I was recently cleaning out some boxes of photos and old papers and came across a letter my dad had sent me years ago about his experiences during World War II. My dad, Albert Sklar, who died several years ago, had written the letter before going back to Normandy for the 60th anniversary of the D-Day invasion. As I read his letter, it struck me that some of his observations might be relevant to us today as we consider the current condition of the world and how we as health professions educators, clinicians, and researchers might be able to address the various divisions and conflicts that are threatening global health.
Waiting, waiting. Waiting. Along with my GI buddies, we were waiting anxiously in Bournemouth, England for the big show, the invasion of France. It was now the middle of May 1944…. At that time, Germany had conquered France, Belgium, Holland, Luxembourg, Austria, Poland, Czechoslovakia, and the Scandinavian countries. D-Day finally came on June 6, 1944.… My artillery company landed on Utah Beach … the first thing I saw was dead German soldiers lying on the sandy beach. Our army did not have time to bury them. We supported the first army, which was the one chosen for the main assault into France…. I pulled the lanyard of our 240 millimeter howitzer. My job was not only to pull the lanyard but with three other GIs I would carry a large steel tray containing the shell, which weighed 500 pounds, and ram it into the gun barrel. We would then place a chemical powder bag into the howitzer to ignite the shell….
The day we entered Paris will always be fresh in my memory. The French people treated us like heroes. They threw flowers at us and gave us bottles of wine. There were lots of pretty girls who even kissed us.…
My father’s words help me realize how formative his war experiences had been for him for the rest of his life. He had been 18 years old when he had entered the Army; before his basic training, he had never traveled more than 50 miles away from home in his life. He was proud of volunteering for the Army and later volunteering to take on the very dangerous role of pulling the lanyard on the howitzer, which meant certain death if a shell backfired. He lost much of his hearing from the explosions. He, his companions, and the soldiers from allied nations who fought with them were united in a common effort to make the world a better, safer place, and they were willing to give their lives in the pursuit of that goal.
After he returned home safely, his experiences in World War II would inform his views of the world and our country’s place in it. If he were still alive and I were to ask what “America First” meant to him, he would probably say that Americans should go first into battle, and our allies would follow us because of our commitment and willingness to take the first bullet. He would say that it was all about developing trust with others based on our shared values, which include honesty, duty, and sacrifice. “America First” would not be expressed by the metaphor of pushing in line ahead of others to claim the biggest part of the pie or to get the best seat on a train, bus, or plane.
My father’s parents were immigrants who did not speak English when they arrived in the United States. His parents had fled the pogroms in their native Russia, and had to give up their farm and all their belongings. He understood what it meant to leave one’s native country to escape violence without any resources and having to sacrifice one’s own career aspirations so that the next generation might have better opportunities. I think he would have been dismayed about our current policies toward immigrants, particularly the mistreatment of immigrant children.
What does all of this have to do with global health and academic medicine?
I think there are both parallels and differences in the responses to the threats that faced the world during my father’s youth and the threats to the world’s health now. While the problems of climate change, population growth, health disparities, and degradation of water and air are different from invading armies, in both cases there were efforts to deny the threats, as well as failures to develop a cohesive and unified response. But in my father’s era, those denials and failures were overcome. The ultimate success of the Allies in World War II depended on countries coming together against a common enemy, recognizing their interdependence and common goals, and developing trust. But unlike the unified opposition to fascism of my father’s time, neither our country nor our world is unified in responding to today’s serious health threats, among others. Instead, there are deep political and ideological divisions internationally and within our own country. Trust in our government’s leaders has fallen, buried under the weight of daily misrepresentations or outright lies. Allies who have shared secrets with us and revealed vulnerabilities as part of a trusting relationship have been attacked as foes rather than being embraced as part of an extended family, disrupting relationships that have taken generations to build. Meanwhile, the destructive effects, including increasing health threats, of climate change become more and more obvious, yet our official policy has weakened international efforts to combat this danger. The world appears to be in disarray, unable to trust friends and neighbors and confront threats together.
