Health inequality. As an editor, we see lots of papers on health inequality; an anodyne, antiseptic term that trips off the tongue without baggage. Not much new. But, in practice it means poor people, who may smoke too much, eat the wrong food, don’t have jobs, live in the wrong place, have lots of illness, and die young. When you see patients suffer unnecessarily simply because of an accident of birth, it makes you acutely aware of the gap between the rhetoric and the reality. And doctors who work at the wrong end of social inequality see a very different world where patients have different priorities and more urgent health needs. If your main concern is getting a job, putting food on the table, and managing from day to day, then health promotion, anticipatory healthcare, and self development don’t seem that important. National healthcare priorities are often determined by people with no experience of areas of deprivation, and who focus on priorities at the other end of Maslow’s hierarchy of needs. Self actualisation is worth sod all if you have no job and no future.
Academic imperialism. Using developing countries as a laboratory for your own medical research and career promotion is, to me, a form of human rights abuse. Not unethical research, not harming patients but, foreign investigators who leave without encouraging local expertise, providing training in research methods, creating a lasting research infrastructure, or giving credit with authorship. Researchers from developed countries need to ask themselves why they are really there, what the balance is between their contribution to the community and their own personal gain and, what is their legacy. If it wasn’t for the grant, the publication, or the promotion, would you be there and have you left something useful behind?
Immigrants and the rights of minorities. Coming from a country where emigration is expected, I feel for minority communities in a foreign land. Every foreign national, doctor, nurse, porter, or cleaner that we meet day to day has a back story—loved ones left behind, parents or even their children still at home, sometimes sending money back to support an entire family. And not just minority immigrants—for many years, our practice cared for the travelling community. They are not saints. But, like any community, they include many kind, generous, and caring people. They have values that are very different to settled people and with which we may not agree. But I cringe when I see how they have been portrayed in recent television programmes.
The legacy of violence. As a GP in west Belfast for most of my career, it doesn’t matter about politics or religion, or which end of the gun. Everyone is a victim. Families are left with the legacy; unnecessary bereavement and persistent suffering. I watch televised armed conflict from around the world on news bulletins—death, maiming, and psychological trauma trivialised by talking heads and meaningless discussion. And, I cannot help but think of the bereaved, injured, and suffering families left to pick up the pieces when the cameras have gone.
Physical activity. The health benefits of exercise are undeniable. But, for me, doctors are best kept away. Search for the evidence, do the research, promote the message. But the key to encouraging exercise is cultural, environmental, social, and behavioural. Pushing the responsibility onto medicine simply allows government to abrogate their responsibility. Its much easier to tell doctors to get people active than to build cycle lanes, change traffic laws, legislate for workplace showers and changing facilities, and enhance the environment. Keep doctors out of it.
Domhnall MacAuley is primary care editor, BMJ.