Review of Literature, 2010

[1]. Yet I would maintain that, at the individual and, sometimes, at the institutional levels, compassion is a core value of global health and a primary source of motivation for those who devote their lives to it.

Evidence to support this assumption is found in the history of modern public health, as it emerged during the 19th century. Recognition of the health importance of poor working and living conditions gave birth to the Sanitary Movement in Europe and the United States, with its focus on reforming factory conditions and improving diet, housing, water, and sanitation.  A strong ethic of compassion and an awareness of shared humanity characterized the campaign to eradicate smallpox during the 1970s. Compassion also is seen in efforts to improve the health of refugees and to eradicate diseases that affect the poorest of the poor, such as Guinea worm disease and lymphatic filariasis.

Evidence for the centrality of compassion in global health also is found in the stories of those who have dedicated their lives to this field.  The most respected global health leaders are those who embody compassion.  Anecdotally, although they are reluctant to do so, when pressed to explain in one word what motivates them, those who work in global health often reply with words such as “compassion,” “caring,” and “concern” – even “love.”  In An Ethic for Health Promotion, David Buchanan asserts that, “Most people in public health still feel that to be a health professional means to have a vocation, a sense of calling.  They strive to create a healthy society in which no one will be handicapped from participating due to unnecessary illness and suffering.  They continue to work in the field out of feelings of sympathy and solidarity with those in need”[2].

If this is true, then why is compassion infrequently mentioned in the public health literature, in textbooks on global health, or within schools and institutions engaged in global health work? In part, this may reflect the scientific foundations of modern public health. In scientific endeavors, which some consider value-free, those who speak publicly about personal values may be considered “soft,” “sentimental,” or otherwise inappropriate.

Perhaps more importantly, public health has been deeply influenced by another world view, one that divides the world into “us” and “them.”  In this view, the role of public health is one of civil defense, i.e., to protect “just us” rather than social justice. The field of tropical medicine originated during the late 1800s, not from an altruistic desire to improve the health of lifelong residents of the tropics, but rather, to protect European soldiers and colonists who were sent to subjugate them [1]. It was fear of bioterrorism during the Cold War that led to the creation of CDC’s elite cadre of disease detectives, the Epidemic Intelligence Service.  The practice of quarantine, for centuries a mainstay for preventing importation of communicable diseases, is based on a dichotomy that contrasts the population to be protected from those who threaten it [3]. For those who view public health primarily in these terms, too much ado about compassion is regarded as sentimentality – a poor basis for making the tough decisions required to protect the public.

Anthropologist Jeannine Coreil writes about these two major historic streams within public health, and suggests that they are often in tension [3].  After September 11, 2001, at least in the United States, the balance between these two positions shifted dramatically.  The role of compassion in public health was eroded, replaced by an attitude of defensiveness, rooted in fear.  Bioterrorism defense soon accounted for a large proportion of CDC’s budget, and the US Public Health Service increasingly has taken on the trappings of the military.  Since 2001, its agenda has, at times, been dominated by emergency preparedness against man-made threats – to the detriment of routine public health and prevention services [3].

Market forces in health care – including public health – represent another challenge to compassion as a core value.  At least in the United States, public health is now seen by investment firms (and some political leaders) not as a public good, but as a commodity that can be bought and sold, a potential source of income for investors and speculators.

If the above analysis is correct, i.e., if compassion is a core value of public health, and if global health policy is increasingly based on a civil defense model where compassion is minimalized, might there be a new model, a new vision of global health, which is rooted in compassion —now expanded to social justice and global health equity— that informs and defines our goals, values, objectives, principles and actions? What power might be unleashed if global health leaders could speak of their shared values?   Such a new model may be an important product of our meeting – perhaps the central product.

Review of Health Literature
In preparation for the Carter Center meeting, I worked with Ms. Valerie DiPonio, a recent graduate of Kalamazoo College, to review the literature on compassion in global health.  Valerie reviewed the indices and tables of contents and looked through the chapters of 31 textbooks on global health, public health, health promotion, and public health history.  Among these, love was mentioned in one book (in relation to marriage) and compassion was mentioned twice: once as part of a mission statement for a community center; and again in John Last’s textbook on Public Health and Ecology, where it appears in a list of public health values.

In contrast, the terms “caring” and “beneficence” appear more frequently in these sources.  Much more common were references to ethics, equity, justice, and rights.  Beneficence (to do what is good for the welfare of another) was often listed as one of the four basic principles of public health ethics (the other principles being justice, nonmaleficence, and autonomy) [4].

This cursory review suggests that, while beneficence has been recognized as a basic principle of public health ethics, compassion per se is not widely regarded as a core value in modern public health.  Such a finding raises several questions.  Does compassion fall outside the domain of systematic articulations of ethical principles?  In other words, is compassion, which arises in response to suffering, more fundamental than ethics – is compassion required for an ethical response to suffering?  Or is compassion subsumed by the broader category of beneficence?  Or perhaps the more commonly-used terms such as “caring” and “beneficence” are safer or more acceptable than compassion (with its overtones of religiosity or sentimentality) in professional company.

