Low-Resource Medicine

Candida susceptible to coconut oil

2012-02-06T18:56:00.001-08:00

Interesting abstract:

J Med Food. 2007 Jun;10(2):384-7.
In vitro antimicrobial properties of coconut oil on Candida species in Ibadan, Nigeria.
Ogbolu DO, Oni AA, Daini OA, Oloko AP.

Department of Medical Microbiology & Parasitology, University College Hospital, Ibadan, Nigeria.

The emergence of antimicrobial resistance, coupled with the availability of fewer antifungal agents with fungicidal actions, prompted this present study to characterize Candida species in our environment and determine the effectiveness of virgin coconut oil as an antifungal agent on these species. In 2004, 52 recent isolates of Candida species were obtained from clinical specimens sent to the Medical Microbiology Laboratory, University College Hospital, Ibadan, Nigeria. Their susceptibilities to virgin coconut oil and fluconazole were studied by using the agar-well diffusion technique. Candida albicans was the most common isolate from clinical specimens (17); others were Candida glabrata (nine), Candida tropicalis (seven), Candida parapsilosis (seven), Candida stellatoidea (six), and Candida krusei (six). C. albicans had the highest susceptibility to coconut oil (100%), with a minimum inhibitory concentration (MIC) of 25% (1:4 dilution), while fluconazole had 100% susceptibility at an MIC of 64 microg/mL (1:2 dilution). C. krusei showed the highest resistance to coconut oil with an MIC of 100% (undiluted), while fluconazole had an MIC of > 128 microg/mL. It is noteworthy that coconut oil was active against species of Candida at 100% concentration compared to fluconazole. Coconut oil should be used in the treatment of fungal infections in view of emerging drug-resistant Candida species.

PMID: 17651080 [PubMed - indexed for MEDLINE]

Squatting to Poop

2012-02-05T09:46:00.000-08:00

Low-resource medicine is all about prevention. There may be substantial health benefits to squatting to poop rather than using a sit toilet: by removing the need to force stool out, hemorrhoids, diverticuli, and other nasty disorders may be averted. In Indonesia, I grew to greatly prefer the squatting position to the throne-sit I'd grown up with, and I'm not the only converted Westerner; a number of companies offer products (like this one) to hack your sit toilet and replicate the experience. But that's a lot costlier than just building a squat toilet in the first place. The lesson for practitioners: Don't assume you have to include sit toilets in your low-resource clinic. You and your patients may be better off in a squat.

Daily wound probing reduces surgical-site infections

2012-01-15T09:25:00.000-08:00

An article in the Archives of Surgery reports that a daily routine of poking between the staples of a healing surgical wound with a Q-tip (a wound-probing protocol or WPP) greatly reduced surgical-site infections in patients recovering from open appendectomies after perforated appendicitis.

"...SSI in contaminated wounds can be dramatically reduced by a simple daily WPP," the study authors write. "This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds."
The investigators note that the mechanism by which wound probing reduces SSIs is not clearly understood but that it may allow for drainage of contaminated fluid within the soft tissue.

Good nursing care prevents an awful lot of complications. It probably costs almost nothing to add this bit of wound care to the routine, especially if performed by trained family members, and may keep many recovering patients in low-resource settings out of trouble. A news article about the study can be found here.

More beans, less rice

2011-09-02T06:20:00.000-07:00

Eating more beans and less rice lowered the risk of metabolic syndrome (thickened waistline, low good cholesterol, high blood pressure, and some other factors that are often precursors to diabetes and cardiovascular disease) in this study of 1,879 Costa Rican people, published recently in the American Journal of Clinical Nutrition.

Recommending less white rice in favor of a protein probably makes good nutritional sense, but many people will be unable to afford the substitution. White rice is cheap and filling, and in some places, whatever's eaten with it is viewed more or less as a condiment.

Why do people eat polished rice when unpolished rice (containing the husk, bran, and germ) is nutritionally superior? I believe the answer is that it's easier to store polished rice, as rice germ contains fats that spoil easily. The price people pay is worse nutrition--not only a higher risk of metabolic syndrome, but also thiamine deficiency.

Easing hyperglycemia with H2O

2011-07-01T07:05:00.000-07:00

French researchers reported some interesting preliminary results of a study of people with diabetes. Those who drank more water had a lesser risk of developing high blood sugar than those who didn't drink as much water. It's not clear if there's a cause-and-effect relationship yet (it may be that a third, unknown factor leads to both a lower blood sugar and a tendency to drink more water), and these results haven't yet been reviewed by other scientists. But it would be awfully convenient if diabetics in a low-resource setting could take better care of themselves by doing something as simple as drinking more water.

