We can be "heroes"

November 7, 2005 -- This week's TIME magazine features a massive report on global health, "Saving One Life at a Time." It discusses preventable and treatable diseases that claim millions of lives each year in the developing world. The 50-page report examines the terrible effects of such diseases, but seems to focus even more on those fighting the diseases and how readers can help. This is commendable. But the piece fosters the impression that physicians provide virtually all important developing world health care, a message that itself poses a threat to public health by perpetuating the undervaluation of nursing that is a critical factor in the global nursing crisis. Slightly more than half of the total report is devoted to profiles of 18 "heroes" whose "energy and passion are making a difference" in the fight against these diseases. Of the 15 health care professionals profiled, 12 are physicians. Not one is recognized for her nursing, though one profile of a nutritionist notes that she has a nursing degree. With all the high-level journalistic effort on display here--an effort celebrated in the editor's less than modest column, "Journalism That Makes a Difference"--we saw only one passage that could be considered a tribute to the valiant work of the world's estimated 12 million nurses to stem disease. That was in the concluding essay by rock star Bono.

The magazine's cover story is a "special report on the world's most dangerous diseases--and the heroes fighting them." The piece includes a brief introduction, a gallery of photos of disease victims (one caption notes that one Zambian with AIDS is very weak but "doctors are hopeful"), an effective foldout chart showing the major killers around the world, and a brief interview with major donors Bill and Melinda Gates.

But the heart of the piece is the set of profiles of the "18 HEROES," drafted by a number of different journalists. The title page of this section invites us to meet "the people who are out there solving" the problems of the developing world. They consist of 12 physicians, the nutritionist, a chemist, a health manager, and three people who are not health care workers. The section includes substantial profiles of the work of "America's most celebrated doctor for the poor" in Rwanda, a "doctor doing battle with Africa's AIDS epidemic," and the "laughing doctor" of Cambodia. All of the "heroes" sound worthy of acclaim, but it seems likely that the editors could have found many more of comparable worth--and some would have been nurses.

And it's not just the choice of "heroes" that excludes nurses. The way the profiles are drafted is utterly physician-centric. One profile begins by noting that when it comes to fighting AIDS, "doctors and clergy don't always see eye to eye." Another begins by informing us that the "job of fixing the African health-care system takes more than physicians and politicians." No nurse (other than the nutritionist) is named or quoted, despite extensive descriptions of clinical practice and research all over the world. We saw two passing references to nursing in the entire report. The first is the mention of the nursing degree of nutritionist Vicky Alvarado. But this is at most one of several secondary elements of her background that the piece suggests helped inform her impressive efforts to improve nutrition in Honduras through community education. Indeed, her profile is pointedly titled "Nutritionist," and we learn the name of the U.S. university granting her nutrition degree, but nothing about her nursing degree. Another profile notes in passing that the clinics reportedly supervised by a Congolese physician are "mostly run by nurses," but all credit for this work goes to the physician. This same profile briefly discusses the "brain drain out of Africa of highly skilled medical personnel" to the developed world--but that apparently consists only of physicians. The nursing shortage is not mentioned. And as is often the case in similar press pieces, when the journalist does not claim that all the relevant health care is being provided by physicians, then we usually hear that it has been done by general categories of persons like "staff," "clinicians," or "caregivers," or else it simply "was provided."

How do such distortions come about? The introductory essay by TIME Managing Editor James Kelly provides a clue. Kelly praises Sciences Editor Philip Elmer-DeWitt, the apparent point person on the project, for actually going to Africa for a few days. We learn that in Rwanda, Elmer-Dewitt shadowed his "longtime hero, Dr. Paul Farmer...as he treated AIDS, TB and malaria patients with food and life-saving drugs. 'This is how medicine is supposed to work,' says Elmer-Dewitt. 'After three days, I was ready to quit my day job and apply to medical school.'" Perhaps Farmer does do all of this by himself. But it seems that if there were any non-physicians providing important health care in Rwanda, Elmer-DeWitt would not have noticed.

Of course, this is nothing unusual. Last year's Discovery Health Channel Medical Honors, which focused mainly on work in the United States, completely ignored the work of nurses. Physicians received the majority of the honors.

But nurses, including local nurses and foreign aid workers, play a central role in preventing and treating deadly disease throughout the world. Many if not most of the health care professionals who volunteer for groups like "Doctors Without Borders" are nurses. Nurses also work to effect innovative systemic change through health research and advocacy at all levels--just the kind of thing TIME seemed to be interested in highlighting.

Examples? Well, we are hampered in providing many current developing nation examples, because of the same widespread journalistic bias evident in this report. The media commonly ignores even highly influential nurses' innovations and achievements, so we don't hear much about them. But we do know of Susie Kim, RN, DNSc, the Korean nurse who developed community-based mental health nursing care centers that the U.N. has recognized as cost-effective in rehabilitating long-term patients in developing nations. We know of Carol Etherington, RN, MSN, the Tennessee nurse who has worked for decades to secure the health and human rights of vulnerable populations worldwide, creating effective community-based programs for survivors of natural disaster, war, and other abuses, and serving as director of the U.S. board of "Doctors Without Borders." And we know of Connie Kganakga, Ph.D., the South African nurse who serves as chief director of HIV/AIDS for her nation's Department of Social Development and who, as HIV/AIDS program manager for the Nelson Mandela Foundation, helped develop a nurse-based model for the rollout of antiretroviral drugs in rural areas.

Despite all the space available in this huge report, and despite the many nurses who play leading roles in the fight against disease in different settings worldwide, it was left to a rock star to make the only statement in the magazine that could reasonably be termed a tribute to the work of nurses. In Bono's concluding essay arguing that fighting disease and poverty in the developing world is this generation's "moon shot," the activist gadfly notes that biomedical "scientists" alone cannot get "lifesaving vaccines and treatments" to those who need them "without our help." He continues:

On that score, there is cause for optimism. From NGOs to CEOs, truckers to nurses, philanthropists to pharmaceutical companies and even Presidents and Prime Ministers, people are putting their talents, time and money to work in the fight against deadly diseases. Just check out Bill Gates.

Of course, Mr. Hewson has placed nurses in a group made up largely of non-health professionals who might be seen as financing and implementing vital delivery systems, in apparent opposition to the "scientists" who actually create the life-saving product. However, as we have seen, nurses play a key role in designing and implementing "life-saving treatments."

We salute TIME's effort to highlight the fight against preventable and treatable diseases in the developing world. But when it comes to fighting the deep-seated media assumption that nurses are insignificant bit players in this story, we still haven't found what we're looking for.

See the TIME magazine articles.