Mark, a Malaysian academic, had done his PhD on palliative care with a particular focus on the delivery of palliative care in low- and middle-income countries (LMICs). For about six months, he and I had been discussing the ethical challenge of delivering palliative care in LMICs. It is a pillar of Universal Health Coverage. Still, there is a possibility that in weak health systems, governments could avoid their obligations to deliver curative care by choosing, instead, to deliver palliative care.
With the development of the COVID-19 pandemic, our conversation had taken a slightly different path. The modelling suggested that many LMICs would have their hospitals and clinics overwhelmed with COVID patients. The basic management tools of oxygen and ventilators, which were being rationed in High-Income Countries, would be a rare resource in poorer ones, leaving many people to die without any care at all. Our thinking returned to the palliative care question. The ethical dilemma, however, had shifted. The issue now was, how do LMICs deliver palliative care at a massive scale?
This was the subject of the letter, “Manage suffering when you cannot manage treatment”. The letter didn’t say anything earth-shattering, but it was necessary, and it had been crafted into a pithy 600 words. We had not seen anyone else raise the issue in the COVID-19 literature, which was (and still is) overwhelmingly focused on the provision of clinical care. We submitted the letter and crossed out fingers.
In terms of an academic career, a letter in a high profile journal does not amount to much. But it is a nice affirmation of one’s relevance in a global conversation. As a mentor, I have certainly encouraged colleagues to use letters as a vehicle for sharing and developing ideas. It also strikes me as important that it is academics and health professionals in LMICs who are the ones highlighting the issues that are important in LMICs. Now, you might take issue with whether I have a legitimate place in that conversation or not, but there is no doubt that Mark does.
I was surprised when, 9 days after the letter was submitted, an editorial appeared in the journal developing similar ideas. It was written by the Editor-in-Chief, a well-known advocate for many worthy causes, who lives in a high-income country. He regularly uses the pages of the journal to discuss challenging global health issues about health equity and human rights. He had more words available to develop the ideas and, in truth, he writes much better than we do. Six days after the editorial was published (15 days after submission), we received the rejection letter.
Thank you for submitting your Letter. Having discussed your Letter with the Editor-in-Chief, and weighing it up against other submissions we have under consideration, I am sorry to say that we are unable to accept it for publication. Please be assured that your Letter has been carefully read and discussed by the Editors.
I did not feel assured at all. It would have been impossible for the journal to publish the letter once the editorial was published. It was redundant. Instead, it made me wonder about whose voice gets heard? Whose voice has enough legitimacy even to have the possibility of being heard? And the reality is that power matters.
Nothing nefarious happened. Ideas are cheap, and the Editor-in-Chief had a similar idea to our’s — and he has a privileged platform from which to deliver it. The message is important, and ultimately it was delivered. Does it matter who delivered it? I think it does. Having the right to say something does not mean it is right that you say it. Comedians are very aware of this. A powerful joke from one person’s mouth falls flat when delivered from another’s. Who tells “a Jewish joke” and who uses the “N” word can shift comedy from hilarious to tone-deaf to the offensive.
To have a platform from which to advocate for justice is a great thing. It is often more important to use that platform to enable, empower and legitimise other voices (and add your voice to theirs) than to be the voice.