(Of course, that's assuming they have access to clean drinking water--not a safe assumption in many parts of the world.)

WHO's List of Essential Medicines

2011-03-16T20:47:00.000-07:00

The World Health Organization publishes a frequently-updated list of essential medicines, organized by type of drug and whether it's a "core" drug to treat high-priority conditions, or a complementary drug for settings with more resources and specialists. It flags drugs for which any equivalent drug in the same class is just as good, as well as those that are only for children or other subgroups. It's worth browsing if you're looking to put together an essential toolkit for a low-resource setting.

I get a little misty looking at this list. Every one of these drugs is a technological achievement, the result of years of work and centuries of scientific investigation into chemistry and physiology. We've gradually learned how the human machine works, and now we have this--a toolkit, a concise record of human smarts directed toward relief of disease and suffering. Creationists, the evolutionists you abhor use the same methods that the inventors of your blood-pressure pills did. And Luddites, take note: technology can serve the good. This list is proof.

Quitting smoking can be a warning sign of lung cancer

2011-03-05T21:25:00.000-08:00

A fascinating study in the March Journal of Thoracic Oncology lends weight to something many of us physicians have long suspected: people who quit smoking after many years may be doing so in response to an early lung cancer, often long before they have symptoms. Here in our low-resource clinic, we already worry more about lung cancer in symptomatic patients who have a history of having randomly quit smoking in the last few years. That little point of history doesn't replace diagnostics, but it does raise our suspicions. This study suggests we have good reason.

Pain relief and opiates--or the lack thereof

2011-03-05T21:01:00.000-08:00

Opiates like morphine or fentanyl are in short supply here in rural Indonesia. Our clinic treats patients who suffer from acute or chronic pain with a mixture of ibuprofen, acetaminophen (paracetamol), and occasionally codeine. Friends who have worked in Uganda and other developing countries tell me the situation is similar there. The lack of opiates condemns many end-stage cancer patients to a nightmare existence.

The International Narcotics Control Board, a United Nations drug organization, recently issued a report decrying the lack of availability of narcotic pain medications in many parts of the world, and argued correctly that such drugs should be considered indispensable in medical practice. Inadequate policies and regulatory constraints are among the reasons why many countries have made pain relief a low priority. One of my American colleagues once opined that that's because some cultures believe in the sanctity of suffering. I don't know enough about Islam to know if that's the case here, but Mother Theresa seems to have believed that, at least when it came to other people's.

But the relief of suffering is at the heart of medicine. If prevention and cure fail, or when there's a delay before a treatment takes effect, there is palliation. At the very least, a health care worker ought to make a patient comfortable. I've never been as glad to have morphine in my toolbox as I was when I took care of a little kid in my ER in the US who had been severely burned and needed to be transferred to a burn center. He was fully conscious, suffering pain few of us can imagine, but we pulled him out of the depths of hell with large and repeated doses of morphine. His agony subsided even as he remained awake, and watching his transformation from tortured to calm made me feel a near-religious sense of gratitude to have been able to do that for him. I think about him from time to time and hope he enjoyed his helicopter ride, at least a little.

Who needs doctors, anyway?! Lessons from rural India.

2011-02-24T00:45:00.000-08:00

I'll let these two important New York Times articles by Tina Rosenberg about community health workers speak for themselves: "Villages Without Doctors" and a follow-up article incorporating important comments on the factors that make or break such programs.

Curative medicine, the kind physicians are trained in, has a tendency to reach the few and the rich rather than the many and the poor. And it treats so many conditions that could have been prevented. What a poor use of resources. The world needs more simple public health initiatives and basic health care, and the vulnerable poor have a perfect right to implement them. Prevention! Prevention! Prevention! Education! Education! Education!

That health care belongs to "the people" is also the core belief of the wonderful Hesperian Foundation, of Where There Is No Doctor fame--a topic for another day.

International Family Medicine: list of core competencies

2011-02-21T20:49:00.000-08:00

A list of the things a family practice physician needs to know will vary from country to country, but as discussed in a study published in the Middle East Journal of Family Medicine last spring, there is a core set of competencies that FPs in every country should have. The researchers surveyed FP docs around the world to see how many of these core skills are being systematically taught in their countries. Australia topped the list, teaching all 44, and Indonesia brought up the rear with only 17. The most-taught subject was "Accident and Emergency," while the least-taught was "Women's Health." (Though I was relieved to see that that was treated as a separate topic from "Obstetrics and Gynecology," that statistic is still unfortunate.)

