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Reviews
Reviewed by Barbara Bamberger Scott
Medical expert Koye Oyerinde probes the reasoning – or lack of it – within the health care systems of multiple nations, finding that they offer scant hope of best practices for many – if not most – of those who rely on them.
Oyerinde’s zestful, zealous account begins with one of his earliest experiences as a practicing “house officer” (comparable to an internship) just setting out on his career in Lagos, Nigeria in 1989. A well-dressed but very poor woman whom he directed to the casualty department when he met her on the street soon became a patient in his care, suffering from a miscarriage that threatened her life. His introduction to the internal hospital system began when he was told that she could not have the surgery she desperately needed until she had purchased the medical supplies required, some of which might not even be available at the hospital. By borrowing and begging, the surgery took place, and her life was saved. But the young doctor had much to contemplate – the practice of charging patients in advance for supplies and services is still a common one in every country, he states, one of many thorny issues raising the question posed by his book’s title.
Oyerinde currently serves as the Policy and Advocacy Chair on the Executive Committee of the Section on Global Health of the American Academy of Pediatrics. As a world traveled physician and health policy researcher, Oyerinde explores these vital issues in depth, with personal stories and professional erudition to underpin his philosophical theses. He makes many salient points including: the pitfalls of medical insurance – who pays and who should pay?; expansion of technologies for better cure rates that paradoxically add more cost and may thus exclude the very people who most need the services; concern that well-meaning actions of charitable organizations such as Médicins Sans Frontiéres may give some national governments the excuse to provide citizens fewer services; and the reality that those charged with investigating health care practices may deal only with the elites of the system, not with the desperate recipients – or non-recipients – of their services.
There exists a tendency for some lower-level medical workers in public facilities to practice what Oyerinde calls “D.N.A.” – disrespect, neglect, abuse of patients – possibly evoked by their own burdens of understaffing and underpayment. He notes that such crises as the Ebola and AIDS outbreaks in Africa, and the Covid pandemic have made the pressure for universally available healthcare ever more crucial. Two international conferences, Alma Ata in 1978 and Astana in 2008, endorsed systems “for achieving health for all” – but those goals have yet to be met. Oyerinde presses for their institution, reminding us that “minorities, poor people, and the elderly” are disproportionately vulnerable in such cases, leaving us to wonder if by not addressing these issues, we are tacitly approving their suffering and death.
Quill says: Oyerinde has written a diligently researched, highly relevant work to alert readers to the necessity for changes in health care policy and practice in all countries, at every level.
Reviewed by Roberta E. Winter
Paying for universal health services? How could we pay for it? “Stop to think of it. We’re never asked how we were going to pay for our years of wars choice. The Bush Administration and his enablers didn’t sit with us in town halls to ask how they were going to spend a trillion dollars in Afghanistan and Iraq.”
At first glance Dr. Oyerinde’s book appears to address the terminally ill, but refreshingly his treatise reflects health care on multiple continents and is about creating health through primary care systems. Though this Nigerian-born pediatrician and global health advocate has many wonderful personal experiences to share, this book suffers from poor editing, which makes it difficult to enjoy the read. The nomenclature wanders back and forth between the stilted Queen’s English, various African patois, and American terminology, without a single defining voice.
This will not be a popular read, but the good doctor has some great health policy insights and the occasional wry observation of culture clashes. It is informative to glean the perspective from an immigrant and especially this globe trotter. However, the book misses the most compelling aspect of Oyerinde’s story: He lives and practices in Minot, North Dakota. North Dakota is a very conservative state and not known as a bastion of cultural integration, so opening with this would have been a stronger pull for the reader.
