong Kong is vastly different than the city I visited
as a college student in 1977. That time I stayed with a Chinese pastor
friend and had no funds for tourism. So it was the common life I saw.
And despite my own indigent state, I was struck then by the relative
poverty all around. Not so in 2010.

This time the economic, medical and generational comparisons are with
the Philippines, where I have been for two weeks prior to this week.
We saw so few elderly people there. Children everywhere. Older people
hardly anywhere. We were not in metro Manila or other urban areas, but
in rural Central Philippines and smaller provincial cities and
neighborhoods.

Our hosts and teaching colleagues were well educated professionals,
including physicians, nurses, professors, and clergy. Mostly young
adults. Gracious, generous, hospitable. Virtually all living on
salaries significantly lower than those of comparably trained
Americans ($8-12k annual salary for a primary care doc; $4k for our
university professor colleagues; $1k per year for the avg Baptist
pastor). Cost of living is less than in the US, but not that much less.

Many of our new Filipino friends seemed to be without living parents
or grandparents, probably due in part to a healthcare system
apparently modeled after the US, but lacking sufficient public funds
and technology to extend and sustain life as is commonly done in the
States currently. At least for some, and especially for elders via
Medicare. Dialysis, for example, is available in Iloilo City mostly
for those who can pay and/or who have the right relationships. (It is
a matter of professional ethics, I was told, that colleagues
reciprocate care and services without charge.)

This is in a provincial capital with several large hospitals, at least
two medical schools, and a number of nursing schools. I gave a
hospital CME lecture at a 350 bed institution, and met for a couple
hours with the chief administrator (an MD with MPH from Boston U),
chaplains, the physician head of a newly established bioethics
committee, et al. In Bacolod City, Ruth and I spent time with a
wonderfully competent psychiatrist friend and others.

My talk in Iloilo was a version of one given at KUMC last month for
medicine grand rounds. On the ethics of medical futility. At KU
Hospital, the typical ethics consult often involves a patient or
surrogate who wants physiologically futile, noneffective treatment
options--and providers who want to say no, but aren't sure they can or
should or are allowed to. At IM Hospital, the case scenario I was
presented with by the pediatrician chair of a "bioethics committee"
was this: What ought we do when a family refuses AMA a curative
treatment for a child who will have ongoing but treatable, health
issues? The family's rationale is that medical treatment of this one
sick(ly) member will have a devastating financial impact on the rest
of the family. Implicitly, the tragic choice they face, and clinicians
then also, is that of the sacrifice of one life for the well-being (or
lives?) of many.

My response was simply, "I'm so sorry. I don't know what you ought to
do. This is such a tragic choice for all of you..."

I also apologized for the economic and political choices I/we have
made in the States that have directly or indirectly affected the
choices available for most Filipinos.

My own clinical ethics case scenario--demands for "futile" hi-tech
treatment, with or without the means to pay--brought blank stares from
my Filipino colleagues. We found commonality and mutual concerns
elsewhere, even in the language of "futility," but differences of
note, also.

Including the (non)use of advance directives, ethics committees and
consultation, organ donation and transplantation, stem cell therapy
(BMT), clinical trials, etc.

And virtually no one I met there had either the time or means to make
known their own contextualized perspectives via publishing or
conferencing. To what extent then do we in the States base our
generalized thinking on the voices of an economically privileged
professional minority, when perhaps the vast majority of our int'l
colleagues remain silenced by a disparity of resources even to engage
in collegial dialogue?

Except when a few of us are privileged to go visit, to listen, and
possibly learn.

Enough 'thumbing' of the iPhone for now. More than enough! But my
reflection, questions, thinking will continue. The world is an
interesting place, filled with much that is good and too much that is
disparately tragic. Of that, I am quite certain--and less so regarding
some other matters apparently more particular than universal.