Making a Difference, One Life at a Time

CHEST

Editorials CHEST | Volume 132 | Number 5 | NOVEMBER 2007

Making a Difference, One Life at a Time I wanted to do something immediate to help people around me, even if it was just one human being, to get through another day with a little more ease. Muhammad Yunus, Nobel Lecture in Oslo, October 20061

issue of CHEST joins with ⬎ 230 other T hismedical and scientific journals that are partici-

pating in a global initiative to examine poverty and human development. Emmelin and Wall2 focus on indoor air pollution and child mortality, Hegewald and Crapo3 on socioeconomic status and lung function, and Bukachi and Pakenham-Walsh4 on technology in the developing world. The article by Akhtar et al5 concerning chronic bronchitis associated with the use of biomass fuels in Pakistan, and the Medical Writing Tip by Oshimi6 on effective written communication with limited English-proficient patients also relate to this theme. Worldwide, the number of people living in poverty has deceased slightly in recent years, but by any definition the number remains staggering.7 As clinicians, we have learned that when variation in outcome exists there are opportunities for improvement. The data from the World Health Report 2006 established that variation and opportunity. For example, the mean life expectancy at birth varied twofold, from 82 years in Japan to 40 years in Botswana and Zambia. The probability of a child dying before the age of 5 years varied 94-fold from 28.3% in Sierra Leone to 0.3% in Iceland and Singapore.8 Combining these outcomes with national per capita total health-care spending data underscores the long-established indirect relationship between poverty and good health. Together, these data may also focus us on the disparate health care in our own country. For despite spending more total dollars on health care, per capita, than any other country on earth (27% more than the next-highest spender, Monaco; $5,711 vs $4,487), the United States does not lead the world in either mean life expectancy or ⬍ 5 years mortality (78 years and 0.8%, respectively).8 Beneath the US data lies the wide variation in health-care outcomes associated with race/ethnicity, access, and education.9 In 2005, 15.7% of the US population was uninwww.chestjournal.org

sured, and 53% of these patients had incomes less than twice the federal poverty level. Hispanics, 12% of the total population, make up 30% of the uninsured.10 Faced with the opportunity these epidemiologic variations present, some, myself included, find it easier to be horrified than to act. Given the demands of our busy practices, it is perhaps rational for us to bundle our genuine concerns about global health into a hope that governmental and nongovernmental agencies will address these variations and eliminate these disparities. This hope ignores the fact that these health inequities have developed despite, or as a result of, government and corporate policies. However, it is surely a pragmatic rationalization to accept as minimal the impact an individual physician might conceivably have on such enormous problems. Yet there are others, a special few among us, whose reaction is not to recoil in disgust but indeed to act, acting to redress even one tiny bit of the enormous problem. As inscribed in the Talmud of the Jewish faith, “to save one life is as if you have saved the world.” This is the approach taken by Muhammad Yunus and the Grameen Bank, winners of the 2006 Nobel Peace Prize. Their microcredit to Bangladeshi victims of poverty has enabled thousands to “bring about their own development.”1 However modestly, through its philanthropic arm, The CHEST Foundation, the American College of Chest Physicians (ACCP) [the publisher of CHEST] has enabled its members to act to redress health-care inequities in the United States and around the world. These acts have taken two distinct forms: pro bono service, and humanitarian awards or grants. Through these mechanisms, all members are given an opportunity to contribute directly their skills or indirectly by their charitable gifts. Curing the disparities in global health care cannot be accomplished solely by money or health-care providers11; but as demonstrated by the Nobel Prize winners this year, even a small sum of money in the right hands at the right time can promote change from the bottom, where the true unidentified (or ignored) gaps in care exist. Since 1999, pro bono efforts of ACCP members have included teams of Fellows focused on disaster response, educational, and humanitarian projects. The Pro Bono Committee of The CHEST Foundation has developed a structure by which members of the ACCP can be notified of how they can particiCHEST / 132 / 5 / NOVEMBER, 2007

