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Bernard Kouchner on health, microcredits, and more

by Lloyd Davis

bernardkouchnerBernard Kouchner, co-founder of Doctors Without Borders (MSF) and of Médecins du Monde. More info at Wikipedia.

I’m going to talk about health and not technology.

Your very important congress is on technology not on health. Of course there’s a connection and EHRs and such are very important but I want to focus on something else.

To talk about health, you need patients because for the largest part of the world, there is no system so while doing this inside Europe is important, outside of our borders people have no access to care

Some real data: a few days ago was the World Water Day. 2.5 billion people have no access to sanitation, not just clean water, but to water at all. And as we are threatened by big pandemics - SARS, Asian Flu - the reality of the world is that we won’t be able to stop diseases at our borders, so we must work in the developing world to help ourselves.

I want to remind you that in Africa, which has 24% of the world’s population, also has 84% of its morbidity while only 3% of itscare resources. The commissioner told us that she believed it’s easier to start from scratch - not at all, first you need to have some doctors.

Today in the world, we’re short at least four million health workers, mainly but not only in the developing world - we will soon face a shortage of some one million in the developed world. Which means 200,000 physicians will be needed to be educated in the next five years. We are attracting nurses and doctors from the third world to our countries and if we want to change the whole picture of the international public health, we have to maintiain doctors in their own country and pay them more. In my country, we are using doctors from other countries, paying them less than French doctors and forbidding them from working for the private sector. Which means they are in the ER every night, running the system. Without them we have no ability to make our big electronic systems work.

We set up MSF in 1971 and sent doctors to where they were needed. It was a successful first step. The second step came about because of the spread of AIDS - it transformed our views on everything and pushed everybody to take care of each other. We used to talk about my patient, our patient, but now we just talk about patients, the understanding of a global context, i.e. patients without borders. Now we are moving to *health* without borders - we not only have to help the rest of the world (your systems are excellent and helpful to patients) but remember that the patient owns his own health. You have to push to develop not only charity, but not to develop the offer of care, the system of care - we don’t want these parts of the world to be dependent on charity. We have to help them develop a healthcare insurance to help them to access a basket of care. For instance, microcredits work because you are involving people in their own system and we must encourage more of the same.

The WHO must lead the system. Otherwise we are developing a very unbalanced system with built-in dependence. We are offering free access to AIDS/HIV treatment - but we are obviously not winning the battle with three million people still dying every year and five million infected. But meanwhile children are dying of diarrhoea and respiratory infections which don’t have free treatment. We must insist on offering country after country, community after community a very basic basket of care based on an insurance system - simple care for mothers and children, step by step enlarging the system and I think that microcredits are the answer.

Technology is great but don’t forget that not all of us find globalization in healthcare to be a benefit - the majority are still unable to benefit from the system, so how do we offer them hope.

Q: Can we expect insurers to use genetic data to discriminate populations?
A: Are you the police? You can’t use it like that - that’s scandalous and a manifestation of racism.

Q: Doesn’t it create borders by being closed?
Yes but the border already exists and we are overcoming them. Globalisation must be a positive thing because disease is global - it was unthinkable before AIDS that we would be helping people all over the world. MSF was called doctors without diplomas and people were disgusted by this movement of “leftists” but that impression is changing.

Q: You were a health minister - would you be encouraged by the ability of IT to help healthcare?
A: I doubt it :). The dialogue is now more balanced and the patient is in the center and this is a great progress. We have to have laws to allow people access to their medical information that previously belonged to the doctor.

Q: What do you think the role of civil society is when government has no capacity and no will? My experience is that mobilising families and carers to create their own systems works well.
A: You’re completely right - it was of course very important in our own countries when we started. It seemed impossible some time ago to see this shift in the relationship between doctors and patients, but now we’re seeing it too and the increased involvement of patients throughout the system. In the third world people want to be involved in their care too, another reason why I’m pushing microcredits. You need to support progress with funding and support from the ministries, but the real change comes from civil society. I want to set up a foundation to establish international health insurance with a mix of private and public players.

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