Debate: Should funds go directly to support the cause or strengthen governmental infrastructure?

Ashlee Metcalf, MD and Natasha Ang, MD

The Case for Direct Allocation of Funds:

The comparison between the rebuilding efforts after the earthquake that devastated Haiti in 2011 and the tsumnami that destroyed Indonesia in 2004 is a great example of why foreign aide should be focuse on the community.  The picture of Haiti in 2014 is only mildly different than the picture of Haiti post earthquake in 2011.  Why is this you may ask? Based on UN estimates, donors chaneled $6 billion in funding to Haiti from 2010 to 2012, but less than 0.6% was invested in Haiti.  Not much of the funding was given directly to the Haitian government due to concerns of disorganziation (post natural disaster), concerns of corruption, concerns of ability to mobilize material.  In times of chaos, it’s important to look at the direct needs of the community and give foreign aide directly to the community.  Take Indonesia for example… Efforts to rebuild were based on employing community development for rebuilding homes and local infrastructure to maximize the effectiveness of community recovery.  Who knows more about the needs of a community more than the people that actually live in it? There’s a sense of ownership and value in the community.  We are able to track funds more directly when we know exactly where the funds are going, instead of depending/relying on a government to disperse funds.

The Case for Strengthened Infrastructure:

80 percent of foreign aid from major donors bypasses the systems of local public institutions, going instead through US-based government contractors or numerous NGOs but there are numerous reasons we should not bypass the local government. Healthcare is not a vacuum. We need other systems in place to make it successful and when we move money through national systems, we strengthen much needed infrastructure. Think about our own US mucipal systems. Water supply, road maintenance, sanitation, regulations regarding where electrical cables can run are not privately owned for a reason. A national government may have better access to the whole nation’s resources – be it natural ones, commodities or people – to apply to a given situation. It may be able to priortize areas of need for the whole country. Paul Farmer has a great piece on this. He also discusses Haiti as an example of lack of coordination of aid and working with the national system allowed a devastating cholera outbreak to continue despite the presence of 12,000 NGOs within the nation. He also discusses how public perception of the level of corruption of foreign aid monies is vastly overestimated.

Debate: Should we allocate global health funds to treatment or prevention?

Andrew Myers, MD and Meena Hasan, MD

The Case For Treatment:

The prevention vs. treatment debate has been very contentious for years with no sign of stopping anytime soon.  For years treatment took precedence without thought to future capacity.  While the world has come around to looking to the future, we cannot sacrifice the present.  HIV is decimating sub Saharan Africa. HIV prevalence is almost 40% in some areas of sub Saharan Africa.  While abstinence, male circumcision, and condoms among many other preventative interventions are important to let a large swath of the African population suffer is inhumane. We have the ability to provide ARVs to patients for $140 per person per year. Without a healthy working ago population a country cannot improve itself.  HIV leads to many debilitating diseases and eventually death if left untreated.  Just as importantly, persons who are treated for HIV and maintain low viral levels of the disease are less likely to pass it to others.  In this case treatment IS prevention. We see this in all infectious diseases.  People cured of a disease do not pass it to other people.

Treatment is also very important in our under 5 mortality.  Diarrheal illnesses and malnutrition run rampant in many underserved parts of the world.  The main treatment for a child with diarrhea is to keep up with his fluids and electrolytes. This doesn’t involve any expensive medications, just a generic version of Gatorade to get kids through the worst parts of the diarrhea.  For malnutrition there is an equally simple solution.  Plumpy Nut is a peanut derived meal replacement for kids that supplies 500 calories per pack and costs about 50 cents to produce.  It is relatively portable and can drastically improve a child’s health which is a great indicator for their productivity later in life.  Public health and preventative measures are important, but we can’t forget the person in need standing right in front of us!

The Case for Prevention:

Forty-seven trillion dollars.  No chump change, right? Well, according to the World Economic Forum, that number is the estimated global cost of treating the five most common, non-infectious diseases including cancer, diabetes, heart disease, lung disease and mental health disorders in aggregate from now until 2030. That’s a REALLY high number and it’s NOT even factoring in other non-infectious diseases, all infectious diseases, loss of productivity and the social burden of caring for the ill. To put it bluntly, our economy will COLLAPSE if we attempt to treat all this disease one patient at a time. So what do we DO? There is only one obvious solution: A focus on prevention.

