Annals of Family Medicine -- Thank you

Dear AFM Journal Editors, Professors Starfield and Fryer, Jr,

I studied your interesting editorials on �Equity --global theme�, �Recruiting PC physicians from abroad�, and research on �The PC physician workforce: ethical and policy implications�,[1-3] as well as the interesting e-responses. I understood well your fair ethical concern and humanitarian interest to improve your country and the poor countries healthcare systems. Nevertheless, I think that to have a more comprehensive discussion I shall contribute some balancing comments, facts and issues in relation to the other face of this very complex same coin.

I would like to mention a reflection of Professor David Landes from Harvard: �The task of the rich countries with the poor countries, in their own interest as well as theirs, is to help the poor become (freer, wiser --my addition), healthier and wealthier. If the rich do not, the poor will seek to take what they cannot make; and if they cannot earn by exporting commodities, they will export people�,[4] (including their university professionals and physicians --my addition).

Since the 1700s, the US has been developed as a first world power in liberties, education, science, medicine, health, wealth, working and living levels with increasing equality and quality of life by European, American, Asian, and African immigrants. In the 1900s, the US became the most competitive society accepting immigrants. These immigrants have been the architects and builders of the modern US.[4-7] The acceptance of them without their quota of doctors would have given the US healthcare system many more difficulties to face the sometimes millenarian lifestyles that some of them bring from abroad, and to decrease the US healthcare inequalities due to the consequent greater shortage of US PC physicians. However, if the US does not accept them, they will go to Europe, Canada, Australia, or other countries anyway.

�Immigration over the past seven years was the highest in American history, bringing 10.3 million immigrants. One in eight people living in the US is an immigrant, for a total of 37.9 million people -- the highest level since the 1920s. The number of foreign-born people who settle here each year, legally and illegally, is about 1.2 million. The US immigration rate is about 4 x 1,000 residents yearly, less than half of the peak annual immigration rate of 10.4 x 1,000 in the decade from 1901 to 1910. Today about 12 % of the US population is foreign-born. That is still below the peak of 1910, when 14.7 % of people were foreign born�.[8]

In my view, the US does not need to court people and physicians from poorest and unhealthiest countries. Our greatest tragedy is that our behind countries are unethically exporting them, because with mistaken policies our unable rulers are not accomplishing their socioeconomic, cultural, political, and civil responsibilities. Our incapable rulers are not allowing their people and physicians to have the modern working and living levels possibilities [9] that they deserve and could enjoy in their own fatherlands, if they had implemented the already known working policies. These are greater ethical and policy problems that the research academicians could face more in international forums and publications.

I will be glad to cite a thought of our Cuban apostle of independence Jose Marti: �When the peoples emigrate, have more than enough rulers�. He lived his last 20 years as US immigrant fighting against the Spanish metropolis to liberate Cuba in the eve of the 1900s (Complete Works).

The world could study the exceptional example of Cuba, once from 1902 to 1951 a democratic, educated, healthy, and middle-income capitalist developing nation of immigrants even from South Europe, having by US standards outstanding living and health levels with an excess of physicians.[10-22] {table} At that times, the emigration rates of people and physicians were very little.[12-13]

The clandestine Soviet revolution imported from 1953 to 1959,[23] achieved the transformation of Cuba in a captive and low-income Soviet/Chinese satellite of semi-healthy people, but panicky, hungry, poorest, corrupted, overwhelmedly indoctrinated, psychopathic, and despaired to emigrate and emigrating to anywhere.[11,21-22]

In Cuba more than 90% of medical graduates are forced since 1961 to do three years of civil rural service, and from 1984 to become PC family medicine specialists. Cuba�s capitalist and socialist --silently rationed-- multi-tier public-private healthcare systems deserve careful comparative research to help improve a deep understanding on human development and healthcare inequalities. In addition, it would be worthwhile to study the four Asian Tigers, China, {table} and Ireland in the eve of the 2000s, and the three Baltic Tigers, India, and Chile in the 2000s.

I would like to bring a consideration of the Nobel Prize Amartya Sen: �Individuals should be free active agents of development (in their country --my addition), rather than passive recipients of dispensed benefits� [6] (and charities from abroad, and much less lance tip of unsuccessful socioeconomic and political systems in other countries --my addition).

