Urbanization!

Last week’s New England Journal of Medicine called attention to another emerging humanitarian disaster – Urbanization! (http://content.nejm.org/cgi/content/full/361/8/741) For many the move to the “big city” often seems be out of an expectation of a better way of life – escape from the confinement or isolation of rural life, escape from conflict, or in search of better work opportunities. The editorials’ authors, however, point out some of the unique challenges of urban healthcare: population density and crowding, lack of social support, lack of disease surveillance in slums, and lack of access to care that may be nearby but unaffordable.

Whew! Just listing the challenges of urban health care helps me remember why I choose to practice in the country! The sheer challenge of thinking through possible solutions is overwhelming – so many challenges, so much complexity, and such a large scale. How do I think about the health of an entire metropolis?

In truth, however, such large-scale thinking is vital to both rural and urban medicine. Answers to the challenges of sickness and healthcare in both the country and the city require thinking on the large scale, and thinking creatively. How can we address the healthcare challenges of our local populations, be they urban or rural? We need to think big, think about the system challenges, and try to keep at least one step AHEAD of the next developing disaster.

We also need to be, first off, good family docs. As big as the scale of urbanization is, we need to remember to think one patient at a time about both diseases, and about social constraints and social conditions. What does my patient have? And how is his or her home, family, or life situation making things better or worse.

For most of the world, life is not all brightness and opportunity in the city, neither is it pastoral tranquility in the country. The challenge of doctoring lies in thinking both about my patient in front of me, and my community of patients “out there,” and about how to help both individuals and systems change for the better.