There is a ridge in southern Chad—I do not remember its name—that is deeply etched in my heart. On one side, looking north, was nothing but sand. To the south, one could see the savannah and the beginnings of greenery beyond. The ridge seemed to be right at the edge of the Sahara desert, right at the height of the Darfur conflict at the time in 2007. It was not easy to get to that ridge. Médecins Sans Frontières had set up field stations for refugees and internally displaced persons and we were busy sorting out how to give transfusions to the many malnourished children with hemolytic malaria in the middle of the desert. We vacillated between patients and parents, trying to explain the concept of transfusion in the middle of a desert. One day, we drove for hours to the ridge for a break. And to look for hope.

Later, in 2010, I worked in another deeply demarcated place. Flying by helicopter from Santo Domingo, Dominican Republic, to Port-au-Prince, Haiti, I noticed a sudden change in the landscape below; again, deep green on one side and brown on the other. When I asked the pilot about it, he said we had just crossed into Haiti. I looked back and realized I was looking at the border between the 2 countries—and the sudden start of human-caused deforestation. It was a sickening feeling; the landscape below looked etched and dusty, like a battlefield after a nuclear explosion.

Border spaces are defined by competition and conflict, but also by trade and progress. There is something real but hopeful about places where humans meet. These are liminal spaces defined by neither one side nor the other, but by something in between. Family medicine, occupying the space between medicine and society, is a liminal discipline. Being community-based, it is deeply influenced by both societal and medical trends, and in turn can have a deep influence on both. It is an awesome responsibility.

During my time as Director of the Besrour Centre for Global Family Medicine at the CFPC, I was often asked, “Why should a national college support efforts overseas instead of focusing on all the problems at home?” My answer was always we can and must do both.

Medicine should not be a zero-sum game. When 2 patients come to the emergency department at the same time, we may prioritize one over the other, but we would not abandon either. Both patients may present because of the same circumstance and may help us understand and improve our approach. Some clinics on the Ottawa side of my liminal space in Ontario recently made the difficult decision to deroster Quebec patients. This invariably means a long wait for these patients to find other family physicians, but I realize the same is true for many patients in Ottawa. Resources are finite but I like to believe that should a major disaster strike one side of the Ontario-Quebec border, those on the other side would rally because it is the right thing to do.

Global health inequities are even more stark: 50% of the world still does not have access to adequate primary care,1 more than 1000 children under the age of 5 years die of malaria every day,2 and only one-third of people in low-income countries have been vaccinated with even a single dose of a COVID-19 vaccine.3 Do we think we will do better, as a species, if so many of us are left alone?

Context is everything in global health and family medicine. By examining differences between contexts, we can draw clearer lessons4 and gain traction through more complete understanding. We have a lot to learn about efficiency and integration to improve Canadian health systems. I know we cannot meet cynicism with righteousness. I just hope we can continue to give space and credence to this approach. By being constructive and aspirational, it may even give us hope.

I wish I remembered the name of that ridge in southern Chad. I will have to go back and figure it out. I imagine it is still prominent and still lets you see the past on one side and future on the other. That ridge is just a few hundred miles from the Great Rift Valley, a place we know well—a valley deeply etched but very wide. It is the place from where we all come.

Dispatches was a quarterly series coordinated by Dr David Ponka, Director of the Besrour Centre for Global Family Medicine at the College of Family Physicians of Canada. This is the final article of the series.