Traffic injuries and trauma care

In 2001, I climbed into a white jeep to travel from the international airport in Delhi to the town of Bhiwani, some 120 kilometers away. Piloted by a hired driver, the vehicle was groaning with suitcases and people. I was placed in the rear passenger seat, which I was lucky to have to myself, but to my horror there were no seat belts. Having read State Department Advisories about the state of Indian roads, I felt ill with fear. Sure enough, the following two hours were full of near misses.

Travelers to developing countries are faced with a grim fact of life for most people in the world: the roads are abattoirs, as lethal as any tainted water or malarial mosquito. Traffic accidents kill hundreds of thousands of people in low- and middle-income countries every year (and plenty of tourists as well). China, India's fast-developing high-population counterpart, is very badly off as well (though neither country has historically devoted much attention to researching the issue, contributing a shockingly low proportion of articles to the medical literature on trauma). In an article about China's air pollution in this month's Atlantic, James Fallows puts black lungs into perspective: “...The big threat to foreigners was not in the air but on the streets. ‘I tell my patients, the most important ‘medical’ step you can take is to put on a seat belt in a car, wear a helmet on a bike, and run for your life in crosswalks,’ a Chinese doctor said. Road safety is that bad. For the foreign diplomatic corps, the leading cause of death is traffic accidents. I worried every day about being mowed down by a bus, since they don’t stop at lights. My wife was run over in Beijing by a motor scooter that was going the opposite way down an eight-lane one-way road and was running a red light too. She’s fine now; the driver roared away, still against traffic, as soon as he climbed back on the bike.”

And so it went for us. Our driver caromed past every sort of vehicle and not a few animals, honking and playing chicken over and over again. We passed overturned trucks. One, I recall, was piled so high with bales of something puffy that it was taller than it was long--or would have been, had it not been lying horizontally. Who knew what had happened to the driver? I clung to the door with the flats of my fingers.

Public health experts consider trauma (and not just that caused by vehicles) to be a disease, one that disproportionately mows down young, fit breadwinners. As such, it is economically devastating. Five million people each year die of traumatic injury. The causes are many, including a culture of careless, aggressive driving; a lack of coordinated emergency services; and a lack of adequate personnel and infrastructure at hospitals. Survival rates are much lower in low-income countries, not only because there are more accidents, but also because victims have less of a fighting chance once they are injured.

Trauma care starts in the field with emergency medical services, then proceeds to the door of the hospital. There, even when doctors are available, many don't know where to begin when faced with a bloodied, flailing trauma victim. Advanced Trauma Life Support, or ATLS, is an orderly approach to caring for an injured patient. It helps doctors focus on what will kill the patient first, while ignoring less serious if more spectacular wounds. ATLS has been shown to save lives even in limited-resource settings. It's not everywhere yet, but at the moment courses are available in 50 countries, including Bolivia, Costa Rica, Pakistan, Thailand, India, and some other lower-resource countries.

But even where an ATLS-ready team is available to stabilize patients, there needs to be a before and an after. There need to be ambulances and crews that know how to move and transport victims safely. After ATLS, there need to be surgeons, operating rooms, blood banks, rehab centers, and so on. All of these things are in short supply in low-resource settings. I made it from Delhi to Bhiwani and back in one piece. But the likely fate of a rural accident victim in India or another poor country that lacks EMS, ATLS, and definitive trauma care haunts me.

Traumatologists are trying. The Essential Trauma Care (EsTC) project, an effort on the part of the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care, have attempted to come to grips with the needs and the resources of low-income countries. They have released sets of guidelines that are adjustable according to circumstance, which would seem to be a realistic and useful approach. A 2007 World Health Assembly resolution called on the WHO and governments to set up and strengthen trauma systems, and although resolutions alone are not enough, they may pave the way to action. Dr. Charles Mock, a trauma surgeon and WHO official, has written eloquently about concrete actions caregivers can take to build trauma infrastructure in the wake of the resolution. He instructs caregivers to remind governments of the resolution, urge ministries of health to pick someone to steer trauma efforts, cite its text when they apply for funding, and network extensively at conferences and meetings.

