In Defense of Irrational Medicine

A recent post at the change.org global health blog discusses a few global health programs that do not improve global health very much for how much they cost. Examples include Hospital ships and flying patients to the US for medical care. You could say that these programs use resources irrationally, Alanna goes so far as to say that such programs are immoral.

I think a key issue at the heart of some such of programs is the balance between long term effectiveness and the fierce urgency of now. I agree that the programs she describes would play a very small role in an ideal global health care service, but ultimately what we need more than any specific program is for people to give a damn. Some people have excess resources; we need them to care enough that they are willing to share some of those resources with the rest of the human family. If irrational programs will occasionally inspire people, perhaps they are worth the cost.

I’d like to discuss an example. The organization Partners in Health works in Haiti, and will occasionally fly patients to Boston to receive complex treatments that are not available in Haiti. They call it their Right To Health Care program. One recent patient was a young boy who needed to have a hole in his skull repaired. The flight and the procedure were admittedly expensive; the same amount of money might have purchased many bed nets or vaccines. But for the health care providers involved, the issue at stake was whether they were willing to treat this little boy like a beloved family member, whether they were willing to do whatever it would take to help him be healthy. In this instance PIH chose to respond to the fierce urgency of now.

PIH’s difficult work is possible in part because they have attracted very dedicated staff by telling controversial and emotionally charged stories, and following up with stories of hope and healing. Such acts are not purely metaphysical, they shape PIH programs. PIH has incredible, even enviable support in the communities where they work, in part because community members hear about stories like this little boy’s and they think, “wow, these people must really truly care about us an awful lot.” I also know individuals in the USA who have had the course of their lives changed by this brand of irrationally inspiring dedication. I’ve met people who heard a PIH story like this and decided that they were going to donate what they could to PIH every month from that point on – indefinitely. In my own case, I read of such efforts and decided that I too would become a doctor for the poor. I dare say my contributions to humanity will outweigh the cost of flying one needy child to Boston and performing a pro-bono surgery. I cannot emphasize enough how plausible it is that I might not have come to care, that I might have marched though life without being inspired.

Logistically, economically, such decisions do not make sense. They are irrational. And yet, a great many people ache for that kind of leadership, and to emulate such reckless devotion. I am forced to conclude that there are depths of the human soul which I do not yet understand.

12 Responses to “In Defense of Irrational Medicine”


  • All I can say after reading this is, “wow.”

  • I just linked to this in my entry!

  • The flight and the procedure were admittedly expensive; the same amount of money might have purchased many bed nets or vaccines. But for the health care providers involved, the issue at stake was whether they were willing to treat this little boy like a beloved family member, whether they were willing to do whatever it would take to help him be healthy. In this instance PIH chose to respond to the fierce urgency of now.

    You’re right about the issue at stake, which is exactly what’s wrong with this picture. Surely health care provision – especially in developing countries, where it is such a valuable commodity – shouldn’t rely on staff privileging individuals, but on a professional approach to medicine that maximises the amount of care provided against the amount of money spent.

    Doubtless everybody felt warm and fuzzy about this particular child, but that’s because any other children who died because of the opportunity costs of this operation were essentially invisible to the organisation. (Luckily they’re also invisible to the community covered by this provision, otherwise they’d have a lot less buy-in.)

    I don’t deny that “the fierce urgency of now” sells better than vaccination programs, but I tend to think it also continues to paint individuals as passive recipients of western largesse and fails to educate the public about the real issues around global health. Interestingly, this seems to be at odds with the stated beliefs of its founders about basic rights – another example of how organisational prerogatives often trump individual beliefs.

  • This is a good call. I also agree with what PIH did, although for a different reason. In Infections and Inequalities, Dr. Farmer makes the argument that thinking about whether to fund HIV prevention or HIV treatment is a “false dilemma.” There is money to do both, it is just not in the right hands (read: the poor are still poor, the rich are still rich). Sending the child to Boston is the same imagined dilemma–we should refuse to let him die because of the cost of the flight, and we should refuse to let someone go without a bednet. We would just need to do more fundraising. “Whatever it takes.”

    I think it’s a little of a circular answer, but it def seems to sound right.

