Dreaming of a fairer world

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c3658 (Published 8 July 2010)
Cite this as: BMJ 2010;341:c3658

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Dreams are amazing. They incorporate the natural with the supernatural, the eidetic with the prophetic. One minute we're socializing with friends, or struggling with careers, and the next minute we're flying, or swimming to the bottom of the ocean. Free of our reality (conscious) and conscience (superego), dreams are a safe (symbolic) enactment (fulfillment) of secret (forbidden) feelings (fantasies) of our inner self (id) that our mind (ego) ignores (suppresses) and denies (represses). By fusing our conscious and unconscious, dreams tell us who we are, and who we can become.

Competing interests: None declared

Hugh Mann, Physician

Eagle Rock, MO 65641 USA

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India is the typical example of a country where primary care in the Goverment sector is pathetic. Most primary health centres are in such pathetic state, and the new generation of doctors are hardly trained in primary care. Everyone's aim here is to specialise and superspecialise and make a big earning. People completely lack skills are primary care specialists after their basic graduation. The result- A generation of robotic doctors who do not go to see a patient as a whole but as a money making machine - very sad indeed!!!!

Competing interests: None declared

Competing interests: None declared

Dr Kusuma Kumari G Jayraman, Doctor, PHC, Kodyaka

Moodabidri 576104

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I fully agree. The system in most third world countries is such that the poor become more poor and the rich become more rich. It's high time that we change the system and get into a better mould. In India, for example, the primary health care system is so bad but they have a superspeciality system which is world class. The result--poor people in villages die from disease which is completely curable. It's high time these disrepancies are corrected.

Competing interests: None declared

Competing interests: None declared

Dr Sumithra Joseph, Doctor,PHC Kunduvellala

671541

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Dear Fiona Godlee,

You have hit the nail on the head. In short, the poor and the disadvantaged, pay for their poverty with their lives. Who cares, though? All over the world the rich are becoming richer and the poor poorer by the day including the poorest of countries in the world. Thanks to corruption in every walk of life, mankind has become cruel to its own brethren. Elite educational system excludes the poor and the downtrodden from its purview. Thus educated, we all become elitist and get impoverished even to talk to our unequals in society. How could a doctor, trained in such elitist stream, empathise with a poor patient on his/her needs?

Even in the advanced countries the rich-poor gap is widening by the day. The patron saint of Laissez Faire, the free market economy, Adam Smith, wrote thus in his book The Wealth of Nations. “All for ourselves and nothing for other people, seems, in every age of the world, to have been the vile maxim of masters of mankind….. No society can surely be flourishing and happy of which far greater part of the members are poor and miserable. It is but equity.” Does any one think that situation has changed now? Bernard Mandeville, Adam Smith’s teacher had, of course, given the mantra for business (including pharmacy and fee-for-service hospital business) “in corporate business the sole goal is profit irrespective of consequences. Altruism has NO PLACE there at all. Your job is to make money for your stake holders!” How can we change that in medicine today? Some of your contributors were advocating small doses of alcohol for good health in past while you wrote the truth that if alcohol is banned mankind will be healthier! See the contradictions within your own society.

Even in societies with greater wealth it does not mean that everyone there is richer. For example, Saudi Arabia is very rich but half the population there is illiterate and their average life expectancy is lower than in Albania, China and Turkey, writes Kenneth Friedman in his wonderful book, The Laissez Faire. Recent UNDP report shows India to be the repository of the largest load of poor people with 429 millions in all which is even worse than the 29 poorest countries of Sub Saharan Africa put together (410 million)! Elite education of doctors makes them uncomfortable even to talk to the poor and miserable, leave alone empathizing with them when they are ill. How do we change that unless we dismantle this kind of education that breeds greed every where and replace it by an inclusive, egalitarian educational set up that could bring forth a new generation of humane doctors and other players in the world economy?

That kind of freakonomics will only solve some of our problems in medicine as well. Broad based rounded education for doctors will be the answer. Narrow sub specialization makes most of us simple robots expert in our technology but very poor in patient care, which is simply CARING for the patient.

Competing interests: None declared

Competing interests: None declared

BM Hegde, Editor in Chief, Journal of the Science of Healing Outcomes

Mangalore-575 004, India

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Generally speaking welfare means caring and promoting the well-being of a community to which all individuals are connected by means of complex social networks that I call a “social matrix.”

Individual humans are biocultural systems that interact within a social matrix, which is comprised of diverse networks such as health-medicine, sanitation, education, communication, transportation, social production (technology), and governance (security).

All these networks are essentially interlocked so that any improvement in one network will positively affect the other networks by increasing the overall survivability of the entire population(s) and its social matrix.

Opposed to welfare are diehard corporate economists and politicians whose noninterventionist capitalism has long been obsolete because corporate capitalism is essentially monopolistic.

Therefore, while welfare doctrine promotes investing in public well-being, the opponents seek prerogatives for the corporations.

The immediate beneficiaries of public spending and welfare are the marginalized and poor sections of the society and their families especially unemployed, single mothers, and young children. While cutting public spending will further depress such low-income groups, the entire society will be harmed at the long run.

This is mainly because all social groups and their activities are ultimately interconnected within a social matrix to which the well-being and survival of the entire community depends.

While public spending can regenerate/renovate the social matrix, restricting welfare will degenerate it for all the interacting individuals within the social matrix.