Valerie also searched the PUBMED database for articles on “love,” “compassion,” “compassion and global health,” and “compassion and public health,” among others.  Of interest, “compassion and public health” and “compassion and global health” yielded 3856 and 88 entries respectively, compared with 4757 for “compassion and nursing.”  Of the articles that were identified through queries of “compassion and global health” or “compassion and public health,” few were central to our interests.  Many dealt with the psychology of compassion, “compassion fatigue,” or related topics, or, surprisingly, seemed to have little to do with the issue.

Major Themes
Some of the most relevant literature is abstracted in the annotated bibliography.  As a way of introduction and overview, the major themes are reviewed here.

Interconnectedness

Global health is based on awareness that all human life is interconnected and that the health of every individual is inextricably linked that of the global community. This theme of unity, of interconnection, also is found in most of the world’s great wisdom and religious traditions. It is the deep recognition of our interconnectedness that make caring and compassion possible. In contrast, our tendency to divide the world into “us and them,” of denying our interconnectedness, may lead to ineffective and harmful public health policy [5].

Relationships and Community

Several authors (e.g., Klinemann [6]) emphasized that compassion and caregiving in human relationships are essential to what it means to be human.  Buchanan writes that, “Change and growth are possible when community members connect with one another as human beings in caring relationships characterized by trust and mutual support” [7].  Compassionate community attitudes are a strong predictor for the success of public hospitals [8].  Kellehear considers the key components of a “compassionate city” and identifies social and public health policies rooted empathy, equality and action [9].

Tension: Compassion at the individual level – or the population (or systems) level?

Compassion and caregiving are major themes in the nursing literature, where the focus is care of the individual patient.  But in global health, one deals with the collective: can one feel compassion, and take compassionate action, for an entire population?  For Crigger and colleagues, writing in the nursing literature, “the compassionate nurse professional” is now being defined along the lines of social justice, rather than compassion alone.  “As compassionate nurse professionals and citizens of the world, nurses embody a commitment to social justice in healthcare for people of all cultures and nations” [10].  At the population level, then, are socially just policies an expression of compassion?  Is compassion more important and relevant for a nurse caring for patients in a burn unit than for an epidemiologist analyzing data?  Some of the above authors (Buchanan, in particular [7]) argue for public health based on deep human relationships, which is only possible in community.  Others, such as Benatar, indicate that we need to think globally and systematically.  He calls for “an ethics of public health to enable us to deal rationally with threats to global health as a systemic challenge” instead of our current focus on “individual autonomy and interpersonal ethics” [11].

Tension: Compassion or Justice?

As noted above, the theme of justice is found much more frequently and explicitly than compassion in the public health literature.  In practice, these two values often seem to be in conflict, although restorative justice, which requires accountability but allows for the possibility of reconciliation, offers a point of intersection.  The relationship between justice and compassion within public health is a topic worth exploring.  Was sanitary movement fueled by one, or both?  Is compassion or anger the most powerful and effective motivation for seeking justice?

As noted above, Benatar and Crigger consider justice of greater value and more fundamental for global health than compassion.  In contrast, Blinderman, in discussing end-of-life care in resource-poor settings, writes, “Palliative care raises issues about compassion and beneficence that go beyond questions of justice” [12].  For him, relief of suffering is a more fundamental principle than justice per se.  Similarly, Dunn, writing in the nursing literature, states, “A nurse may perform actions for the nursed with a sense of duty or moral obligation.  The nurse, in this case, acts out of duty, not out of compassion.  The value of human care and caring involves a higher sense of spirit of self” [13]. Thus, Blinderman and Dunn seem to argue that there is something deeper and more important than duty or principles of justice, something that cuts to the core of who we are as human beings.

The tension between compassion and justice is not new.  The Hebrew psalmist longed for the day when “mercy and truth have met together; righteousness and peace have kissed each other” (Psalms 85:10).

Among the articles that focused on justice, they were emphatic in their position that inequity at the root of social injustice [14,15].

Ethics

As noted above, the theme of ethics is an important one for public health.  What struck me in reviewing much of the ethics literature was the absence of any mention of compassion as an underlying value [14-17]. I have speculated on possible reasons for this above, but it gives one pause.

Spirituality or the “inner life”

Several authors reflected on the importance of the “inner life” in cultivating compassion.  The deep compassion expressed in the life of Florence Nightingale was apparently motivated by a profound spirituality and mystical experience of the Divine [18].  Rumbold argues that spirituality is at the heart of compassion [19] and Christina Puchalski makes the same point [20].  Chokyi Nyima Rimpoche and David Shlim, writing from the Buddhist perspective, highlight the importance of self-awareness and spirituality in cultivating compassion [21].  Thus, compassion requires both heart and mind.  This perspective has implications for fostering the inner qualities required for global health leadership in the coming decades. What are the qualities that these leaders need to have?  What qualities will they need if they are going to lead the charge for global health equity?

