“Pathogens do not recognize international borders. But much churn – social and microbial – is introduced at the borders.” – Re-Imagining Global Health, Paul Farmer and colleagues
I was recently stationed in the Emergency Department at BMC when we received a middle-aged gentleman who had arrived directly from the airport with his cousin, a younger woman living in Boston. He presented with fevers and shortness of breath. His cousin and other family members had grown concerned over reports of his health in his home country in the Caribbean and had managed to arrange for him to come to the States. Over a couple hours, we pieced together a basic story: he had been in the hospital abroad for weeks, on dialysis for unknown reasons, had a first-time seizure for unknown reasons, and had been treated with unknown antibiotics for unknown reasons. We found a central line in his groin that appeared to be dressed with packing tape. I was scared for him. He had the kind of breathing that time in an ICU teaches you is the breathing of someone who is drowning in his own lungs. I watched his chart for weeks after my shift as the diagnoses rolled in: a polymicrobial infection of the central line, bacteremia, infective endocarditis with heart failure, and septic emboli to the brain. Thankfully, his condition slowly improved with the diagnostic and therapeutic tools at our disposal in the ICU. This is one kind of the global health we practice at BMC.
This kind of global health is a distinctly different challenge from caring for the same gentleman on the other side of his airplane ride in an extremely resource poor setting, however. As providers, we do not face any struggle to obtain sterile dressing or the political strife and violence outside the hospital walls that is occurring in this patient’s home country. But knowing the real etiology of how this patient came to be so sick requires curiosity about global health problems. My Emergency Department stint was brief and did not allow me to ask some of the deeper questions, but this experience led me to want to learn more about this patient’s home country and the clinicians who treated him there. In Infectious Diseases, diagnosing bacteremia leads to an immediate question of the source; in this gentleman’s case, I would argue the source of his infection was the set of conditions that led his family to fight to get him on an airplane with an infected femoral line in place seeking care abroad.
And yet, immigrant, refugee, and migrant health is often seen in a separate arena from global health. During a series of interviews for Infectious Diseases fellowship, a common follow-up question to my interests in global health was “do you see yourself devoting a prolonged period of time living in another country to establish relationships and research connections?” Yes, I see myself pursuing a career in global health, but I hope to focus on the myriad global health needs that we see within the United States.
I have a hypothesis that many powerhouse universities with strong global health programs do not serve a proportional number of immigrant patients or invest as much money in migrant health. I sought to test this hypothesis by looking at global health vs. migrant health expenditures by university or hospital, but this proved difficult to find by internet search alone. Fogarty grant awards (https://www.fic.nih.gov/Grants/Search/Pages/search-grants.aspx?sort=+institution&search=) give a sense of research spending by individual universities but it is difficult to glean spending patterns in migrant health. I believe that US-based universities investing in global health research (the fruits of which often disproportionately benefit the US-based university as opposed to in-country partners1) have a responsibility to serving immigrant and refugee populations within their own borders.
I think there are several reasons to change the narrative around global health and more actively link work in global health to domestic immigrant and refugee health. First, many young people have been excited by global health and there is an opportunity to galvanize this interest into more providers serving immigrant and other underserved populations within United States’ borders, which is sorely needed. Second, the multi-disciplinary and public health-informed approach that is a central tenet of global health is similarly useful in understanding migrant health issues and working towards health equity. Third, given the current political context in the United States with heavy anti-immigrant rhetoric and policy, renewed attention and advocacy in the area of immigrant and refugee health is critical. Living in an era of globalization, we all have an opportunity to engage with the “social and microbial churn” at “the borders” to promote health equity.