Opinion-Editorial

The Emergency Physician’s “Dereliction of Duty”

The presidential race is in full swing, and health care is a major focus. From a single payer, Medicare-for-all system to mild Obamacare reforms, almost all the candidates have voiced an opinion.

As an EM resident, I share the enthusiasm of many in the medical profession who find encouragement in a field of candidates engaged in a serious debate on how to improve our health care system. U.S. foreign policy, on the other hand, has been a second-tier issue at best, and as a physician, I find this incredibly disheartening. But perhaps even more disheartening is the disinterest and apathy I’ve noticed in my fellow physicians vis-à-vis American foreign policy—an issue that desperately needs our profession’s voice.

U.S. Foreign Policy: A Neglected Global Health Issue
In today’s world with unprecedented forced migration — according to United Nations High Commissioner for Refugees, we are witnessing the highest levels of displacement on record1 — U.S. foreign policy is inseparable from unprecedented global health challenges, making it well within the physician’s purview.

Take the example of Yemen. The U.S. is supporting Saudi Arabia’s role as combatants on one side of the fight in Yemen’s civil war. As a result of this conflict, every 5 minutes a child under age 5 dies of a preventable illness.2 Or Venezuela, where, in the backdrop of political unrest that includes U.S. supporting an opposition leader's claim that the current president is illegitimate, outbreaks of measles and diphtheria are rampant.3

In a report aptly titled Why Health Is Important to U.S. Foreign Policy, the Council on Foreign Relations proclaimed “Supporting public health worldwide will enhance U.S. national security, increase prosperity at home and abroad, and promote democracy…”4

There is an interesting discussion to be had about what role U.S. foreign policy could have in alleviating or exacerbating these public health crises — but no one is having it. And that’s not new. During the 2016 presidential primary, moderators asked, on average, only 2 foreign policy questions per Democratic Party debate. The 2020 debates are on track to see only a mild improvement.5  

Unilaterality of Foreign Policy
When it comes to presidential politics, the neglect of substantial foreign policy debate in favor of domestic issues is exactly backwards. Making or changing domestic laws requires Congress to do the heavy lifting; the president just signs on the dotted line. Foreign policy, on the other hand, is an area in which the president takes the lead.

S/he could choose to pursue a bombing campaign or enforce an embargo, restricting access to desperately needed medicines, inflaming a public health crisis. S/he could, for example, use a phony polio vaccination campaign as a means of intelligence gathering, putting public health workers’ lives in jeopardy, compromising legitimate vaccination campaigns, and exacerbating polio’s spread through one of the last vestiges of this eradicable epidemic (this is not a hypothetical; it was a strategy employed by the CIA while in pursuit of Osama bin Laden).6 The Commander-in-Chief could mobilize resources to stifle the next ebola crisis, lead vaccination campaigns, or pressure allies to end wars — all with the stroke of a pen or a phone call. No Congressional input necessary.

The Emergency Physician’s Duty
There is a reason Democratic primary candidates are ignoring foreign policy. American voters prioritize other issues: the economy, health care costs, and education,7 which is understandable on a personal scale. But ignoring U.S. foreign policy is a perilous mistake when it comes to presidential politics.

Emergency physicians should use their influential voices to advocate for a robust foreign policy debate. We should demand that our leaders articulate their plans for America’s role in the world and challenge them to take ownership of the health consequences of those plans. Obviously, we are not all global health experts, but that doesn’t absolve us of the responsibility to be informed and engaged. 

Other health care professionals have heeded the call. The American Public Health Association, the World Federation of Public Health Associations, the International Federation of Medical Students’ Associations, and the International Council of Nurses have all passed antiwar resolutions on public health grounds.8 Where is EM?

Since starting residency I’ve been inspired by witnessing the real impact emergency physicians can have on society. We’re in journals, magazines, news outlets, and social media. Our voices are heard on a range of issues, from health care reform and gun violence to human trafficking and domestic abuse. But when it comes to foreign policy and its profound impact on the public health, we’ve been shamefully silent. It is up to us to change the narrative and to ensure our specialty’s relevance continues to grow in an increasingly globalized society.

It’s time we pushed for a robust foreign policy debate. I don’t expect everyone to agree with my politics. I’m not asking for us all to endorse the same presidential candidate. But I do expect each and every one of us to be informed and engaged. To quote the Jesuit peace activist and poet Daniel Berrigan, when it comes to U.S. foreign policy, all I’m asking is that you “know where you stand and stand there.”

References
1. Edwards A. Global forced displacement tops 70 million. The UN Refuge Agency. Available at: https://www.unhcr.org/news/stories/2019/6/5d08b6614/global-forced-displacement-tops-70-million.html. Accessed: October 2, 2019.
2. 11 Facts You Need To Know About Yemen. UN Crisis Relief. Available at: https://crisisrelief.un.org/11-facts-about-yemen. Accessed: October 2, 2019.
3. Venezuela’s Humanitarian Emergency. Large-Scale UN Response Needed to Address Health and Food Crises. Human Rights Watch. Available at: https://www.hrw.org/report/2019/04/04/venezuelas-humanitarian-emergency/large-scale-un-response-needed-address-health. Accessed: October 2, 2019.
4. Klassalow JS. Why Health Is Important to U.S. Foreign Policy. Council on Foreign Relations. Available at: https://www.cfr.org/excerpt-why-health-important-us-foreign-policy. Accessed: October 2, 2019.
5. Hickey CK, Gandhi M. 11 Charts That Track the Weight of Foreign Policy in U.S. Primary Debates. Foreign Policy. Availble at: https://foreignpolicy.com/2019/06/26/11-charts-that-track-the-weight-of-foreign-policy-in-us-primary-debates-presidential-election-2020/. Accessed: October 2, 2019.
6. Shah S. CIA organised fake vaccination drive to get Osama bin Laden’s family DNA. The Guardian. Available at: https://www.theguardian.com/world/2011/jul/11/cia-fake-vaccinations-osama-bin-ladens-dna. Published 2011. Accessed: October 2, 2019.
7. Public’s 2019 Priorities: Economy, Health Care, Education and Security All Near Top of List. Pew Research Center. Available at: https://www.people-press.org/2019/01/24/publics-2019-priorities-economy-health-care-education-and-security-all-near-top-of-list/. Accessed: October 2, 2019.
8. Wiist WH, Barker K, Arya N, et al. The role of public health in the prevention of war: rationale and competencies. Am J Public Health. 2014;104(6):e34-e47.

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