Lacking trust, we in this country are instead attempting to wall off these dangers and protect ourselves through isolation. One example is our approach to immigrants, despite the fact that as a country of many immigrants, we have benefited by the richness of ideas and cultures brought to our country. Isolation and demonization of those who look, speak, or act differently from us is a denial of our historical identity. Nakae et al1 have written about the Deferred Action for Childhood Arrivals (DACA) program, an initiative that has allowed immigrant children to attend medical school and enter residency programs. However, the DACA program has increasingly come under attack, creating uncertainty about future policy.
Antagonism to immigrants also goes against the health care oaths and principles that guide the health professions and that assert that we caregivers will provide our services to all who need them regardless of their race, country of origin, or social or religious beliefs. While I notice the problem most clearly in the United States, I realize that around the world, there are similar currents of fear and mistrust of immigrants and others perceived to be different and foreign.
Compounding our fear of immigrants and those who are different is a growing mistrust of scientific facts. Scientific information and analyses have been laid aside or actually suppressed, leading to mistrust or even denial of expert opinion even in areas with a strong scientific basis and important health policy implications, such as climate change. Wellbery et al2 in this issue stress the importance of science in understanding the health effects of climate change:
[T]he scope of the health effects of climate change is unprecedented. New data on cardiovascular and pulmonary impacts of air pollution are of particular concern, because climate change potentiates the damage caused by air pollution while, conversely, air pollution accelerates climate change.
The authors conclude by advocating the inclusion of climate change topics in medical school curricula to improve the ability of students to address climate-related health problems and to encourage advocacy activities of students to combat climate change.
Similarly, there is much known—and much more that could be known if further research were supported—about public health problems like gun-related violence. Dzau and Leshner3 describe how data about gun violence could be collected while still protecting civil liberties. Kuhl and Lieberman,4 two current medical students who are alumni of the Marjory Stoneman Douglas High School where a recent mass shooting occurred, describe the burden of gun-related violence on our communities and the lack of research funding and adequate health policy to address it. They note,
As two people on the cusp of beginning their medical careers—careers that began in the classrooms of Stoneman Douglas—we cannot sit idly on the sidelines as the weapons of war continue to ravage our communities.
They encourage conversations based on current science and the research we still need to inform our public discussions about how to end gun violence.
I agree with these courageous students. Taking our cue from them, we health professions educators must be willing to write about and talk about not only issues of gun violence but other public health problems as well, based on the evidence that we have. We must also support research that seeks the evidence that is still lacking. Finally, we must be willing to act as health advocates at local, state, national, and international levels to promote policies that will address public health problems, including the problems of gun-related injuries and deaths.
These approaches are part of a larger picture where health professions educators can provide leadership to combat the disturbing trends that I have described. Below I propose four priority areas for that leadership.
We must reestablish trust in health professionals. Trust is a fundamental element of the healing relationship, leading to better outcomes for patients when they have higher trust in their health professional.5 Trust is also critical to the relationship between students and faculty6 and communities and hospitals.7 Unfortunately, trust in health professionals has fallen from 73% of Americans having great confidence in the leaders of medicine in 1966 to 34% in 20128—and I see no signs that matters have improved in the six years since. We need to understand how that happened, repair the damage, and reestablish trust. There is an additional reason for taking these steps: If we can set an example in health care for reestablishing trust, we might just be able to provide a model for the rest of society.
In a previous editorial,9 I suggested that trust is a two-way street. Trust grows out of a relationship, and both parties have responsibilities to nurture it. In medical education we might start with authentic commitment to resident and student wellness through following the suggestions of West et al.10 The two-way nature of trust is also true for the relationships with patients, families, and communities. However, the power differentials in the relationship require special care. When we or our families switch roles and become patients in the care delivery system, it quickly becomes clear how easily trust can be disrupted. Our health professions education should help our students develop an empathetic understanding of what the world looks like through the eyes of our patients so that they can preserve trust and also be effective advocates for their patients.