A focus on prevention means tackling disease before any chance for harm. Prevention strategies include building town infrastructure (ex roads, electricity), improving sanitation, and focusing on education, especially of girls. Improvement in these areas has been shown to improve the health of communities and has countless global benefits. It also includes strategies such as vaccination campaigns, hand washing initiatives and non-communicable disease prevention through the promotion of healthy eating and exercise. If we instead focus on treatment, we are tackling disease after the fact, allowing patients to suffer the symptoms and social isolation that results from illness before attempting to heal. Treatment is no simple task – many diseases take several years to cure, if at all, and require costly medications with side effects, numerous health visits, and systems in place to support patient care.

Our resources are limited. The burden of disease is astronomical. Our only solution for coping is to prevent. Prevention makes most CENTS.

Diabetes or Dengue? Where should we allocate our global funds?

Shelton McMullen, MD and Ashley Freeman, MD

In focusing on global health, where is our money best spent – on combatting non-communicable disease (NCD) or communicable disease (CD)?

There is, of course, no clear cut answer to such a complicated question, and sound arguments can support either camp.

The Case for Communicable Disease Funding:

1. Health leads to wealth:
Many CDs are indeed the plight of the world’s poorest individuals, who suffer tremendously from easily-treatable infection. Their position as victims demands our attention as soon as possible. Health is a precursor to wealth.

2. It’s less complicated:
CD is often far easier to treat than non-communicable diseases, which can be sometimes more chronic in nature and tied more to lifestyle, diet and other ingrained social determinants compared to many CDs. Many helminth infections can be cured with one dose of medication.

3. Kids:
The peak burden of many CDs is felt by the world’s youth. How can we choose to neglect treating these children?!

4. Treatment = Prevention:
In the case of many CDs, treatment means prevention. Simple treatment of a transmissible disease stops its spread – it’s that simple.

5. Necessity:
The global burden of tuberculosis is enormous. Regarding MDR TB, poor countries/patients cannot begin to afford the necessary treatment.

For some great information on infectious disease statistics, news and guidelines, check out the WHO’s website at www.who.int (go to Infectious Diseases under the Health Topics tab).

The Case for Non-Communicable Disease Funding:

Chronic disease is no longer a problem of the rich and old.  According to the WHO, if current trends continue, non-communicable diseases (NCDs) will be the leading cause of death in Africa by the year 2030.  In fact, the number of deaths from NCDs will exceed the total number of deaths in Africa caused by infectious disease, nutritional deficiency, maternal death and perinatal deaths combined.

Consistent with the impact of health disparities on most health outcomes, the greatest burden of chronic disease falls on the poor.  Ninety percent of premature deaths (before age 60) due to NCDs occur in low-income countries.   Death at this young age preceded by years of disability drains limited resources and prevents formation of an effective workforce.

The causes of this alarming increase chronic disease are not surprising: smoking, poor diet and inactivity.  This means the vast majority of NCDs are preventable.   We have an opportunity to intervene before this global health threat cripples development in low-income countries.  This will require a coordinated commitment from global heath stakeholders, local governments and industry.  It is time to prioritize health over profit and focus on prevention efforts.

 

http://www.who.int/mediacentre/factsheets/fs355/en/

Debate: Are Medical Missions Good for Global Health

Paul Blair and Nika Safaie

The Case Against Burdensome Medical Missions

Global brigades are bad for global health. Although they may seem well intentioned it is in those misinformed intentions that poor outcomes are rooted.  These intentions shared by college or health professions students are often naive  and become dangerous when there is a component of the savior complex. The NGOs that facilitate medical missions are driven by the systemic post colonial guilt complex of global aid (see The Crisis Caravan or work by William Easterly).

A shared feeling of superiority over low income countries leads to an inflated feeling of ones abilities to help. Not only is this condescending but it is dangerous. Students practice beyond their abilities and this is often very explicit in advertising for medical brigades that participants will be able to do practice medicine in ways they couldn’t in their home country. For example, the Unite For Site organization website provides a real example of a student that saw a patient with polyuria and polydipsia and told the patient to stop drinking caffeine without follow up despite the real possibility of a deadly medical condition called DKA.  This website also highlights an anesthesia study on the Operation Smile complication rate.  Although the rate was the same intraoperatively it increased postoperatively due to lack of follow up.  There are many stories of surgeries which dump the postoperative care on the local system as highlighted by The Crisis Caravan in which a well meaning Evangelical organization provided a surgical brigade which left actively bleeding patients to be cared for by unprepared local health care workers.  The care itself is also ineffective in providing lasting health changes. There are few resources dedicated to addressing upstream factors by these organizations. Monitoring and evaluation is also rare given the intrinsic nearsightedness of short term missions.