This principal egalitarian argument is fundamental to universality of human condition. Especially at the ongoing global phase of human social evolution we need more to invest on our social and global matrix rather than otherwise.

Similarly the actual implications of “preventive medicine” goes much beyond simple hand washing and immunization. This is because in order to prevent the occurrence of diseases the real investments should be on welfare and social matrix of the entire community.

Further reading: “Humanity and Solidarity at the Global Scale: The Federation of Planet Earth.” http://docs.google.com/viewer? a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxibWNzcmN8Z3g6N2UzYjhl NzA3NTFmN2IzNg

Dr. Kazem A. Zarrabi, Copenhagen, Denmark.

Competing interests: None declared

Competing interests: None declared

Kazem A. Zarrabi, academic researcher

BMCSRC, 2200 Copenhagen N., Denmark

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‘... at a meeting last week, delegates discussed how to get the MDGs back on track... there are three 'straightforward actions' that are cost effective and that could make a big difference: promoting free access to health care for the poor, strengthening the health workforce in developing countries, and involving affected communities in decision making’ Fiona Godlee. BMJ 2010;2010:Editor’s Choice

I congratulate the delegates for putting 'involving affected communities in decision making' at the top of the agenda for achieving the Millennium Development Goals. There has been an abject failure of the whole MDG process to involve affected communities. Real involvement does not simply mean strengthening civil society, important though that is. To be effective, real involvement means giving a voice to all stakeholders, especially those whose lives are affected by global injustice, in a context of shared learning, collective understanding, and advocacy, involving all stakeholder groups. Such a context is necessary not only for needs and priorities to be properly expressed and heard, but for those in a position of influence effectively to respond.

This is the human rights-based premise of Healthcare Information For All by 2015: www.hifa2015.org

We are a knowledge network and global campaign, supported by the BMA, with more than 4000 members in 157 countries worldwide. Our members range from senior executives at WHO Geneva to community health workers in Uganda, and including publishers, librarians, technologists, researchers and policymakers. Our shared goal is: 'By 2015, every person worldwide will have access to an informed healthcare provider.' Our focus is to explore and address the information and learning needs of family caregivers, primary health workers, and district health workers. Tens of thousands of people die every day, often for the simple reason that the parent, carer or health worker lacks the information and knowledge they need to save them. Our vision is a future where people are no longer dying for lack of knowledge. Increasingly, with access to email and mobile phones, we are able to give a voice more and more to those at community level.

The MDGs will only be achieved if we focus on the needs of healthcare providers. Healthcare providers have seven basic needs: skills, equipment, information, structural support, medicines, incentives, and communication facilities (SEISMIC). A seismic shift is required to better understand and meet these needs. Thanks to the internet and Web 2.0 technologies, the international community now has the capacity to harness the collective intelligence of all stakeholders to more effectively address these needs.

Global informal networks/campaigns such as HIF2015 have an important practical role in achieving all three global priorities mentioned in the ondon meeting: free access to health care for the poor, a strong health workforce in developing countries, and involvement of affected communities in decision making.

Dr Neil Pakenham-Walsh MB,BS Coordinator, HIFA2015 Co-director, Global Healthcare Information Network 16 Woodfield Drive Charlbury, Oxfordshire OX7 3SE, UK Tel: +44 (0)1608 811338 Email: neil.pakenham-walsh@ghi-net.org HIFA2015: http://www.hifa2015.org

Join HIFA2015 and CHILD2015 - send your name, organisation and brief description of your professional interests to hifa2015-admin@dgroups.org and child2015-admin@dgroups.org (or direct to Neil PW at neil.pakenham- walsh@ghi-net.org )

"Healthcare Information For All by 2015: By 2015, every person worldwide will have access to an informed healthcare provider"

With thanks to our 2010 financial supporters: British Medical Association, International Child Health Group (Royal College of Paediatrics and Child Health), Network for Information and Digital Access, Royal College of Midwives, Royal College of Nursing, and TRIP Database

Competing interests: None declared

Competing interests: None declared

Neil M Pakenham-Walsh, Coordinator, HIFA2015

Global Healthcare Information Network, OX7 3SE

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9 July 2010

Fiona Godlee comments that disappointment reigned at a recent millenium goal meeting in London, because targets of child mortality haven`t improved, and absolutely, this is disappointing. Seemingly disappointing also is that only 25% of sub-saharan women have contraception. How this slipped into the choreography of good demographics or epidemiology escapes me. At least, sub-sahara has an indigenous population unlike Europe, which is dwindling inexorably due to contracepting the indigenous population out of the labour market, and if things continue right into the nursing home. Europe is the old man/woman of the new age and burgeoning populations like China, Africa, Asia are the new developing nations with economies in some cases to show this. What we need is a young indigenous population to bequeath our inheritance to - money, infrastructure, economy, health and education systems...-and what the new nations need is clean water and air, food and education, and stable equitable social and political structures. Fertility is their strength, and time is already proving them right. They need to realise this and shun aid packages from the world bank or other outfits that insist on imposing contraception as a requirement for getting their money.

Europe and the western world are faced with the enormous situation of an increasingly diminishing young population, trying to support and care for an increasingly growing and dependent elderly society. This cannot be a millenium goal to foist on young nations, and unfortunately if they accept it, it is truely a crucial own goal.

Competing interests: None declared

Competing interests: None declared

Eugene G Breen, Consultant Psychiatrist

Mater Misericordiae Hospital, Dublin 7, Ireland.

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