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pate in relief missions. This committee has coordinated its efforts with other related organizations. In the 10 years since its founding, The CHEST Foundation has given ⬎ $1 million dollars in humanitarian awards to 157 projects: 78 in the United States and 79 in other countries. These projects, led by our Fellows, identified a need and filled that gap, usually on a shoestring budget. One of our first awardees developed a project to bring potable water to an Argentine Mapuche village. The plurality of the needs projects recognized by our awards have been free clinics (45% of the awards) in cities throughout the world from Houston, Toronto, and Nairobi, to Saigon. Others have focused on health education (such as one in Ibadan, Nigeria) or disease screening (tuberculosis in Vinnitsa, Ukraine). The CHEST Foundation recognizes that the impact of these modest awards needs to be analyzed (but practically our Board of Trustees generally favors giving more, and larger, grants rather than using limited resources to track outcomes). A review of our required 1-year postfunding reports reveals invariably grateful narratives that defy quantification. Yet, even as we are unable to precisely quantify the impact these projects have had, we offer up our experience of a committed medical professional organization going beyond advocacy into action for the elimination of health disparities. Through The CHEST Foundation, our members have chosen to be a small part of a solution to close disparity gaps that can, perhaps, only be identified and treated by those who toil here and in countries around the globe on the very edge of these gaps themselves. It is in those spaces, vacuums of health-care bureaucracy, that we can make a difference one life at a time. Robert G. Johnson, MD, FCCP St. Louis, MO Dr. Johnson is President, The CHEST Foundation, and Chair, Department of Surgery, Saint Louis University. The author has no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Robert G. Johnson, MD, FCCP, President, The CHEST Foundation, Chair, Department of Surgery, Saint Louis University, 3635 Vista at Grand Blvd/FDT-3, St. Louis, MO 63110; e-mail: [email protected] DOI: 10.1378/chest.07-1071

References 1 Yunus M. Nobel lecture. Oslo, Norway, December 2006. Available at: http://nobelprize.org/nobel prizes/peace/laureates/2006/yunus-lecture-en.html. Accessed April 25, 2007 2 Emmelin A, Wall S. Indoor air pollution: a poverty-related cause of mortality among children of the world. Chest 2007; 132:1615–1623 3 Hegewald M, Crapo R. Socioeconomic status and lung 1416

function. Chest 2007; 132:1608 –1614 4 Bukachi F, Pakenham-Walsh N. Information technology for health in developing countries. Chest 2007; 132:1624 –1630 5 Akhtar T, Ullah Z, Khan M, et al. Chronic bronchitis in females using solid biomass fuel in rural Peshawar, Pakistan. Chest 2007; 132:1472–1475 6 Oshimi T. Effective written communication with limited English-proficient patients. Chest 2007; 132:1688 –1690 7 Flanagin A, Winker MA. Theme issue on poverty and human development. JAMA 2006; 296:2970 –2971 8 World Health Organization. The world health report: 2006; Working together for health. Available at: www.who.int/whr/ 2006/whr06 en.pdf. Accessed April 25, 2007 9 Centers for Disease Control and Prevention, Office of Minority Health. Eliminating racial and ethnic health disparities. Available at: www.cdc.gov/omh/AboutUs/disparities.htm. Accessed April 25, 2007 10 Overview of the uninsured in the United States: an analysis of the 2005 current population survey. US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, September 22, 2005. Available at: http://aspe.hhs.gov/health/reports/05/uninsured-cps/. Accessed April 25, 2007 11 Garrett L. The challenge of global health: foreign affairs; Jan/Feb 2007. Available at: http// www.foreignaffairs.org. Accessed April 25, 2007

Testing for Cheyne-Stokes Respiration in Patients With Heart Failure While Sleeping or Cycling? by Brack et al in this issue of CHEST (see T hepagestudy 1463) sheds bright light on the circadian aspects 1

of Cheyne-Stokes respiration (CSR) in heart failure (HF) patients. We know that ⬎ 25% of HF patients exhibit CSR, which has been traditionally described as a crescendo/decrescendo pattern of ventilation, followed by an apnea (thus, CSR-central sleep apnea [CSA]), occurring during the transition from wakefulness to stages 1 ⫹ 2 non-rapid eye movement sleep along with a low prevailing Paco2 and arousals at the peak of ventilation.2 Pathophysiologically, three main factors contribute: increased ventilatory response, reduced lung volumes, and prolonged circulatory delay.2 In recent times, a number of clinical subtleties of CSR have been described: a male predominance; a strong postural component (supine greater than lateral); poor sleep quality with orthopnea; paroxysmal nocturnal dyspnea and fatigue (rather than sleepiness); periodic limb movements; atrial fibrillation and ventricular ectopy; enlarged left atrial and ventricular size; elevated left ventricular filling pressures; and high levels of norepinephrine, atrial natriuretic peptide, and brain natriuretic peptide.2–4 Polysomnographic features of CSR include a narrow eupneic-apneic threshold, an open or closed Editorials