Lastly, not only is the care ineffective at providing lasting health changes, but it is burdensome to the the local community.  Towns spend resources preparing for a medical brigade while neglecting other needs such as X-ray machines that remain in disrepair. Often wealthy local people will take advantage of free healthcare to be treated by foreigners who are viewed as highly trained taking away income from local health care workers. Often there is no community assessment of what is needed. Hospitals become full of donated worthless junk. It is also diverting translators from where they might need to be most. This diversion of precious resources turns ignorance into economic and medical harm.  Although there are notable exceptions to these major issues, they are problems that afflict medical missions across the board. We should leave global health to responsible and knowledgeable professionals that work in concert with local communities long term

A Case for Short Term Medical Missions: Bridging Disparities in Global Health Together

It is certainly no secret that with the rapid advancement of technology and communication, the world is becoming increasingly interconnected. Every day, we see more examples of how instability and injustice in any part of the world affect people everywhere, including right here at home. We can no longer afford to view the world as “us” and “them”—our vision needs to be world-embracing.

But if we believe we have a social responsibility to global neighbors as much as our local communities, how then can we work to ensure the security of all global citizens? Particularly, do short-term medical missions offer a way for clinicians to contribute to bridging global health disparities?

Although there has been a rise in the number of physicians who volunteer in these projects, many critics are asking if they are sustainable, if they are effective, or if they are in fact harmful to local populations. Do they empower local people to take ownership of their health and also their own social, intellectual and moral development? These questions spotlight some very real challenges.

But are these challenges really as insurmountable as we think? Maybe not.

Here’s one take on the issue.

One-pill wonder for HIV? Reflections from Tugela Ferry, South Africa

By Monique Duwell, MD, MPH

The South African government recently announced the roll-out of a fixed-dose combination anti-retroviral (ARV) pill  potentially reducing the pill burden for those living with HIV from three to five pills per day down to one.  The pill, which contains emtricitabine, efavirenz and tenofovir, will be offered to those newly diagnosed with HIV, HIV-positive pregnant women, as well as breast-feeding mothers.

The ARV Clinic at the Church of Scotland Hospital in Tugela Ferry, South Africa

This news prompted me to reflect on my recent medical rotation South Africa.  In Fall 2012, I traveled to Tugela Ferry, a rural town in the KwaZulu-Natal Province of South Africa.  This area has high rates of poverty and unemployment, low literacy rates and many people live without access to clean water.  I spent more than a month working in the Antiretroviral (ARV) Clinic affiliated with the Church of Scotland Hospital (COSH), a hospital serving nearly 200,000 people living in the surrounding Umsinga District.   The ARV clinic has been delivering HIV treatment to those living in this area since the national rollout of government-funded ARVs in 2004.

One of the most striking aspects of providing clinical care in this clinic is the demands on individual patients to comply with their medication regimen.  The first-line regimen for adults initiating HIV treatment includes three pills.  Many persons with HIV in this area are also co-infected with TB, so a patient may also take a combination pill for TB, along with pyridoxine.  Most patients are prescribed a multivitamin.  Many suffer from peripheral neuropathy and use amitriptyline and/or other pain medicines.  Still others require treatment for hypertension and other chronic conditions.  One can see how daily pill counts can easily reach into the double digits.

This is particularly daunting when one considers the other social and financial challenges facing many of the patients in this region.  I vividly recall a 14-year old girl who came to the ARV clinic on a Friday afternoon.  She had been diagnosed with HIV earlier that week, and referred to initiate treatment.   She was in a hurry to complete the visit, telling the nurse translator that she was concerned because she has left her baby home with her much younger brother.  In fact, her parents had both died recently, and she was the primary caregiver for both her brother and her baby.  I remember thinking, how will this young patient possible manage one more responsibility?  An array of daily pills, monthly clinic visits to pick up her medicines, and routine blood draws to monitor for complications.

Adding to these challenges, many patients in the area surrounding Tugela Ferry live in remote areas.  They face the added challenge of traversing rough terrain and walking long distances simply to obtain their medicines.

A view during a home visit in the rural area surrounding Tugela Ferry, South Africa

It is easy to see that initiating ARVs can be challenge for any patient, and particularly for patients in resource-poor and remote areas.  Yet, remarkably, my experience was that patients in Tugela Ferry were generally far more compliant than patients in the U.S.  My anecdotal experience is in fact supported by a 2006 meta-analysis by Mills and colleagues, which showed a higher percentage of patients were adherent to ARVs in Sub-Saharan African studies than in North American studies (77% vs. 55%).

