Hit men pursuing rivals into intensive care units and emergency rooms. Shootouts in lobbies and corridors. Doctors kidnapped and held for ransom, or threatened with death if a wounded gunman dies under their care. With alarming speed, Mexico’s violent drug war is finding its way into the seeming sanctuary of the nation’s hospitals, shaking the health care system and leaving workers fearing for their lives while trying to save the lives of others.

It seems to me that the systematic intimidation of medical personnel and the violent disruption of care are hallmarks of a civil war. It happened in El Salvador (Geiger et al., 1989). It's why MSF left Afghanistan (MSF, 2004). It happened in Rwanda. Now it is happening in Mexico.

I wonder if it is fair to say that whenever we find organized groups intent on preventing the care of others by whatever means they find expedient, civil war isn't too far off? This, of course, raises a bigger question, which is, what counts as an organized group and what counts as systematic intimidation? Do abortion clinic bombings, for instance, fit this model? I'd venture to say that they do, though I'd hesitate to call such attacks a war.

I guess it is all a question of semantics, of how willing we are to call pervasive or persistent violence a war. In any case, it's worth thinking about it: the more we reflect on this sort of question, the more likely we are to uncover threats to public health we didn't even know existed.

The difficult birth this week of a new baby girl to one of our staff has reminded us of the stark differences between becoming a mother in the rich world and in the poor world. The difference is not so much that having a baby is without risk for rich-world women: ask your colleagues and neighbors about their own experiences of childbirth and you’ll be surprised how many dramatic stories emerge. In my own case, a flawless pregnancy suddenly turned life-threatening due to pre-eclampsia at 32 weeks gestation.

The difference is in how childbirth happens – and how frequently it can mean death for a developing country woman. Had I been a poor woman in a developing country, the chances are good that neither me nor my twins would have survived. The lifetime chance of dying from maternal causes is one in 61 for women in developing country. The same risk has a probability of 1 in 2800 in the developed world (PRB, 2005) . Wherever they live, rich women benefit from better health and pre-natal care that greatly improve their chances for safe delivery. But childbirth can still be a terrifying experience.

This got me thinking about what childbirth is like for limited English proficiency women here in the U.S. Naturally, I did what any self-respecting med student would do: I turned to PubMed. To my surprise, in spite of the expected evidence confirming that non-English-speaking immigrants experience poorer-quality primary care (Pippins et al., 2007), have less access to mental health care (Sentell et al., 2007), and often do not receive recommended health services such as cardiovascular screening and flu shots (Cheng et al., 2007), there was also evidence that being Hispanic and non-acculturated was predictive of a similar incidence of low birth weight and infant mortality to that experienced by white, non-Hispanic women (Callister and Birkhead, 2002). As one author puts it, "Despite having many of the risk factors for poor pregnancy outcomes, Mexican immigrants have superior birth outcomes when compared to U.S.-born women. Social support, familism, healthy diet, limited use of cigarettes and alcohol, and religion may play a role in improved outcomes. The superior outcomes diminish with the process of acculturation as the individual adapts to her new culture," (Page, 2004).

So it is true that motherhood is not a universal experience, but nor is it a national experience, nor an experience determined by socio-economic status alone. Page posits some factors which may help to explain the apparent positive impact of being an unacculturated mother in the United States, and it's well worth examining their protective potential. The larger message however, is that globalization exerts complex influences on the individual and therefore on the community. While one might expect a poor, non-English speaker to have subpar perinatal outcomes, it turns out that the cultures of health which some Hispanic women bring with them when they immigrate actually mitigate other risk factors. While we often assume that outcomes are predicated upon the disparities endemic to the United States, then, we cannot lose sight of the values and practices which immigrants bring to our health care system and the changes such imported attitudes engender.

The cases I see in Olneyville are pretty typical of any internal medicine practice: bronchitis, diabetes, hypertension, asthma and depression. What I find most impressive about our office, however, is the extent to which globalization is reflected in the stories of the people I meet there. I see patients in conjunction with my mentor, a physician who got his medical degree in Colombia and did his residency at the University of Massachusetts. All the other doctors at the center are also foreign-born and we work with a multi-national, multi-lingual nursing staff. Our patients are, by my rough estimate, 95% Spanish-speaking, hailing mostly from the Dominican Republic, Guatemala and Mexico.

This is global health gone local. It is impossible at the Olneyville Health Center to ignore the impact of fluid borders and large-scale migration: we see patients who suffer with the isolation of being poor and unable to communicate with many of their neighbors; patients who do not have legal residency in the United States and who therefore can't get access to essential social services; patients who are far from home and have trouble managing chronic disease without the support systems a family provides. Of course, not all the stories are tragic: there are parents who work tirelessly to send their children to school and children who come to each appointment with their aging parents, asking questions and writing notes on every medicine, treatment and test we order. I even met a man who became a U.S. citizen on October 31st and voted for Barack Obama on November 4th.

These cases may seem like caricatures of the immigrant experience, but the challenges they highlight are very real factors in the day-to-day business of providing care for the patients I see. Language and cultural barriers, legal troubles, being far from home. All these take a toll on people's health, and they are part and parcel of migration and globalization.

In his book, When Bodies Remember, Didier Fassin posits that we literally embody our history, that we are physically shaped by our experiences. I see this process taking place in the lives of my patients, and I believe that those of us in the medical field must help to expand global health's scope of inquiry to include such local repercussions of transnational forces. We cannot relegate this discipline to the campo of Nicaragua or the favela of Rio de Janeiro. Rather, we must use our understanding of international relations and global migration to inform the study of medicine and public health in the United States as well as abroad.

So this is my pet project. I'm going to try to update this blog regularly with news about my exploration of global health issues in and around Providence. I hope this becomes a worthwhile project, and I welcome your feedback.