This spring issue of JN is largely devoted to three interlinked themes: kidney care in pregnancy, paediatric nephrology and education, which account for more than two thirds of our articles.

Pregnancy gives kidney patients hope, and pregnancy in advanced CKD is often seen as “vindication”—life triumphing over disease. Yet there are differences worldwide, and these differences are sharp. Pregnancy is also a moment when previously unknown problems come to light, diagnoses of life-long diseases may be made, and unexpected dramatic problems may occur.

Commenting on AKI, pregnancy outcomes and maternal deaths in Africa, Alejandra Orozco Guillen begins: “Death from pregnancy-related acute kidney injury (PRAKI) caused by pre-eclampsia is not the outcome a woman has in mind when she gets pregnant. (…) Can we, as a nephrology community, continue to accept this outcome for women?” [1, 2].

We probably all agree that we should not, yet we still do.

In this exciting but schizophrenic era of discoveries, we have reason to hope that there will soon be artificial kidneys and targeted therapies for cancers and kidney diseases, but medicine is becoming a discipline running at different speeds in different settings.

We are appalled when we hear about the wars currently being waged, but rapidly turn our attention elsewhere. Women in Africa and Latin America die of diseases that are no longer life-threatening in Europe and the US. Even in rich countries, although we are constantly reminded of the importance of prevention, simple measures like testing serum creatinine in pregnancy, at the almost risible cost of 10 euro cents, are not routinely prescribed.

Can medical education, empowering patients and forging wiser, kinder physicians help reduce inequalities? (Fig. 1).

Fig. 1
figure 1

In his iconic series “On Reading” the photographer André Kertész gathers images of people reading. The photographer’s gentle, slightly detached vision reminds us of the importance of observing, and not just watching, the world around us

Full size image

A recent series of papers in the New England Journal of Medicine dealt with these issues. The focus is on how to improve education, respecting young trainees and students, nudging rather than shoving them. This is of course fundamental—where are patients in the dilemma “Well, for my wellness, I can’t do that for the patient,” versus “You are talking about altruism because you’re trying to get me to do more work”? [3]. If medicine is seen as a profession and not “work”, the answer might be different: how much is that patient really in need, can he or she wait, and is the resident being asked the question really the only one who can attend to that patient, or are they just a face above a white coat?

When I recently asked our residents to choose between a lesson on high-risk pregnancy and kidney diseases, a situation they will rarely encounter, and a lesson on the main bioethical approaches to complex decisions, an issue that is at the basis of everything we do, I would have bet (and won) they would have chosen the former.

Reflections on our role, role-playing, and empathy are still seen as weaknesses by many physicians. “We are here to get things done, not to think about them”, I have been told on more than one occasion (Fig. 1).

Yet, in this issue, JN proudly gathers accounts of experiences of teaching, questioning, and ethical challenges. As usual, some will remark they are “drops in the ocean”; as usual the answer will be “oceans are made of drops”.

In the same 30th March issue of the New England Journal of Medicine, we find a challenging reflection on historical injustices “that the Journal has helped to perpetuate”, published in “the hope it will enable us to learn from our mistakes and prevent new ones”. Years of silence elapsed between the report of changes in the health care system in Hitler’s Germany in 1935 and the NEJM’s acknowledgement of “epidemic starvation” in 1944 [4].

Will the humble, albeit persistent defence of the fragile and forgotten, of the victims of all wars, that JN is engaged in contribute to saving the lives of African mothers? Perhaps not. Yet, the commitment of the Italian Society of Nephrology through its journal is, at the least, not to forget. However, as the article in the NEJM concludes, “We must consider not only expressions of explicit and implicit bias, discrimination, racism, and oppression, but also how rationalization and denial may lead to silence, omission, and acquiescence—considerations that are critical to understanding systematic historical injustices and their powerful, tragic legacies.” [4].