Not surprisingly, evidence suggests that fixed-dose combination pills improve medication adherence.  In one meta-analysis, Bangalore and colleagues found that rates of non-adherence for patients with chronic diseases (e.g. hypertension, diabetes, HIV) were 26% lower among patients on fixed-dosed combinations compared to free-drug combination regimens.  Additionally, research by Airoldi et al. shows that one-pill, once-daily regimen improve not only adherence, but also quality of life for patients living with HIV.

In summary, my own experience in Tugela Ferry showed me that so many people are able to overcome enormous obstacles to obtain and adhere to HIV treatment.  Yet, particularly as the South African government continues its efforts to scale-up HIV treatment, it is critically important to support patients in their efforts to adhere to lifelong HIV treatment. The roll-out of the fixed-drug combination pill is likely to be an important step in this process.

For more information about efforts to improve care of people living with HIV and TB in Tugela Ferry, visit The Tugela Ferry Care and Research Collaboration (TF CARES) and Philanjalo websites.

The Little Emperor That Could

Chad Henson, M.D.

One of the best examples of political satire is Jonathon Swift’s “A Modest Proposal.” Written in 1729, this essay proposes a policy of selling poor Irish babies to feed the wealthy gentleman and ladies as a means to reduce economic hardship and control the population. As should be with all Juvenalism, the piece is persuasive and believable, meant to fool the reader into acceptance. Jump to the mid 1970’s and Deng Xioa Ping’s economic reform program. Proposed as a goal to prevent widespread hunger and devastation in China, the Family Planning Commission implemented a policy known today as the One-Child Policy. Already in the midst of the “late, long, few” program in which parents were encouraged to delay and space childbirth, the government mandated a restriction of one child per couple. Albeit with certain exemptions, the policy was a controversial way to maintain the population.

Like many strict population control efforts (the Holocaust, genocide), the One-Child Policy was very effective at its primary goal – to prevent hundreds of millions of birth – and even in its unstated objective – to become one of the world’s premier political powers. Even when viewing China from the perspective of the Millennium Development Goals (MDG), one cannot deny the impact of the pragmatic intervention. Infant and maternal mortality are only a fraction of their rates in 1980, and China has already met MDG1, which is to reduce extreme starvation. Women have more access to contraception, and there are reports of decreased abortion rates in the country, even when compared to the United States.

While Machiavelli might argue that the aforementioned successes are sufficient, I would challenge that the ramifications of OCP are deleterious to Chinese society and economic progress. Some of these effects are more theory than fact, such as the “Little Emperor Syndrome” of spoiled brats-turned-sociopaths and gender imbalance leading to sex trafficking and rise in HIV rates. But there are tangible consequences that have impacted the health and well being of the Chinese population, including adverse maternal and fetal outcomes from clandestine second pregnancies, sex-selective abortion (although illegal), and female infanticide. In fact, the inadequate pension policy in China has led to an unanticipated problem known as the “4:2:1” conundrum, in which every child born under OCP has two parents and four grandparents for whom he or she will be responsible in their retirement. It is akin to Full House, but without the adorable Olsen twins.

Whether OCP will stand the test of time is currently under debate, with speculation of an end to the policy as early as in 2015. The impact will inevitably remain for decades, and we as clinicians must remain cognizant of the deleterious outcomes of this policy on both health and human rights.

A New Form of OCP

Nancy Maaty, M.D.

The United Nation’s Millennium Development Goals (MDGs) are ambitious despite their good intentions. While in the past 13 of the 15 allotted years we have seen some improvement, I would argue we have not quite met our goals. Quite honestly, I find it difficult to believe that we will eradicate poverty or improve environmental sustainability in the remaining two years. But what if I told you that there is one thing that could “fix it all”?

Family Planning. Recognized by the WHO and USAID, to name a few, as an essential means to reaching (or at least getting closer) to our millennium goals. Theoretically, fewer pregnancies mean women would be less exposed to the risk and trauma of labor. This would result in a decrease in the total number of babies born that would be then subject to neonatal mortality. In the end, by avoiding an exponential increase in population size, we will preserve more resources.

