When Australia’s east coast was recently devastated by floods, everyone was debating about who needed to do what and the radio crackled with the sound of discontent – a voice broke through all of that saying something like “the people need us, so we are going”.
It was at once such a simple and pragmatic statement of fact that was impossible to ignore. The voice belonged to Dr Daniel Nour, mostly unknown until his recognition as the 2022 Young Australian of the Year.
Two years ago, after an eye-opening experience on the streets of London during a medical elective, Nour founded the Street Side Medics; a charity that provides medical care to the homeless. It’s a mobile van (soon to be two) with healthcare professionals equipped with a pharmacy and point-of-care testing to meet and serve homeless people where they are. A lack of judgment, the understanding of the many paths to homelessness (including extreme weather events) paired with a welcoming attitude that requires no proof of identity are some of the key values of this young charity.
I realised that I was particularly struck by Nour’s words that day on the radio because I had spent the morning with medical students eager to discuss their future. Among the budding neurologists and cardiologists, there were plastic surgeons and sports physicians.
Finally, the quietest student – and to my mind the most impressive – spoke. Her grandmother was a GP, getting on in age but so well-loved by her patients that every day at work felt like a gift. She could be content with just that life, she smiled, as I hurried to correct the false and pervasive impression that there was anything “just” about being a GP.
Aspiring doctors in the rich world want to do many things but mostly end up doing one – becoming a specialist in a large city. They lament the corporate nature and the fragmentation of the field of medicine but are soon engulfed by the system. An ounce of passion is drowned in an ocean of regulations because the establishment, conservative by nature, does not have a great appetite for change.
It is not that those who enter medicine don’t want to help the disadvantaged, homeless or otherwise vulnerable – indeed, many think this would be a life ideally spent. The fact that so few end up doing this is because well, it is not considered a “path”, as much as an indulgence.
As a young doctor when I dared tell my boss that I volunteered at a refugee clinic, he admonished me to do something useful. Stunned at the time, I have since realised that he meant well but genuinely didn’t appreciate how the experience of a refugee clinic could help me succeed in the way he defined it, namely in terms of grants won and papers written.
What I wished he understood was that volunteering did not dilute my potential, rather it enhanced my world view. Ironically, it was that experience that gave me a foundation for understanding the complex lives of the refugees and asylum seekers I treat today.
In the shadow of the Covid-19 pandemic that has exposed many health inequities, a central tension in the field of medicine seems even more pronounced – how to honour purpose while meeting exacting standards of efficiency.
The hospital is a revolving door for patients who don’t receive the holistic care they deserve. Less time with a GP (if one is available) means less discourse and less problem-solving, leading to a slew of costly complications down the track.
Healthcare professionals haven’t lost their ability to know what a patient needs but they feel thwarted meeting those needs. It’s inexplicable that a patient might get the very expensive and unnecessary scan but not the counsellor who could offer her life-changing advice. Or that an emergency department might save the patient from an overdose and then send him right back to the dangerous streets.
The insidious thing about medicine is that when you are constantly turning away people in need or offering them less or making excuses to yourself as to why they are not getting the care they deserve, you eventually become convinced it is enough, inevitable and acceptable.
When patients with a critical illness face agonising delays in the public system but not in the private sector, somehow, the problem of affordability becomes theirs. When we lower our standards, we let ourselves down as well as our patients. In such times, we need beacons of moral clarity like Nour to remind us to do better and be better.
Last month, the world lost Dr Paul Farmer; an extraordinary doctor and public health physician committed to global health equity.
In a fine essay in the New England Journal of Medicine, my colleague Lisa Rosenbaum, recalled his footprint that spread from Harvard to Haiti and Rwanda.
Farmer rejected the mindset of clinical nihilism that holds patients responsible for the miserable conditions that imperil their treatment.
In Haiti, when many blamed the spiritual beliefs for non-compliance with tuberculosis therapy, Farmer ran a trial showing that patients who received medication as well as economic assistance, transport and community health visits had a 100% cure rate compared to 57% in the standard care (free medication only) group.
Farmer was a prolific scholar who rejected the arrogance and orthodoxy of academia. What distinguished him, however, were not the papers and plaudits, but his genuine care for people apparent in his dealings. He made the time to sit by his dying patients and to check in on colleagues.
Where medical training cautions against becoming emotionally involved with patients, he warned that this detachment could trap one into thinking that suffering was acceptable. He argued that without direct exposure to the ill and suffering, it was hard to formulate good policy.
Doctors like Paul Farmer and Daniel Nour remind us of the rightful place of social justice in the world of medicine.
Their work moves us because it shatters the assumption that one doctor alone cannot start a movement for change. They teach us that there is a role each person can play through volunteering, advocacy and sometimes choosing to take the path less travelled.
Admittedly, it’s not for everyone, but I can’t help thinking that many doctors would find the alternatives more satisfying than what is served up as modern medicine.
The healing profession contains many ways to fulfil our duty to patients and Farmer and Nour should not be an exception. When those who spot a gap in the healthcare system and steps up to use their social conscience to address it, we must not ask why but rather, why not.