  • Important point Alex, I was already thinking of a follow up post on that point. In Mountains Beyond Mountains, Kidder documents a more personal version of this argument regarding the “false-dilemma” of many cost-effectiveness arguments. Dr. Farmer thinks we must develop a certain “spirit” to overcome such dilemmas and understand abundance in a social economy that emphasizes scarcity and risk. I agree.

    “But some would ask, ‘How can you expect others to replicate what you’re doing?’ What would be your answer to that?”

    He (Dr. Farmer) turned back and, smiling sweetly, said, “F**k you.” Then, in a stentorian voice, he corrected himself: “No. I would say, ‘The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB.’” He was grinning, his face alight. He looked very young just then. “In other words, ‘F**k you.’ ”

    We started on again, Farmer saying over his shoulder, “And if it takes five-hour treks or giving patients milk or nail clippers or raisins, radios, watches, then do it. We can spend $68,000 per TB patient in New York City, but if you start giving watches or radios to patients here, suddenly the international health community jumps on you for creating nonsustainable projects. If a patient says, I really need a Bible or nail clippers, well, for God’s sake!”

  • There is money to do both, it is just not in the right hands… Sending the child to Boston is the same imagined dilemma

    No, it very clearly isn’t. Unless this organisation has access to an infinite amount of resources, there will always be choices about how to use those resources. Since an infinite amount of resources does not exist in the world, it has to make those choices. In this instance, it chose to spend its resources in a way which I consider undermines its stated goals.

  • Thanks for being part of the discussion Paul,

    Unless this organisation has access to an infinite amount of resources…

    The point Alex was making was that the world’s collective resources are much more than sufficient to meet the world’s collective needs, and so I think you are exactly right when you say that the issue is accessing those (not infinite but surely excessive) resources. Whether we can explain it or not, whether we like it or not, making people feel warm and fuzzy can increase access to resources like publicity, money, and volunteer energy. Ultimately it’s not a zero-sum game. Symbolic acts are crazy and immeasurable, they won’t submit to the “if I can’t quantify it precisely than it doesn’t exist” theory of cost-benefit analysis, but they are important.

    Partners In Health is a case study, they’ve been very successful at accessing resources lately (the Clinton Global Initiative is helping them build a comprehensive national health service in Rwanda right now). I’m also a case study. From personal experience, I think critical analysis and prudent use of resources are necessary but not sufficient conditions for the change we need. Passion is also necessary to unleash the world’s resources.

  • Whether we can explain it or not, whether we like it or not, making people feel warm and fuzzy can increase access to resources like publicity, money, and volunteer energy.

    Unfortunately my position is that making people feel warm and fuzzy is a symptom of the problem, not part of the solution.

    Symbolic acts are crazy and immeasurable, they won’t submit to the “if I can’t quantify it precisely than it doesn’t exist” theory of cost-benefit analysis, but they are important.

    My principle here is simple. I wouldn’t find this behaviour acceptable if my local hospital did it; just because the recipients are poor in this case doesn’t make it any more palatable. I have a strong suspicion that (ironically) organisations like PiH can continue to get away with it precisely because their constituency has no voice of their own.

  • p.s. While I realise that I sound particularly harsh, I hope it will be taken in the constructive spirit in which it was meant. This has been a particular issue for me ever since I started working in the humanitarian sector, and I really worry that we don’t seem to be changing this very Victorian idea of philanthropy.

  • Hi Paul,

    I definitely take your comments in the most constructive way possible, I really do appreciate the dialog. Perhaps something we could agree on is the idea that humanitarian work should be more evidence based and data driven. We could probably agree on making something like the BACO test a standard procedure for just about every project. We could probably agree that most organizations should do more to constantly experiment and tweak their operations to bring down costs per unit of result, and that funders should encourage, help pay for, and expect such innovation.

    Perhaps the common ground is that our first priority should be to reach the many people and organizations that aren’t even thinking about measuring and increasing units of output per unit of input. Some of us will measure and improve the reach of our programs and still choose to make certain expenditures that are not very sustainable or even sensible in a zero-sum world, but that is different than not even knowing or caring about comparative effectiveness or opportunity costs.

    Completely unrelated note: it looks like the Chronicle of Philanthropy picked up this conversation (not sure why it didn’t auto-pingback). Cool! Thanks.

  • Hey All,

    Alanna at the change.org global health blog touches on this theme in a recent post. I recommend you check it out.

    cheers
    Isaac

Comments are currently closed.



© isaacholeman.org | colophon