Now, there is one country, which one could argue was “ahead of its time” when it proposed a radical idea in the 1970s. This idea received negative press worldwide and continues to be a topic of debate: OCP. No, not oral contraceptives, but the One-Child Policy in China. Putting aside the controversies regarding the concept and execution of the OCP, it should be noted that as of 2010, China had reached 3 of 8 MDGs, notably in eradication of hunger, universal primary education, and in child mortality. The impact on infant and maternal mortality has been drastic and out of proportion to neighboring countries. Had China maintained a birth rate of 5.9% (as reported in 1970), its limited resources would have put a strain on the country’s economic development. Previously, an International Development Association (IDA) country, China was able to graduate from this program of aide in 1999. Would this have been possible without the OCP in place?

While I may not ethically endorse the OCP as a form of family planning, I cannot ignore the likely positive impact the policy has had on China’s achievement of MDGs. Although the means by which family planning is attained in China should not be encouraged, perhaps there is still something we can all learn from China.

Resources:

• Cates, W et al. “Family Planning and the Millennium Development Goals.” Science. 2010 Sept;329(5999): 1603. <http://www.sciencemag.org/content/329/5999/1603.full >

• “Country Comparison: Total Fertility Rate.” The World Factbook. 2013. <https://www.cia.gov/library/publications/the-world-factbook/rankorder/2127rank.html&gt;

• “Country Comparison: Maternal Mortality Rate.” The World Factbook. 2013. <https://www.cia.gov/library/publications/the-world-factbook/rankorder/2223rank.html&gt;

• “Country Comparison: Infant Mortality Rate.” The World Factbook. 2013. <https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html&gt;

• “Trends in Infant Mortality Rate, 1960-2011.” Child Info. <http://www.childinfo.org/mortality_imrcountrydata.php&gt;

• Feng XL et al. “Social, economic, political and health system and program determinants of child mortality reduction in China between 1990 and 2006: A systematic analysis.” J Glob Health. 2012 Jun;2(1):10405. <http://www.ncbi.nlm.nih.gov/pubmed/23198134&gt;

• Greenland, Susan. “Science, Modernity, and the Making of China’s One-Child Policy.” Population and Development Review. 2003 June; 29(2): 163-196. < https://webspace.utexas.edu/hl4958/contemporary-chinese-history/Greenhalgh%20-%20Science,%20Modernity,%20and%20the%20Making%20of%20China%27s%20One-Child%20Policy.pdf >

The Health Impact of Economic Sanctions: What Physicians Should Know

By Wesley Fiser, MD

Throughout the modern era of US foreign policy, the use of economic sanctions towards belligerent, terroristic, or repressive regimes has proven an important and powerful tool. Recent humanitarian crises in countries such as North Korea, Syria, Iran, and Sudan make news headlines daily and highlight the gaining public awareness of US involvement against the repressive leaders of these nations. The US Treasury Department’s Office of Foreign Assets Control is responsible for administering comprehensive economic sanctions towards other countries and currently lists 22 active sanctions. Economic sanctions are rarely unilateral. The United Nations Security Council Sanctions Committee serves as a platform for the international community  to exert collaborative pressure on selected nations. The mechanisms of economic sanctions vary but often include: prohibitive transactions with US accounts, embargoed imports and exports, blockade of military supplies, and travel restrictions.

Sanctions applied against repressive regimes can be effective mechanisms for political change; however their overall repercussions can adversely affect an already disadvantaged population. Ultimately, it is the most vulnerable sectors of society who bear the brunt of sanctions against imported assets, such as medical supplies, food staples, and general cash flow. Anecdotally, we see the suffering of Syrians from government persecution; their internal displacement as refugees have left them dependent on foreign aid. However, embargos against the country severely limit supplies of meaningful medical and food aid. One European inspector of the Syrian refugee camps described conditions as  “unjust and inhumane” (McTighe). The traditional corollary to alleviate the burdens of economic sanctions is direct humanitarian aid from third party NGOs, but these efforts largely fail to meet demand. And, humanitarian aid is easily intercepted by warring factions and diverted from reaching the populations in greatest need.

Image by Wesley Fiser

The true health impact of political sanctions is only beginning to be studied in depth.  Sanctioned populations, especially those living in refugee camps, are at great risk of waterborne illnesses, such as cholera and typhoid. The leading cause of death among children under economic sanctions is  malnourishment and starvation, worsened by lack of imported food. In addition, infant malnourishment is compounded by poor access to safe milk formulas under some sanctions.  One investigator demonstrated that infant mortality, birth height, and birth weight were directly related to living under economic sanctions (Petruescu). Another investigator working in post-war Iraq highlighted the plight of many cancer patients who can no longer receive chemotherapeutics. Since the imposition of sanctions from the West, cancer related medications can no longer be found in the country, and most must travel to neighboring countries for care (Skelton).

