Reaching out

Peter MacPherson swapped clinical medicine for a career in public health. He explains how studying for a degree in public health changed his perception of medicine and life

Call me an idealist. You can even say that I’m naïve. Maybe by now you’ve realised that medicine is about survival. Your survival through countless ward rounds, the survival of your friends and classmates during another exam period, and ultimately, the impossibly hoped for survival of the patients you meet on the wards.

Second thoughts
During medical school, I began to realise that this constant struggle for survival was vastly different from what I had imagined for my life within medicine. Didn’t I study medicine to help people and cure disease? It wasn’t that I didn’t enjoy learning the anatomy of the brainstem, but surreptitious thoughts kept sneaking into my head, saying what was the point in learning this when there are millions of people dying from diarrhoea and pneumonia throughout the world? Lecturers, of course, never told us how many people were dying of diarrhoea, preferring instead to ramble on about the importance of sodium channels.

Need for a change
On starting work as a medical house officer, this unsettling feeling grew stronger. I quickly realised that being a successful PRHO (preregistration house officer) involved patching people up as best as possible and helping them organise their life so that their next admission could be averted, or at least delayed. While working as a surgical house officer, it seemed like the majority of my nights were spent sewing up cuts in drunken people’s heads. Throughout my PRHO year, my overriding feeling was of being in the wrong place at the wrong time. Preventing disease was surely much more worthwhile than trying to deal with the consequences, wasn’t it? And there were areas of the world where running water, let alone a CT scan, were a luxury.

The epiphany
During one particularly quiet night on call, I stumbled across the website of the Harvard School of Public Health. Maybe it was just because of all the coffee I had drunk, but the words disparity, global burden of disease, and avoidable deaths seemed to leap off the page. The articles written by eminent scientists, and the links to research papers detailing studies into child mortality rates and clean drinking water projects, made the Harvard School of Public Health seem like the most academically exciting place on earth, and exactly the sort of thing I was looking for. In addition, the school seemed to possess an ethos of determination to reduce inequalities in health that resounded with my feeling that poor health is mostly caused by poverty and oppression.

Further research led me to the Kennedy Memorial Trust. Devised as the British people’s memorial to President Kennedy, the trust was established in 1964 in order to give graduates who were interested in global cooperation the opportunity to study at Harvard or the Massachusetts Institute of Technology. After mountains of paperwork, entrance exams in maths and English that I had forgotten years ago, numerous interviews—not to mention the particular intricacies of the American visa system—I was awarded the first ever Kennedy Memorial Scholarship to undertake the Masters in Public Health programme at the Harvard School of Public Health. I was to be enrolled in the International Health Concentration, which meant that I would be studying public health topics with a global focus, such as international development.

When I mentioned to colleagues on the wards that I wasn’t applying for SHO (senior house officer) rotations, but instead would be studying public health, I would usually get a biphasic response—initial gentle bemusement, followed by the sharp exclamation, “I could never go back to sitting in a lecture theatre!”

Making sense of it all
Admittedly, on the first morning of the term, I felt a little nervous walking into the biostatistics classroom. What if they jumped right in at linear regression and I thus felt completely lost? Would I be able to stay awake? Like any other junior doctor, shouldn’t I be clerking patients and running after the consultant instead?

Fortunately, the initial shock of actually using a calculator wore off quickly and I found myself absorbed in working out odds ratios proving that people who smoked were more likely to get lung cancer. For the first time, I was able to see the link between the suspicions of a sharp clinician, the design of a study that could prove his hypothesis, and the shocking conclusions that demanded a public health intervention. For me, far from being abstract calculations, this was all cuttingly human.

Learning about global health
As I was in the International Health Concentration, in addition to the basic public health sciences such as epidemiology and study design, I was required to take classes with a focus on global health. I was beginning to appreciate that there were many other people like me who realised there was a tremendous amount of injustice in the distribution of health, liberty, and opportunity in our world.

In a class on infectious disease in the developing world, I learned how cholera, a disease that I thought was a historical relic, still scythes through India, Bangladesh, and other developing countries today. I even learnt that those sodium channels are actually quite important in treating diarrhoea!

In another class I was told how, in Afghanistan, one quarter of women do not survive child birth, dying of infections, bleeding, or simply because there was no path through the snowy mountains, or no midwife to recognise an obstructed labour. In others, we discussed how corruption, greed, and sheer indifference to the suffering of millions had led to famines in times when crops were plentiful.

