American Health Is Global Health
I am an international medical student with a preexisting health condition studying in New York. I have had excellent experiences with the U.S. health care system: Last year, I contrasted the tragic manner in which my father died of hypertrophic cardiomyopathy in Zimbabwe with the outstanding care I received in the United States for the same genetic disease (1) Today, as I create my rank order list for residency, I am less naively optimistic about the future than I was just a few months ago. My ability to provide and receive health care is now at risk. At the very time when population health in the United States has become fragile because of proposals to repeal the Patient Protection and Affordable Care Act, President Trump's stance on immigration ignores a global community of health specialists that could be of critical assistance to this country. As I prepare to enter internal medicine residency this Julywhere I will treat thousands of U.S. patientsmy immigration status is tenuous, my long term commitment to global health is challenged, and my own health could be affected. There are substantial concerns about the future of H 1B visas: the most sought after visa for international residents. A current bill in the U.S. House of Representatives, for example, proposes increasing the income floor for these visas to $130000 (2) Because medical residents earn an average salary between $50000 and $65000, such a reform would make international residents like myself ineligible. The alternative J 1 visa would allow me to complete a residency but requires that I then return to Zimbabwe after over a decade of training in the United States. That would be a personal loss for me and a substantial waste of resources and potential future doctoring for this country. My case is not unique. Nearly one quarter of physicians in the United States are international medical graduates (3) many of whom work as primary care physicians in underserved communities. Like them, I speak multiple languages and have firsthand experience of how cultural differences and social circumstances affect health outcomesknowledge that will enhance my clinical practice. Chairs of major U.S. academic medicine departments argue that President Trump's executive order and future plans for immigration will limit the free exchange of knowledge that critically improves patient outcomes (4) The health of millions of U.S. citizens will be hurt by blocking talented physicians from providing excellent care here. As a Zimbabwean researcher with the privilege of studying medicine in the United States, I am dedicated to improving health systems and promoting learning between my colleagues in both countries. However, stringent immigration control and cuts in development aid will impede this type of generative global health work. For years, in the face of limited resources, global health implementation has focused on mobilizing communities and strengthening social networks as strategies to improve population health. In Zimbabwe, for example, where there are only 12 psychiatrists, specialists train lay community members to deliver basic supportive therapy through a cost effective intervention that has been scaled to reach thousands of patients (5) In the face of potential repeal of the Affordable Care Act, threatened reproductive rights, and funding cuts for health interventions and scientific innovation, such strategies from low income countries could help fill widening gaps in health care delivery in the United States. However, because most global health specialists live outside this country, travel and immigration restrictions could block the flow of such knowledge, sidelining the United States in global dialogues on health care just when it would benefit most. The work that my colleagues and I do in Zimbabwe is primarily funded by U.S. agencies, such as the National Institutes of Health and Centers for Disease Control and Prevention, that could see drastic cuts in international aid (6) Such cuts are not only un American, they further undermine the mutually beneficial process of working together to improve health in developing countries and the United States. On a personal level, the repeal of the Affordable Care Act could affect my own health. When I was diagnosed with hypertrophic cardiomyopathy as a first year medical student, I was covered by a student health insurance plan that my medical school provided. As I transition into residency, I must find coverage under a new insurance program. In this transition, now with a preexisting condition, my future insurance coverage is uncertain. My experience receiving excellent health care in the United States compared with that of my father in Zimbabwe has driven my efforts to become a better physician, and the irony of becoming a medicine resident who might not be able to afford a cardiologist is not lost on me. Reflecting on years of thinking about global health as a way of bridging the differences between high and low income countries, I realize the inherent hypocrisy in presuming that knowledge and best practices originate only in high income countries and that the United States thus has little to gain from the developing world. In reality, a flow of knowledge and talent in the reverse direction could help this country cope with shortages in health care workers, reduced insurance coverage, and a challenging partisan policy environment. We should preserve such conduits of information, not eliminate them with immigration restrictions. Growing up in Zimbabwe, I saw authoritarian leaders decimate health systems over decades. Living in the United States the past few weeks, I now realize that such devastation can happen overnight. The global exchange of knowledge is more urgent now than ever before. As health gaps widen, we need to turn humbly to our colleagues in developing countries and learn strategies for resilience.
Annals of Internal Medicine.