As guardians and advocates of universal well-being and human rights, physicians must understand the inherent health impacts of economic sanctions. The vocation of “do no harm” obligates physicians around the world to advocate for safer sanctions that consider the health of the public. To this end, the American College of Physicians (ACP) published a position paper which defined the physician’s role as informants to political sanctions.  The ACP argues: “Individual physicians cannot alleviate the suffering caused by sanctions. However, the medical and public health professions can help shape the structure and application of economic sanctions to ensure that they protect the health of the persons in nations that are subject to them.”

ACP Recommendations:

1. Exclude from sanctions humanitarian goods – food, medicines, etc – that reduce the morbidity and mortality of civilians.
2. Empower third party, neutral agencies to expeditiously address humanitarian crises and study the health effects of economic sanctions.
3. The imposing body should offset increased morbidity caused by sanctions by providing medical and health services.
4. Delivery of humanitarian aid should be closely and transparently monitored.

Effectively, as advocates for health, physicians of all nations are called to remain informed of the health burdens around them. As guardians of the sick, physicians are called to respond to humanitarian crises, which threaten the most vulnerable sectors of society. And the physician’s role places him or her in position to inform foreign policy as it pertains to health and economic sanctions.

Wesley Fiser, MD
George Washington University Hospital
PGY-2 Resident, Department of Internal Medicine

Resources:

McTighe, K, “Syrian Insurgents Say Aid Isn’t Getting Where It Needs to Go,” The New York Times, 7 March 2013. http://www.nytimes.com/2013/03/07/world/middleeast/syrian-insurgents-say-aid-isnt-getting-where-it-needs-to-go.html?ref=basharalassad&_r=1&

Morin, K and Miles, SH, “The Health Effects of Economic Sanctions and Embargoes: The Role of Health Professionals,” Annals of Internal Medicine, 18 Jan 2000, Vol 132, No 2, p158-161.

Petruescu, IM, “The Humanitarian Impact of Economic Sanctions,” American Enterprise Institute. July 2010.

Skelton, Mac. “Health and Health Care Decline in Iraq: The Example of Cancer & Oncology.” http://costsofwar.org/sites/all/themes/costsofwar/images/Health_and_Health%20Care.pdf 2012. Accessed March 14, 2013.

US Treasury Department’s Office of Foreign Assets Control website. http://www.treasury.gov/resource-center/sanctions/Programs/Pages/Programs.aspx. Accessed March 14, 2013.

United Nations Security Council Sanctions Committee  http://www.un.org/sc/committees/ Accessed March 14, 2013.

Going abroad? Tips for physicians planning to go on a medical mission

By John Jordan, M.D.

In 2010, I took the opportunity to go on a medical mission to Haiti after the earthquake.  As part of the BCFS group based in San Antonio, I spent a week at Hospital Adventiste in Port Au Prince.  I saw a country that was devastated.  Thousands of people lost their lives and many more were struggling to rebuild.  The country’s limited medical capacity was quickly overwhelmed.

Working in Haiti was a truly eye opening experience. I recommend any physician take a trip abroad to practice medicine at some point in their career.  If you have any interest in going abroad, here are some tips to get ready for an international adventure.

 

Start preparing today!

The most important thing to do is start planning early.  Medical missions typically require months of preparations, so I recommend 6 months before your trip to be on the safe side…yes, really!  Given the unpredictable situation in Haiti, I only had about a week to plan before hopping on the plane.  Fortunately, the essential requirements I needed were already in place.  Although you may not be interested in flying to a natural disaster, serendipity may still guide you to your first medical mission abroad.  Maybe, you’ll find an unexpected break in your schedule or stumble into a last minute opening on a trip already planned.

Essentials:

You may find yourself sitting at home while your friends are flying around the world, if you don’t take care of these.

–          Passport: Make sure you have a valid passport.

• These expire after 10 years (or after 5 years, if you were less than 15 years old).  If you don’t remember the last time you saw your passport or used it, it’s probably expired, or worse…lost!
• Assuming you have all the right paperwork (forms, proof of citizenship, photos, ID, fees, etc); expect that processing will take about 6 weeks.  Passports can be expedited, but the Dept of State will charge extra for that.
• More info can be found here. http://travel.state.gov/passport/passport_1738.html.