Sounds like more time on the road for caregivers in low-income countries. Let's hope their vehicles have seat belts.

Breast cancer in developing countries

Cancers don't make top-ten lists of causes of death in poor countries, but that is because even larger numbers of people are killed by infections like diarrhea and TB. Make no mistake, those countries' cancer rates are high, and climbing. (The reasons for rising cancer rates are still unclear. Some think that nocturnal light as a byproduct of development is partly to blame.)

One of the worst offenders is breast cancer, now being called a worldwide epidemic at over a million new cases a year. I spoke last summer with Dr. Fred Okuku, a Ugandan physician who was at Yale learning medical techniques which he later took back to his own country. He told me that 95% of Ugandan women with breast cancer already have Stage IV disease when diagnosed. They notice a lump, then wait an average of two years before seeking treatment. As a result, many patients in Uganda recapitulate the terrible natural history of cancers with a thoroughness most Western doctors haven't seen in many decades. Okuku returned home with a mammography van and an ultrasound machine to try to change the grim statistics. (His colleagues there are well aware of the challenge and have risen to meet it: read on.)

What do doctors have to offer breast cancer patients in low-resource settings? What guidelines are available to those doctors? Which organizations are thinking about this?

Breast Health Global Initiative: Their 2008 Guideline implementation for breast healthcare in low-income and middle-income countries looks to be practical and comprehensive. They certainly know the need for such a guideline: "In high-resource countries, evidence-based guidelines...are resource neutral, they fail to consider variable resource distributions where overall standards of living are high, and they fail to recognize ubiquitous deficits in infrastructure and resources in LMCs. Moreover, they do not consider implementation costs or provide guidance on how a suboptimal system can be improved incrementally toward an optimal system. Such guidelines defining optimal breast care and services...have limited use in resource-constrained countries, and there is a need for resource-based guidance related to strategies for reducing the burden of breast cancer for settings in which optimal care is not feasible." 

Breast Surgery International: a group of surgeons interested in breast cancer in developing countries. Their 2002 paper is a summary of the breast cancer situation in Malaysia, South Africa, and Nigeria. It stops short of offering firm clinical guidelines. 

The Uganda Cancer Working Group, a group of Ugandan physicians based at Makarere Medical School in Kampala (Fred Okuku's school) in 2008 published a second edition of a set of guidelines for managing breast cancer in that country. (The first edition, report the authors, was well-received and heavily cited.) Interestingly, these guidelines emphasize breast self-examination while acknowledging that such measures are no longer being pushed in developing countries. What works in one context does not necessarily work in another.

Non-free journal articles on this topic include a set of guidelines from Stanford physicians, a review of treatment trends in the Arab world from the American University of Beirut, and a discussion of breast-conservation strategies in the developing world from Banaras Hindu University. Those with access to Breast Journal can find a number of relevant articles, including an article analyzing testimonials from patients in limited-resource countries which found several themes: "1) the experiences and fears of breast cancer survivors, 2) beliefs and taboos about breast cancer that hinder awareness programs and treatment, 3) the need for public education and breast cancer awareness programs in countries with limited resources, 4) difficulty in translating the concept and ethos of advocacy into many languages, and 5) the experiences in establishing and maintaining advocacy groups to promote breast cancer awareness and to inform public policy."

Strange sheep and their blood

Sometimes the right person spots the right sheep at the right time. It was several years ago in Botswana that Ellen Jo Baron, Ph.D., first laid eyes on the sheep that she now thinks will revolutionize the diagnosis of infectious disease in poor countries.

Baron, an internationally recognized Stanford pathologist, has spent years training lab technicians in the developing world to diagnose infectious diseases. In fact, she literally wrote the book on microbial diagnosis. But she realized it was time to adapt when she discovered one of her densely-worded textbooks locked away and covered in dust in a Malaysian hospital office. She created a low-text, flowchart-rich version of the book for non-English-speaking settings.

