BMJ  2005;331 (10 September), doi:10.1136/bmj.331.7516.0-f

Editor's choice

The kindness of strangers

On the fourth anniversary of 9/11, Americans find themselves once again counting the cost of an unimaginable catastrophe. This time though, the world has looked on not in awe at the human spirit arising from the ashes of the Twin Towers, but in shock and shame at the sight of the world's richest country doing so little so late for its poorest people. The fallout from Hurricane Katrina will be weighed in thousands of lives lost and many more thousands wrecked (pp 526, 531, 582), and in further damage to America's reputation around the world.

When the US government finally accepted offers of help from the United Nations last week, secretary general Kofi Annan might have been forgiven for feeling a certain degree of schadenfreude. This is after all also the UN's 60th anniversary, an opportunity for the UN's critics to crank up pressure to reform. Few would disagree that the UN is inefficient, bureaucratic, and encumbered with an impossibly broad mandate. In this week's BMJ, Kelly Lee calls it "a management consultant's worst nightmare" (p 525). But in the build up to next week's UN summit, US criticism of the UN—embodied in the form of US ambassador, John Bolton—has moved beyond these well worn gripes to questioning key aspects of the UN's strategy. Most significantly, Bolton has called for the removal from next week's agenda of all reference to the millennium development goals (MDGs).

Whatever one's view of the MDGs (seen by some as reflecting the priorities of donors rather than recipient nations and by most people as probably unachievable), they do focus attention in the rich world on the health needs of the poor. Targets give the international community a stick with which to beat itself when it falls short on commitments, as it is clearly doing (p 536).

The US government wants the world's attention to shift elsewhere, but the UN must resist this, whatever threats its largest donor makes to withdraw funding. America's own recent experience shows the dangers of diverting funds from routine public health initiatives to perceived, and probably overestimated, threats to homeland security. Erica Frank estimates that on 11 September 2001, and on every day since then, over 5000 people died in the US from 10 leading causes, including heart disease, cancer, and stroke (p 526). "Predictable tragedies happen every day," she says, but funds are being diverted to prevent bioterrorism, leaving health departments in the US without money for basic disease surveillance. The most recent effects of the diversions of funds can be seen in the disastrous flooding after Hurricane Katrina.

The neglected levees will be repaired, the flood waters will recede, and street cars will again ply their routes to New Orleans' sunken districts of Desire and Cemetery. But how much will America's leaders be willing to learn from their unfamiliar and uncomfortable experience of having had to depend on the kindness of strangers?