Our work must be guided by scientific evidence. As health professionals whose education is grounded in science, we must base our advice and our teaching on the best evidence in conjunction with the values of our patients and strive to arrive at shared decisions about health care. In discussion with patients and their families about health-related issues, we should be clear about what is scientifically known and what is opinion based on experience. There will continue to be politically sensitive topics—such as end-of-life care, the effects of climate change on health, and vaccination policies—in which policy decisions will have to be made that could affect the delivery of health care. In such cases, our knowledge of research findings and their implications for the health of our population should be the foundation of our contribution to the discussion with our patients and our communities about various policy options. We have a responsibility to understand and explain the scientific facts and uncertainties related to health to our colleagues, students, and patients.
We must create an inclusive, just health system in which all patients are treated with respect. How we treat each other at our most vulnerable times will be a measure of whether we can reverse the cruelty and prejudice and other factors that have helped lead to disparities in health outcomes based on race, ethnicity, gender, and social class. Our health professionals, clinics, and hospitals must welcome all.
The New Conversation that the journal started in January 201811 about vulnerable populations and health equity must continue. In 2019, we plan to augment what we started with a New Conversation12 that explores trust in health care, health professions education, and research because we believe that trust and health equity are intimately connected. We cannot have one without the other. Our patients and our communities must be able to trust that our first priority is their health and welfare. We look forward to the contributions of our community to the New Conversation on trust.
We must explore new metaphors for how we think about health and health care that incorporate our current understanding of the problems. Metaphors help us visualize complex ideas with familiar images and can help focus conversations about how to find solutions. Bleakly13 described the previous metaphors used for health care such as a war, or the metaphor of the body as a machine, and suggested that these are outdated and will not help us develop the ideas we need for our future. He suggested instead ecological metaphors that emphasize collaboration and presence. Ecology is the study of the relationships of organisms to one another and to the environment in which they live.
One ecological metaphor that has been appealing to me is that of the earth as the patient. Using such a metaphor, one can view the increasing global temperatures, growing population, worsening pollution of our air and water, and the disappearance of numerous species as signs of illness that can affect the health of the earth, just as if the earth were a patient in a clinic or hospital. All of us who live on the earth would have a stake in its recovery from illness. Such a metaphor might encourage health professionals to develop a global health identity to help reverse these trends, which we could encourage through health professions education.
My father became a global citizen when he recognized that the fates of the United States, England, France, and even those countries that were defeated were intimately tied together. I hope it will not take a war for us to recognize this relationship again, but it seems that we have lost sight of this key lesson that came out of World War II. Fortunately, we have powerful tools to share information across borders that did not exist in my father’s time—the Internet, cell phones, and computers that can analyze huge databases and provide health information to the most isolated populations. We also have students who are our ambassadors as they visit countries around the globe and understand the connections between them. They have grown up as global citizens without many of the biases that have limited our ability to think and act globally. Many of our country’s institutions have also developed partnerships with foreign institutions that demonstrate the opportunities for cooperative learning and problem solving; the faculty and students have brought back to their home institutions an appreciation for what is possible when working together. Their stories provide rays of hope.14
My father ended his letter to me with, “I will always remember my experiences in the Army during World War II. I was very proud to serve my country.” I hope that as his voice and the voices of our other World War II veterans fade into history, we do not forget their sacrifices or the lessons they learned. They had to resort to dangerous warfare to heal the planet from the scourge of fascism. Many people died, and others suffered terrible losses. I hope that we can reestablish trust in the health professions, respect for science, and a commitment to health equity without such sacrifices, but I suspect we will have to make other sacrifices. I am not sure what they will be, but I hope that our health professions education community will provide the leadership within our academic community and serve as an example of what we can do to heal the planet and all of us who live on it.
David P. Sklar, MD