Having simplified her textbook, she then had to confront the fact that the photos in it didn't correspond to what her trainees were seeing under their microscopes. The book featured pictures of organisms grown on standard Western lab plates, which are based on sheep- or horse-blood agar. Those animals require too much expensive care and handling to make them available to low-resource labs, which must use human blood instead. Apart from being a biohazard, human blood doesn't behave the same way that animal blood does in diagnostic tests--so the labs that use it couldn't make sense of the photos in her textbook.

Then came her trip to Botswana, where she saw one of these. "'What is that?'" she recalls asking herself. "Clearly, it wasn't a goat and it wasn't a sheep--it was some other thing." It was a hair sheep, a cousin of the familiar wool sheep that has some unsheeplike traits. It is happy in hot climates and small pastures, resistant to parasites and other infections, and, of course, needs no shearing. Such a low-maintenance animal, Baron realized, could be a big boon to labs in the developing world. After finding a rare herd of wool sheep at an experimental farm in California and convincing the owners to let her tap the sheeps' jugulars, Baron tried the standard microbial diagnostic tests on hair sheep blood, at her own expense. All the tests worked beautifully. The blood produces standard results without the need for expensive techniques or unaffordable animals.

Clinical laboratories are unsung and unglamorous places, but they are in many ways the brains of the hospital--or at least the left hemisphere to the physician's right. Microscopes and centrifuges and other analytic equipment allow for the types of decision-making--about patients' health, about germs and their drug susceptibilities, about genes even--that revolutionized 20th-century medicine. Yet few American doctors visit their hospital's lab or know the name of its director. Few of us have looked down a microscope or counted colonies since those squirmy afternoon sessions in medical school, and that leaves us both unprepared to diagnose malaria or anemia singlehandedly and unappreciative of the equipment and supplies and expertise that are needed to make that diagnosis. In short, we seldom think about how central the laboratory is to any medical effort. Photogenic medical missions to fix cleft lips and congenital heart defects are sorely needed, but so are the bent backs of the microscopists--perhaps more so.

Hearing of Baron's discovery, people have begun to come out of the woodwork, wanting to help. An American hair sheep breeders' association is interested in sending sheep to Southeast Asia and training people in their simple husbandry. A Brazilian blood distribution company has offered a citrated blood-storage bag. And one Botswanan lab is beginning to use hair sheep already. All Baron needs is the time and money to put the hair sheep where they're needed. She's determined to do it. As she told a Stanford interviewer last fall, getting hair sheep to labs in the developing world "is going to change everything."

High-volume medicine: lower costs, and--surprise!--better care.

India is a poor country, but at least one hospital group there is managing to drive down costs in part by driving up volume. And guess what--outcomes are better, too. The Wall Street Journal reported yesterday that cardiac surgeon Dr. Devi Shetty of Bangalore has set up specialized surgical hospitals that allow for similar types of operations to be performed on huge numbers of patients, including the poor. These hospitals appear to be both cheap and safe by Western standards. The fact that doing the same operation over and over again improves patient safety and saves money is something Canada already knows; its Shouldice Hernia Centre, examined by Atul Gawande in his 2002 book Complications, has achieved good results for decades.

To wit: when setting up a clinic or hospital in low-resource settings, there are ways to beat Western-sized budgets, and not by just a little. Smarter expenditure can make all the difference. As Dr. Shetty put it, "What health care needs is process innovation, not product innovation." And it is low-resource practitioners who have perhaps the greatest incentive to make process innovation work.

On meetings: Global Health and Innovation Summit, April 2010

The Global Health and Innovation Summit will be held at Yale University next April. Unite for Sight sponsors this conference every year. Here's what their website has to say:

"200 speakers representing all disciplines of global health, social entrepreneurship, international development, and innovation. Keynote speakers include Seth Godin, Jacqueline Novogratz, Jeffrey Sachs and Sonia Sachs....Partners in Health, WaterPartners, Save The Children....2,200 participants from all 50 states and from more than 55 countries who are immersed in global health and international development, public health, eye care, medicine, social entrepreneurship, nonprofits, philanthropy, microfinance, human rights, anthropology, health policy, advocacy, public service, environmental health, and education."