In Cuba, it could be studied since the 1990s, how a population covered with the double of physicians and of PC physicians needed, has been so abandoned. In the 2000s, the healthcare crisis has worsened, because one third of the Cuban doctors are abroad, doing �Trojan horse� ideological agitation within the poverty class of Venezuelans and others peoples, to finance the Cuban socialist moribund tyranny.[10-11,21-22]

Today Cuba�s human development index ranks in the world place 51.[18] It would be over the 100 place, if it was calculated including a individual civil freedoms/political rights variable.[10,24] In 1951, with relatively high life expectancy at birth, literacy/school enrollment, GNP per capita, and individual freedoms/rights observance, for those times, Cuba would have ranked very probably below the 25 world place.[10-22]

If in Cuba, the people that would like to emigrate safely to anyplace could do it freely, the island would lose in short at least a fifth of its 11.3 million population and 71,500 physicians.[25] The working and living conditions of the Cuban doctors, are in average as those described for sub-Saharan Africa,[2] but worsened by the world lowest mean wages (less than one US$ daily), more unfreedoms and discrimination than even for the common Cuban natives, situation only worst in North Korea. {table}

The IMF and the World Bank policies are very hard as has been the capitalist take off in the most advanced nations, to help develop the behind countries going out of the authoritarian primitive non capitalist or socialist socioeconomic, cultural, political, civil, legal, and moral chaos. These policies are not to reward their governing irresponsible, unscrupulous and corrupted bureaucracies, which do not let the aid arrive to their people and doctors. The UN agencies and other international agencies (mainly using US aid), could learn more from this approach to be able to enhance quicker many poor developing countries.[21-22]

It is a great fortune that very few of the American people and physicians have had to emigrate abroad in 250 years. This is a good final indicator that the US living and healthcare system with all their problems have been improving and reducing the living and health inequalities. The world research academicians especially in developing countries, need to study and learn still very much of the so unfairly reviled US model.

Thank you for reading me.

IMF: International Monetary Fund

PC: Primary Health Care

UN: United Nations

UNDP: United Nations Development Program

UNESCO: United Nations Educational, Scientific and Cultural Organization

UNICEF: United Nations Children's Fund

US: United States of America

US$: US dollars

References:

1. Stange KC. Equity--Global Theme Issue on Poverty and Human Development. Ann Fam Med. 2007;5(6):482-483. http://www.annfammed.org/cgi/content/full/5/6/482

2. Hagopian A. Recruiting Primary Care Physicians From Abroad: Is Poaching From Low-Income Countries Morally Defensible? Ann Fam Med. 2007;5(6):483�485. http://www.annfammed.org/cgi/content/full/5/6/483

3. Starfield B, Fryer, Jr, GE. The Primary Care Physician Workforce: Ethical and Policy Implications. Ann Fam Med. 2007;5(6):486-491. http://www.annfammed.org/cgi/content/full/5/6/486

4. Landes DS. The Wealth and Poverty of Nations: Why Some Are So Rich and Some So Poor? 1st Ed. New York, NY: W.W. Norton Co. & Inc.; 1999.

5. Sachs JD. The End of Poverty. Economic Possibilities for Our Time. 1st Ed. New York, NY: The Penguin Press; 2005.

6. Sen A. Development as freedom. 1st edn. New York, NY: Alfred A. Knopf, Inc.; 1999.

7. Fogel RW. The escape from hunger and premature death, 1700�2100: Europe, America, and the third world. 1st Ed. New York, NY: Cambridge University Press; 2004.

8. Cato Institute. Immigration at Record Level, Analysis Finds. Cato Daily Dispatch. 2007 (Nov 29). http://www.cato.org/view_ddispatch.php?viewdate=20071129

9. United Nations. Report on international definition and measurement of standards and levels of living. New York, NY: UN Publ; 1954.

10. McGuire JW, Frankel LM. Dimensions and determinants of mortality decline in pre-revolutionary Cuba. Harvard Center for Population and Development Studies, Working Paper Series. vol. 14 no. 6. Cambridge, MA, 2004. Available: http://www.globalhealth.harvard.edu/hcpds/wpweb/McGuire_wp1406.pdf Accessed December 2, 2007.

11. Anon. Cuba's delayed transition needs. Lancet. 2006;368:1323. http://www.thelancet.com/journals/lancet/article/PIIS0140673606695445/fulltext

12. UN. Demographic yearbook 1948-2004. New York, NY: UN Publ; 1949-2005.

13. UN. Statistical yearbook 1948-2005. New York, NY: UN Publ; 1949-2006.

14. UNICEF. The state of the world�s children 2007 statistical tables. New York, NY: UNICEF Database; 2007. Available: http://hdr.undp.org/en/media/hdr_20072008_tables.pdf Accessed December 2, 2007.