Teaching and Maintaining Compassion

A critical question is whether compassion can be taught and learned, and if so, how?  Chokyi Nyima Rimpoche and David Shlim introduce the reader to specific meditation practices used by Buddhists for centuries to cultivate compassion, and suggest that they work in modern clinical settings as well [21]. Several articles focused on “educating for compassion.”  Smith and colleagues showed that international experiences foster compassion and idealism in medical students [22]. “Schwartz Rounds,” conducted in medical centers around the world, focus on creating an environment where compassionate care becomes the norm.  Repeated “chronic” encouragement was noted to be important in maintaining compassionate care [23].  Lown evaluated Schwartz Rounds in one setting in the Netherlands, where health care workers reported a decreased sense of isolation, but no measurable effect on empathy was observed [24]. Danielson and Crawley reviewed the concept of compassion in health care settings, as well as different measures used to measure it [25].

Compassion, caring, and empathy

Several studies addressed antecedents and consequences of compassionate action.  Keltner and other evolutionary biologists and social psychologists view compassion as innate to humans [26].  Finfgeld identified factors associated with caring in the health care setting [27], and Schout explored qualities required to gain the trust of patients with mental illness, one of which was empathy [28].  An emerging literature on compassionate love, mostly limited to social psychology, has identified other factors associated with compassion; this literature was not reviewed in detail for our meeting.

References

1.     Farley J. Bilharzia: A History of Imperial Tropical Medicine. New York, NY: Cambridge University Press; 1991.

2.     Buchanan DR. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being. New York, NY: Oxford University Press; 2000.

3.     Coreil J.  Public health and the military: An uneasy alliance of organizational culture. Revised August, 2010.

4.     Beauchamp T, Childress JF.. 1994. Principles of Biomedical Ethics, 4^th ed. New York: Oxford University Press

5.     K Morone JA. Enemies of the people: the moral dimension to public health. J Health Polit Policy Law. 1997; 22(4):993-1020.

6.     Kleinman A. On caregiving: a scholar experiences the moral acts that come before – and go beyond – modern medicine. Harvard Magazine. 2010; July-August:25-29.

7.     Buchanan DR. An Ethic for Health Promotion: Rethinking the Sources of Human Well-Being. New York, NY: Oxford University Press; 2000.

8.     Altman SH, Brecher C, Henderson MG, et al. Competition and Compassion: Conflicting Roles for Public Hospitals. Ann Arbor, MI: Health Administration Press; 1989.

9.     Kellehear A. Compassionate Cities. New York, NY: Routledge; 2005.

10.  Crigger NK, Brannigan M, Baird M. Compassionate nursing professionals as good citizens of the world. ANS Adv Nurs Sci. 2006;29(1):15-26.

11.  Benatar SR, Lister G, Thacker SC. Values in global health governance. Global Public Health. 2010;5(2):143-153.

12.  Blinderman C. Palliative care, public health and justice: setting priorities in resource poor countries. Dev World Bioeth. 2009; 9(3):105-110.

13.  Dunn DJ. The intentionality of compassion energy. Holist Nurs Pract. 2009;23(4):222-229.

14.  Levy B, Sidel V. Social Injustice and Public Health. New York, NY: Oxford University Press; 2009.

15.  Hofrichter R. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease (Public Health/Vulnerable Populations). San Francisco, CA: Jossey-Bass; 2003.

16.  Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776-82.

17.  Childress JF, Faden RR, Gaare RD, et al. Public health ethics: mapping the terrain. J Law Med Ethics. 2002;32(2):232-242.

18.  Dossey BM. Florence Nighingale: a 19th-century mystic. J Holst Nurs. 2010;28(1):10-35.

19.  Rumbold B. The spirituality of compassion: a public health response to ageing and end-of-life care. Journal of Religion, Spirituality & Aging. 2006;18(2):31-44.

20.  Puchalski C, Lunsford B. The Relationship of Spirituality and Compassion in Health Care (paper prepared for the Fetzer Institute).

21.  Chokyi Nyima Rinpoche and David R. Shlim. Medicine and Compassion: A Tibetan Lama’s Advice for Caregivers. Boston, MA: Wisdom Publications; 2006.

22.  Smith JK, Weaver DB. Capturing medical students’ idealism. Ann Fam Med. 2006;4(1):32-37.

23.  Sanghavi DM. What makes for a compassionate patient-caregiver relationship? Jt Comm J Qual Patient Saf. 2006;32(5):283-292.

24.  Lown BA, Manning CF. The Schwartz Center Rounds: evaluation of an interdisciplinary approach to enhancing patient-centered communication, teamwork, and provider support. Acad Med. 2010;85(6):1073-1081.

25.  Danielson RD, Crawley JF. Compassion and integrity in health professions education. The Internet Journal of Allies Health Sciences and Practice. 2007; 5:2. http://ijahsp.nova.edu/articles/vol5num2/cawley.pdf. Accessed August 12, 2010.

26.  Keltner D, Marsh J, Smith JA. The Compassionate Instinct: The Science of Human Goodness. New York, NY: The Greater Good Science Center; 2010.

27.  Finfgeld-Connett D. Meta-synthesis of caring in nursing. J Clin Nurs. 2008;17(2):196-204.

28.  Schout G, de Jong G, Zeelen J. Establishing contact and gaining trust: an exploratory study of care avoidance. J Adv Nurs. 2010;66(2):324-333.