Well, it sounds like a fabulous conference. (It costs $140.00 to attend, much less than most medical conferences cost.) But it is precisely because I'd love to go and sit at the feet of all these bright and well-meaning people that I'm filled with skepticism. Will tangible change result from this conference, or any other? Will it turn out to be a lot of talk? Will anyone who is poor be measurably better off because this conference happened? Will it set good changes in motion, soon?

Don't get me wrong. Ideas move the world, I know. Without thought, planning, and strategy, many of our efforts are wasted. And so it's sophomoric of me to be haunted by the idea that what we actually need to do is walk out the door, visit the ATM, then keep walking, driving, or flying until we hit our first emergency. Then fix that emergency. Then keep walking.

To assuage my own impatience, to guard against the possibility that reading and writing about poverty and going to conferences amounts to so much hand-waving, I make microloans. It feels good to do this; it feels like a temporizing measure, a substitute for fighting on the front lines, although sober minds have assessed microloans and found them wanting.

So it looks as if I need to learn more about what does work. Time to visit the ATM, I suppose, and take out $140.

Textbooks about low-resource medicine

Low-resource medicine overlaps to some degree with tropical medicine and with what is sometimes referred to as international medicine. Wilderness medicine, too, operates almost by definition in low-resource settings.

If you're suiting up to practice in a low-resource setting, what kinds of books might give you some guidance? Of course, the usual medical textbooks apply to some degree, although at least one clinic I know has been specifically requesting older editions of pediatric cardiology texts, for reasons one can readily imagine. When MRI is the modern standard for diagnosing something, but you haven't one, you'd like to know what people did before MRI was invented.

So are there books designed for such settings? Typing "low-resource medicine" into Amazon's search engine brings nothing relevant. (It's not a particularly oft-used term. Maybe that will change soon: I hope that in time there will be residencies and a specialty board devoted to low-resource medicine.)

* Where There Is No Doctor: A Village Health Care Handbook, by David Werner et al. Aimed at laypeople, this book is based on the democratic principle that a person possessed of common sense and clear information can diagnose and treat many ailments. I ordered a copy months ago and have read it with interest, and it comes highly recommended by Amazon reviewers who, unlike me, have used it in the field. (It does have its critics , though.) I found some out-of-date recommendations--the information about ear infections, for example, doesn't reflect recent research--but on the whole it looks like a decent resource. It has sister books about women's health and dentistry.

* The Oxford Handbook of Tropical Medicine, by Michael Eddleston et al. Compact and orange, with water-resistant covers. I'll report back about this book once I've used it abroad, but it gets rave reviews on Amazon.

* Wilderness Medicine, by Paul S. Auerbach. On its 5th edition. Handbook is available as well.

* The Little Black Book of International Medicine, by William A. Alto. Just ordered this.

Has anyone practicing in a low-resource setting used any of these textbooks? I'll update this post with comments and recommendations.

Ultrasound in Rwanda

Ultrasound is something I've blogged about before--I'm excited about an inexpensive pocket-sized version. Something like that may be what replaces the stethoscope in the near future, and American medical students and residents are already being urged to make it part of their armamentarium--though takeup is still not as good as it could be. My father frequently laments the difficulty of getting his residents to look for pleural effusions at the bedside, and very few ER physicians routinely do an ultrasound of the heart to determine if an elderly patient with low blood pressure is suffering from a weak pump or a dry one.

But as helpful as ultrasound will eventually prove in wealthy settings, it could be revolutionary in low-resource clinics. Paul Farmer's NGO Partners in Health studied ultrasound in Rwanda, training local physicians in its use. They found that the scans were accurate and sustainable: the Rwandans' and the American trainers' image interpretations agreed 96% of the time, and the clinic continued to scan avidly after the Americans had left. It was found to be particularly beneficial in planning surgeries and in caring for pregnant women.

Every low-resource clinic should have at least one ultrasound machine. The trouble is that the damn things are expensive--but there are a lot of older-generation models lying around the US, and getting those to where there are none would be a good start. Thomas Jefferson University has an equipment donation program, as does the World Federation for Ultrasound in Medicine and Biology.