15. University of California-Berkeley/Max Planck�s Institute for Demography Research. Human mortality and life tables databases. 2007. Available: http://www.mortality.org ; http://www.lifetable.de� Accessed December 2, 2007.�

16. UN. World population prospects: the 2006 revision population database. New York, NY: UNPD Database; 2007.2007. Available: http://esa.un.org/unpp/ Accessed December 2, 2007.��

17. UNESCO. Progress of literacy in various countries; World illiteracy at mid-century. Monographs on fundamental education VI, XI. Paris: UNESCO Publ; 1953, 1957. Available: http://unesdoc.unesco.org/images/0000/000029/002930eo.pdf Accessed December 2, 2007.��

18. UNDP. Human-development-index tables 1975-2005. New York, NY: UNDP Database; 2007. Available: http://hdr.undp.org/en/media/hdr_20072008_tables.pdf Accessed December 2, 2007.��

19. US National Bureau of Economic Research. Occupational wages around the world; International labor organization. 2007. Available: http://www.nber.org/oww/; http://laborsta.ilo.org Accessed December 2, 2007. ��

20. Freedom House. Freedom in the world 2006. Annual global survey of political-rights and civil-liberties. Washington, D.C.: FH Think Tank, 2007. Available:� http://www.freedomhouse.org/uploads/pdf/charts2006.pdf� Accessed December 2, 2007.

21. Anonymous Cuban Professional. UN and WHO Leaders could Welcome a Bioeconomic-Psychosocial Paradigm. BMJ. 2006 (Nov 15). http://www.bmj.com/cgi/eletters/333/7576/1015#149265

22. Anonymous Cuban professional.� Achieving health equity with more liberty, wealth, and ethics. BMJ. 2007 (Oct 5). http://www.bmj.com/cgi/eletters/335/7621/628-b#177601

23. Andrew C, Mitrokhin V. The world was going our way. The KGB and the battle for the Third World. 1st Ed. New York, NY: Basic Books; 2005.

24. UN. Universal declaration of human rights. New York, NY: UN Publ; 1948. Available: http://www.un.org/Overview/rights.html Accessed December 2, 2007.

25. Cuban National Statistical Office. Statistical yearbook 2006. Havana, NSO Publ; 2007. Available: http://www.one.cu/aec_web/aec2006_gif1.htm Accessed December 2, 2007.

Table

Relation of freedoms with social growth and wage in some countries

*� Index-Year /� Countries**	Infant mortality�� (<1-yr x 1000 live-births)�� [rate]�� (1-4) **��			Life expectancy at birth�� [yr]�� (1-5) **��			Total adult literacy�� (over 14-yr)�� [%]� (6) **			Urban population� ��[%]�� (5) **			Inhabitant per physician [ratio]�� (2,7)� **��		General/doctor monthly wage [US$]� (8) **	Civil rights/political liberties [ratings 2-14]� (9) *******
Countries	1900	1957	2005	1900	1957	2005	1900	1957	2005	1900	1957	2005	1957	2000-4	1994-2004	2005
Cuba�	195	32	6	32	63	78	51	85	100	30	53	76	999	169	25	14
Iceland��	126	17	2	47	74	81	>90	99	100	60	77	93	921	276	>5100	2
North Korea��	>240	>85	42	<30	53	64	>24	47	99	3	32	62	<3500	303	<20	14
South Korea��	>240	90	5	<30	53	78	>23	46	98	5	27	81	3523	553	>4000	3
Singapore�	>240	41	3	<30	63	79	>35	60	93	>80	100	100	2221	714	5263	9
China�	>300	>175	23	<28	46	73	>20	>60	91	<5	15	41	8427	609	120	13
Taiwan	>200	36	6	<30	62	77	>35	66	96	<10	30	75	2348	<500	>4000	2
Hong Kong�	>240	56	2	<30	65	82	>35	65	94	>60	84	95	3050	<500	>5000	7
Japan	>220	40	3	43	66	82	>80	98	100	<10	39	66	948	496	10208	3
Russia (USSR)�	>270	57	14	<28	67	65	25	90	99	<20	49	73	562	240	>120	11
United States	135	26	6	47	69	78	95	99	100	40	67	81	809	182	14320	2
* �See other indexes per years of the same countries in complementary table in previous e-response.[13] Adjustment/estimations (<# & >#) were made from multiple sources, when exact data for all population groups were not available. *** Political rights (7) country ratings were summed with civil liberties (7) country ratings totaling from (14) less free to (2) most free. Source: [10-22]**

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