–          Immunizations: If you’re planning to travel anywhere outside of Canada, Europe or Australia, you’ll probably need to get extra vaccinations.  If you need a vaccine series, it may take 6 months to be fully protected.

• Consider vaccination against Hepatitis A, Japanese Encephalitis, Polio, Rabies, Typhoid and Yellow Fever.
• Don’t forget your routine vaccinations too!
• More info can be found here. http://www.cdc.gov/vaccines/vpd-vac/default.htm
• GWU Travel clinic is also available if you would prefer to talk with someone in person.  http://www.gwdocs.com/travelers-clinic

–          Malaria: Malaria is common in many other countries.  Here are a few options and considerations to prevent infection.

• Medications:
  • Malarone – it’s well tolerated and you only need to start it 2 days before your trip and continue to take it for 7 days after your trip.  However, it’s expensive.
  • Doxycycline – it’s inexpensive and readily available.  However, photosensitivity is a common side-effect and it needs to be taken for 30 days after your trip.
  • Chloroquine – has high rates of resistance.
  • Mefloquine – has high rate of psychiatric side-effects.
  • More info: http://www.cdc.gov/malaria/travelers/drugs.html
• Bed net: If you’re going to an area
  that has malaria, you may want to bring a mosquito net.  Even if you have a place to stay indoors, they may not have air conditioning or adequate screening to keep the mosquitoes out.
• Bug repellant:  Consider bringing DEET or picaridin
• Cover your arms and legs with clothing whenever possible (e.g. long sleeves, long pants and long socks).

Read about your destination:

Every country is unique and the more
you know about a foreign country the
safer you’ll be.  While the guidebooks for tourists are a great way to get excited about a vacation, you may want to have some practical information too.  The Dept of State posts the latest travel advisories and is a credible source of background information.  The CDC’s Traveler’s Health website is a great resource about the common communicable diseases you may encounter.

–          The Dept of State country specific information: http://travel.state.gov/travel/cis_pa_tw/cis/cis_4965.html#H.

–          The CDC’s Traveler’s Health: http://wwwnc.cdc.gov/travel/destinations/list.htm#h.

Pack your bags:

You’ve done your homework, now it’s time to get ready for the trip.  Here’s a sample of items you may want to take with you.

–          Medical equipment: In some areas, the only medical equipment available will be items you bring.  Consider taking stethoscope, reflex hammer, tuning fork, flashlight, BP cuff, pulse oximeter, otoscope, reference books, etc

–          Personal hygiene: Consider taking shampoo, conditioner, soap, toothbrush, toothpaste, mouthwash, floss, brush, deodorant, towel, wash cloth.  If clean water is not available (or only limited), consider brining hand sanitizer and baby wipes.

–          Eye care: Consider bringing two pairs of eyeglasses.  Even if you wear contacts, I strongly recommend bringing two pairs of glasses, in addition to your contact supplies.   Keep in mind that you may not have access to clean water.

–          Prescriptions:  Don’t forget to bring any prescription medications with you.

–          Clothing:  You may not be able to wash clothes during your trip.  Consider taking enough clean clothes to change every day.  I would also recommend putting aside a clean set of clothes for the trip home.

–          Bathing: Some places may not have private bathing areas.  Consider bringing bathing suit and flip flops for outdoor showers.

–          Label your bags:  I suggest investing in some durable luggage tags.  I almost lost my luggage in the pile of other large black bags at the airport in Haiti, but my bright green tags helped me find my luggage.

–          Protect yourself from the environment:  In some areas, you may be outdoors a lot more often than you’re used to.  Consider brining hats, sunglasses, sunscreen or chapstick.  A small rain poncho that can be easily packed is a good idea too.

–          Electronics: Power outages are common in other countries.  Consider bringing battery powered devices and plenty of batteries.  Given the power outages, you may want to bring a flashlight or head lamp.

–          Cell phones: Cellular service is expanding rapidly in foreign countries.  However, be sure to inquire about your international calling plan.  Don’t forget your cell phone charger.  You’ll also need to bring a power converter if you plan to plug into electrical outlets.

–          Comforts: You’ll be far away from home and may not like the local foods.  I brought instant coffee and some snacks, which kept me going during the long days.  Consider bringing drink mixes, protein bars, trail mix, instant coffee, peanut butter crackers and other non-perishable foods.

–          Take care of yourself: Remember that you may be miles away from any grocery stores or pharmacies.  Consider bringing band-aids, antiseptic ointment, Tylenol, ibuprofen, cough syrup, antacids, Benadryl, or any other over-the-counter medicines you may want.