Eritrean medical school and its partnerships

Encouraging signs: a new medical school in Eritrea. The Orotta School of Medicine in Asmara has formed partnerships with Yale University; George Washington University; and no doubt others I don't know yet.

The idea of partnerships between medical centers in the developing world and the developed world is gaining momentum. Both have much to learn from each other, and equal partnerships should supersede exploitative or brain-drain relationships. Here's an article I wrote about Yale's philosophy on these matters (scroll to third headline).

Statistics: How to find them

Statistics, though they numb the imagination, can serve as a flight-at-40,000-feet and give us some sense of the scope of the problem. Here is a website from which to embark:

WHOSIS, the World Health Organization Statistical Information System. Easy to use; searchable by one or more country at a time. Covers 193 member states. All the data you could want is here, though not all of it is recent. Another helpful website that works a little differently from WHOSIS is at the Kaiser Family Foundation, which maintains a Global Health Facts site.

In a couple of minutes of playing with WHOSIS, I learned that:

* As of 2006, only 8% of HIV-positive Armenians received antiretrovirals.
* Thirteen per cent of Cameroonian children under age 5 sleep under insecticide-treated bed nets. (Each net costs about $10.00. Click here if you feel like donating one.)
* Fewer than 1 in 5 Haitians has "access to sanitation" (that is, they can poop in a functioning toilet).

Can you imagine? Probably not. Stats like these are not merely imcomprehensible; they can even annoy the reader. But I'm not sure we need to experience them emotionally. If one is too immersed in others' miseries, if one attempts to grasp the enormity of the problem, there's a risk of throwing up one's hands, of turning away. No one person can own these problems. But no one may ethically ignore them, either. "You are not required to complete the task," said one sage, "yet you are not free to withdraw from it."

Gadgets in the field: Cell-phone microscope

The cell-phone microscope appeared recently in the New York Times. It costs a few dollars, hooks onto a cell phone, and allows to examine blood samples microscopically. A version called the Cellophone and created by Aydogan Ozcan's group at UCLA creates digital holograms of the cells and allows for mathematical analysis of the image. (Ozcan has created a fledgling company called Microskia to develop the idea.) A related invention out of Berkeley is Daniel Fletcher's CellScope.

Wow. Here's a reason to be thankful that cell phones blanket the earth. If cell-phone microscopes can replace the full-sized version even for limited applications like malaria screening, they could be immensely helpful.

When will these devices be ready for marketing and distribution where they're needed most? Who's going to buy them up and send them into action?

Journals about low-resource medicine

I grew interested in low-resource medicine when I was making preparations to go to a clinic in the Indonesian jungle. Having trained as a doc in the United States, I'm used to lab results, CT scans, and expert colleagues being immediately available. I thought there must be some sort of journal for docs and other health care workers who are going to have to get along without these luxuries. I could imagine it covering not only straight clinical topics, but also policy, architectural, and cultural issues, as well as serving as a forum for practitioners to swap tips (ever treated a diabetic ulcer with honey?).

So far, I've found the Internet Journal of Tropical Medicine (accessible online without a subscription), the Journal of Urban Health (bimonthly, peer-reviewed, but not free), the American Journal of Tropical Medicine and Hygiene, and the Journal of Health Care for the Poor and Underserved (focuses on policy issues). World Health and Populations also looks promising. I'm not able to access all of these journals without a subscription and I'd be interested in knowing if any of them is considered an indispensable resource to workers in low-resource settings.

Come to that, given that there are many docs with an interest in international medicine (and, in an unfortunate comment on global health, "international" is often a code word for "low-resource"), shouldn't there be a separate specialty with its own residency, training docs in rich countries to function on their own in poor ones? But that'll be a topic for another post.

Low-resource medicine

Welcome. This blog will discuss low-resource medicine--that is, medicine that is practiced in settings where the things we take for granted in a modern hospital may not be available on a consistent basis. This blog is about places where creative improvisation is needed, where corners must be cut, where human judgment may have to take the place of technology--and where certain kinds of technology can make all the difference in the world. This blog is intended not only to provoke conversation but also serve as an electronic resource to health care workers around the world.