Learning to make decisions
The statistics I learnt were shocking. Eleven million children die every year from preventable diseases.¹ Every minute, six people die of HIV/AIDS.² But still, 90% of medical research goes towards curing diseases that affect only 10% of the world’s population, the so called 10/90 gap.³

I was becoming a bit overwhelmed with the raw amount of suffering in the world. My colleagues and I discussed the impossibility of working to improve the health of millions of people. One doctor from Kenya commented, “The government cannot afford to buy me a motorbike so that I can see patients at the HIV clinic in the next village. How can they possibly provide the drugs, food, and doctors people need?”

In considering these disparities, I was struggling with questions about how we should make decisions about healthcare interventions and how, having formulated these plans, we could actually implement them.

Ethics lectures gave me grounding in the major moral philosophies without the infuriating inaccessibility that had befuddled my previous tangles with the subject. I went on to examine quandaries in public health practice through real-life case studies, such as whether it is acceptable to use a vaccine for an epidemic disease in the developing world if it has rare but potentially life-threatening side effects, or if we should respect ritual female circumcision as a cultural tradition, even if it can cause tremendous physical and psychological trauma?

I applied the various schools of ethical thinking to these and more examples, and slowly I began to appreciate the implications of my actions. I could see how public health decisions I would make could lead to benefit or harm for individuals and communities. Through these examples I was able to develop my idea of what it means to be just when making healthcare decisions.

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Start local, think global

Learning to solve problems
Even though ethics was helping me to see how I should act when making public health decisions, there was still the tricky question of how I could actually get anything done. For example, what if government and religious leaders were opposed to polio vaccinations because they believed that the drops were tainted with HIV virus, which was the case in Nigeria in early 2004?^{4 5}

In the Political Economy of Public Health lectures, I was taught about how to conduct a political analysis. I learnt how to identify key players, both in opposition and in favour of change and assess the power they hold. Through this I was able to develop strategies for bringing about change.

In addition to learning the analytical skills vital for public health practice, I was able to gain practical experience in a wide variety of fields. Tabletop exercises, where the class acted out the roles of public health professionals during a simulated chemical agent attack on Boston in a bioterrorism class, video interviews with former news presenters in a media and health promotion class, and mock investigations of food poisonings after church fairs were particularly memorable. These practical classes all provided skills that are essential for effective public health practice. Interaction with the media, reassuring a concerned general public, and investigating episodes of ill health are the core skills of public health, ones that I will use every day in practice.

Thinking global
Throughout this feast of information and experience, one source of education stood out. My fellow classmates had come from every corner of the world, all with the deep-seated drive to improve health and fight injustice. I had afternoon coffee with an Australian psychiatrist who had helped the people of the Balkans address their post-traumatic stress, and played football with a Kenyan who was helping his government develop a sustainable health system for the rural population. Sharing experiences with such a diverse group reinforced my belief in the global importance of public health.

A revamped career path
I graduated from the Masters of Public Health programme in June and this amazing academic experience has undoubtedly not only altered my medical career, but also my outlook on life. I am currently completing an unpaid internship with WHO’s Regional Office for Europe in Copenhagen, Denmark. I am working with the Disaster Preparedness and Response programme, helping to coordinate the public health strategies for the war-torn countries of the former Yugoslavia. It is the epitome of everything I have learnt during my time at Harvard.

On completion of this internship, I intend to begin working towards a training rotation in public health within the NHS. Ultimately, I envisage myself in a public health policy-making role where I can help to create the strategies that can improve the health of the most disadvantaged people in the world. Although in the short term this will entail a few more years of clinical medicine, I now have a clear goal of the direction I want my medical career to take.

Perhaps more importantly, I am beginning to realise that the values which first drew me into medicine are now shaping my medical career. I understand that there are others who believe that the world can be a more just place and that people should not be denied health or freedom for callous greed or shallow indifference. Most of all, I understand that in the public health community, as we become increasingly aware of the disparities in health throughout the globe, there is a real determination to take action and banish unnecessary suffering forever.

Like I said, call me an idealist…

Peter MacPherson, intern, WHO Regional Office for Europe, Disaster Preparedness and Response Programme, Copenhagen
Email: petermacpherson@mac.com


studentBMJ 2005;13:397 - 440 November ISSN 0966-6494

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2. United Nations Millennium Project. Fast facts: the faces of poverty. http://www.unmillenniumproject.org/facts/ (accessed 7 Oct 2005).
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   http: //www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf (accessed 7 Oct 2005).
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