In particular his nuanced comparisons of certain aspects of U.S. primary health care to African nations is refreshing. In his native land of Nigeria, he found the health care had diminished drastically from his youth to the present day. “When governments got bad and become unaccountable to the electorate, public services such as education and health care services are the first to deteriorate.” One can easily draw comparisons to the Blue/Red divide in America today. Blue states have expanded health care services to those in need, and the red states for the most part have restricted them. Oyerinde speaks of his experience watching totalitarian regimes allowing health services to deteriorate and lose any semblance of value while the jet setting junta fly off to Dubai or Turkey or Switzerland for care.
Americans so often recite theirs is the best healthcare in the world, but from what vantage point are they drawing this conclusion? Certainly not from care coordination, affordability, or access to primary health care services for all. This is the meat of his work: The provision of accessible and affordable primary health care can improve health and avoid the reliance on more expensive secondary care in hospitals. “The primary health care system is not a treatment system but a system in which prevention of disease and death and the promotion of wellbeing are paramount.”
An irritating aspect of Oyerinde’s book is his constant referencing of conferences and global health entities for which laypersons will be unfamiliar, and the absence of an acronym dictionary, chapter notes, bibliography, or index, make it difficult to follow seamlessly. Halfdan Mahler, a Danish world health executive decades ago, is not a household name, for example. Alma Alta Conference? Again, no reference for most readers outside of the global health intelligentsia.
Who Should We Let Die has moments of political intrigue, because who knew that the Obama Administration used a doctor and a vaccine ruse to gain access to Osama Bin Laden?
Overinde’s knowledge and understanding of maternal health is welcomed, especially in light of the recent spate of male legislators who ponder why they, as males have to pay for a woman’s childbirth costs. I particularly enjoyed this sanguine observation, “It is time to wish health insurance middlemen eternal rest; may perpetual light shine upon them.”
“Once again, as you cross the threshold from a free citizen to in-patient, you lose most of your control over the cost of your care.”
Lest you think this treatise is all about bashing US health care, you will be glad for our coordinated and vaunted emergency 911 services, highway safety standards, and controls to protect the distribution of counterfeit drugs compared to Africa. Expat Africans working in health care and policy wonks will enjoy his practical view on health care. His astute observations on the unintended complexity and consequences of nongovernmental organizations trying to apply industrial fixes to rural communities in Africa is so true. “Why don’t we ask the locals?” he opines, infuriating a Scottish advisor. He speaks of the importance of trust in a health care system, and this has certainly been demonstrated in the vaccine hesitancy in the U.S. Finally, his definition of the U.S. health system as GoFundMe would be hysterical if it weren’t so true.
“In the U.S. we have rationing by staffers motivated by company profits.”
Reviewed by Kathy L. Brown
Dr. Koye Oyerinde diagnoses the ills of healthcare systems around the world and recommends a treatment plan in this engaging treatise
Koye Oyerinde is a pediatrician who has practiced in developing nations and the United States for decades. As a public health professor, he advised the national health ministries of over thirty countries regarding maternal and child health services. Oyerinde is well positioned to see the systemic problems inherent in the structure of healthcare provision across diverse settings.
In a clear conversational voice, Who Should We Let Die breaks down public health policy and clinical medicine issues in an engaging manner that will make sense to healthcare consumers around the world. Given the global COVID-19 pandemic, the book’s analysis of past pandemics, insights into the current one, and advice for the future are particularly pertinent. It helps that the book also acts as a fascinating memoir of Oyerinde’s thirty years in healthcare.
The book grabs the reader with a story. In 1989 as a new house officer (medical school graduate in training at a teaching hospital), Oyerinde encountered a daunting set of challenges to save a street vendor’s life.
Mama Jamila showed up in the emergency department of a Lagos megalopolis hospital, but without family or financial resources. This story illustrates the book’s issues, from the dysfunctional medical supply system, to staffing drama, to the big one: money. Oyerinde recalls, “I walked zombie-like for about ten minutes, not sure what to do. But we can’t just let her die was the recurring thought in my head.”