What you’ll experience:

–          Be prepared to practice out of your comfort zone.  In many places, it doesn’t matter whether you’re a radiologist, a surgeon or pathologist.  You’re still a doctor and people want you to treat them.  You may be asked to see anyone that walks in the door (Pediatrics, OB, Adults, etc).

–          Be prepared to be creative.  Here’s a picture of an improvised breast pump, assembled a suction cup and a vacuum container.  Many places don’t have modern medical supplies.

 

 

 

–          Be prepared to try new things. 
Here’s a picture of the hospital pharmacy.  You may find that your pharmacy doesn’t carry many of the medicines you usually order.

 

 

 

–         Be prepared to live a different
lifestyle.  Here’s a picture of our sleeping cots.  Cots were lined up in an open air deck.  No windows.  No air conditioning.  Fans were a luxury!

 

 

 

–          Be prepared to be your own
diagnostic lab.  At the Hospital Adventiste, the only test we could order was a malaria smear (no CBC, Chem 7, blood cultures, etc) and the only imaging we had was a portable x-ray (no CT, MRI, ultrasound, etc).  So, your diagnosis will be based on your history and physical (bring your stethoscope!).  Here’s a picture of the Emergency Department.

 

As you can probably tell, being a physician in Haiti was unlike anything I had ever experienced before.  Patients literally waited for hours outside the hospital in 90 degree heat, just to see a physician.  Many of the patients that were too sick to go home lived in tents on the hospital grounds and their family members provided nursing care.  Some patients had tropical diseases like malaria or typhoid that we could treat.  Others probably had diseases like cancer, but we didn’t have the resources to diagnose and wouldn’t be able to treat anyways.  Despite the imperfections of health care in the U.S., I have a new found appreciation for our medical system after practicing in these conditions.

I hope you’ve found these tips helpful and are excited to do a medical mission abroad.  Remember, start planning today!

Addressing Physician Absenteeism: A Novel Approach

By Swathi Namburi, M.D.

Inadequate government infrastructure is a serious barrier to provision of adequate rural health care in many developing countries. In India, there is chronic shortage of physicians and nurses; the situation becomes dismal when these vital health care workers do not show up to work. A survey conducted in 2003 of over 1400 public health centers across 19 major states found that nearly 40% of doctors and medical service providers are absent from work on a typical day. Staff salaries can comprise up to 90% of a state’s budget for healthcare, so absenteeism actually means direct losses of already low health care resources. Rural people then turn to the local private village “doctor” – often someone with only rudimentary primary school education – who can provide things like injections that patients in developing countries often demand. There is virtually no primary care provided in the so-called “primary health centers.” For example, 25% of all cases of cervical cancer occur in India, often detected at later stages requiring aggressive therapies.

The issue of physician absenteeism is multi-factorial. There are no professional or financial repercussions to absenteeism. There is a lack of incentives for these professionals to go to work as scheduled. Most physicians prefer to work in a city as there is a better quality of life there. Their children can attend better schools and most of their family and friends likely live in a large city. Moreover, even if a nurse or public health worker does go to work as scheduled, there are constant issues with lack of available diagnostic tests or medications, which can be quite discouraging for even earnest health care providers.

To bring some accountability for absenteeism, a recent project was launched by the Indo-Deutsch Project Management Society (IDPMS) called the “Transparency and Accountability Program.” While cell phone use is not ubiquitous, the use of mobile technology is cheap and abundant enough in India for at least some people to have access per group in a village. This project encourages the people who are unable to see a physician to send a text message to IDPMS; the overall goal is to compile enough data to convince the local governments to take action. Currently, lack of medical care is not as active of a political topic as it should be. Often, malnourishment and poor health are the norm for wide swaths of the rural population. Through empowerment of the local population affected by physician absenteeism, perhaps some changes can be made to increase access to care.

There are no easy solutions to such an overwhelming problem, but building a case to demand for constitutionally guaranteed rights should hopefully be a good start.

References
http://tap.resultsfordevelopment.org/news/video-using-ict-address-health-worker-absenteeism-india

Deolalikar, A. B., D. T. Jamison, P. Jha and R. Laxminarayan (2008). “Financing health improvements in India.” Health Aff (Millwood) 27(4): 978-90.

http://www.economics.harvard.edu/faculty/kremer/files/Is%20There%20a%20Doctor%20in%20the%20House%20-%2012%20April%202011.pdf