The 1978 Alma Ata Declaration’s slogan, “Health for All by the Year 2000,” promised that health is a human right and guided Oyerinde’s medical training. Yet, that deadline has come and gone. A restated goal took the Alma Ata Declaration’s place: Universal Health Coverage by 2030. “The year 2030 is less than a decade away. Are we going to achieve universal health coverage? I don’t know,” says Oyerinde, “but I am convinced that we have a fair chance.”
The book assesses the world’s health status against these global objectives and, frankly— Dr. Oyerinde is always frank—the patient isn’t looking well at all. “If our governments do not provide for our basic health needs, can we really trust them with a serious public health crisis?”
In addition to measuring society against the world’s long-term health goals, the book also explores topics impacting community and individual health such as governments’ obligations to their citizens; the civil rights issues at the heart of healthcare inequalities; healthcare workers’ motivations, training, and rights; environmental pollution’s impact on health; technology’s role in healthcare delivery, and effective measures against disease outbreak. As the book makes clear, all these issues, like health itself, are intertwined and global.
The book’s voice is conversational and frequently illustrates a point with a vivid personal anecdote from the author’s wide experience. It delivers complicated concepts and information with clarity, warmth, and humor.
Who Should We Let Die will provoke discussion among a general audience. It presents a healthcare practitioner’s conclusions based on his personal experience and informed by his studies and research. The book calls on the reader to examine their values and think globally. The book’s overriding point is that we are all interconnected, whether we realize it or not.
Readers interested in learning about people interacting with their healthcare systems in the United States, Africa, Asia, and Europe will enjoy this book. It provides much food for thought and should provoke lively discussion of healthcare policy, law, and regulation.
Interviews
Today, Feathered Quill reviewer Barbara Bamberger Scott is talking with Koye Oyerinde, author of Who Should We Let Die?: How Health For All Failed, And How Not To Fail Again
FQ: How long did it take you to write this remarkably wide-ranging book?
OYERINDE: I started taking notes and jotting down ideas about two years ago but it took about eighteen months of dedication to get the book through to publishing and release.
FQ: Will you offer the book as a manual for workshops/gatherings concentrating on this important material?
OYERINDE: The book will be a good study material amongst other books for students of health policy and management, especially those with a strong global health focus
FQ: Does writing about a botched system and the ways it might be changed and reformed give you a sense of hope?
OYERINDE: It is only possible to write this book from a hopeful position. Central to the health for all campaign was a grassroots organization around health issues. It is only active citizens agitating for health for all that will make it possible. I draw my hopefulness from campaigns by young people around the world against police brutalities such as the George Floyd demonstrations in the US, and the ENDSARS campaign in Nigeria. After all health for all is a social justice issue.
FQ: Do you use a fair dose of humor, as you did in your book, for speaking engagements regarding this material?
OYERINDE: I think health policy is a boring subject for the general public. I tried to use humor in my writing to lighten the boredom of readers. In speaking engagements, I am not naturally humorous, but it depends on the conversation and the vibes among the participants.
FQ: Would you recommend the book to those who work outside the medical profession but who might face similar pitfalls in work serving the public?
OYERINDE: Yes, the book will be useful for all who provide public services such as education, housing, and public safety.
FQ: Are there any nations that, in your observation, come close to offering the healthcare ideals you propose for all?
OYERINDE: We need not look far. The US Indian Health Service provides healthcare as a right of citizenship. In terms of other countries, practically every other Western country provides health services as a right. The National Health Service (NHS) in the UK is a good example. Cuba, a much poorer country, under decades of US embargo, manages to provide health services to its citizens.
FQ: Could you envision a documentary film concentrating on these issues?
OYERINDE: There have certainly been documentaries on related subjects. Michael Moore’s 2007 film, Sicko, focuses on the US health system.
FQ: What are your future plans as an author, speaker, and universal healthcare advocate?
OYERINDE: I hope that the book will provide a platform for me to continue to advocate for universal healthcare. I plan to author a few short pieces in local newspapers and academic journals soon.