This study is helpful for putting family practice curricular issues into a global perspective, and I recommend that anyone involved in teaching family practitioners in the developing world read it. At the very least, it provides an important checklist of the topics to emphasize in your curriculum.

"High-touch" medicine leads to lower costs--and yet it's low-resource in its way

2011-02-17T03:21:00.000-08:00

One of the things I admire about low-resource medicine is that, by definition, it doesn't cost much. By contrast, ER visits and hospitalizations in the high-resource American system can be tremendously expensive. And it's sobering to consider how those visits could so often have been prevented, how many of those resources are spent wastefully. We've all heard about how many trauma patients might not have been hurt if only some simple measures had been in place: helmets, handing over the car keys, wearing a seat belt. What's less obvious is that ER visits for chronic diseases could also be reduced--not with even snazzier drugs and higher-tech diagnostics, but with little things, the kinds of things that the US system isn't designed to pay for. Things like careful follow-up for outpatients, coordination of prescriptions among all a patient's doctors, and robust social supports.

One Dr. Jeff Brenner is trying to do just that in Camden, New Jersey. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” Brenner told Atul Gawande in the latter's recent New Yorker article about "high-touch" medical care. Damn right.

Gawande's article examines strategies by Brenner and some like-minded colleagues to cut costs by preventing repeat ER visits and hospitalizations in the people most vulnerable to them. In any given group of patients, it often turns out that a small number of people account for a huge chunk of medical costs; these reformers scrutinize databases and figure out who those patients are. Is it the residents of a particular building, who seem to suffer a lot of injurious falls? Is it someone suffering from several overwhelming chronic diseases and not enough social support? Is it a woman who faithfully fills her ineffective ER migraine prescriptions, yet never seems to find an outpatient neurologist who will tweak them till they work?

The reformers target those patients for meticulous outpatient care--"high-touch" care that relies heavily on building trust between patients and caregivers and on locating medical care in its social context. Their methods are revolutionary and low-tech. For starters, these caregivers are organized, and they talk to each other. Doctors and nurses and social workers and lay health "coaches" hold daily team meetings about their patients, making changes to prescriptions, discussing whom to track down via relatives after a no-show or who needs a same-day follow-up for that test result. Then, they pick up the slack for patients who don't adequately care for themselves. They send nurse practitioners to do blood sugar checks and health coaches to deliver moral support. They see to it that prescriptions get filled and that patients get help taking their meds. They work with social services to get vulnerable people into better housing. They even forestall 911 calls by physically taking the patient's cell phone and entering the clinic's 24-hour number into them, since some patients don't have the number handy and don't know how to program their own phones. The result: Tailored medical regimens that actually get followed, not just prescribed and forgotten. And patients grow to believe the clinic workers really do have their interests in mind, and that trust inspires many of them to do what they can to improve their own health--they quit smoking, they lose weight, they join AA.

All the attention at these clinics reminds me of Directly Observed Treatment Short-Course (DOTS) for tuberculosis, in which health workers actually watch TB patients swallow their medications several days a week throughout the long slog of treatment, routinely traveling to patients' homes when necessary. That simple strategy turns out to be both powerful and cost-effective--much more so than simply prescribing TB meds to an unsupervised patient, a method which for various reasons often leads to treatment failures and drug-resistant TB. Prescriptions are not enough. DOTS works so well that researchers have proposed using this strategy for other difficult diseases like hypertension and type I diabetes.

Similarly, when the numbers are crunched, the high-touch clinics Gawande investigated are worth it: They prevent hospitalizations and save money. (Hospitals stand to lose patients, of course: the country of Denmark, Gawande reports, has closed half its hospitals using similar strategies to prevent hospitalization.)

In short, high-touch clinics don't just examine and prescribe. They act as if they care about sick people, and they do whatever it takes to get the best available care into patients' hands. How interesting: That's often all we can do in a low-resource clinic here on the other side of the world. Our DOTS workers ride their bicycles to patients' houses, sit down with them, and help them take their pills; their efforts are the reason we cure most of our TB patients. It's high time the American health system realizes what low-resource practitioners already know: sometimes, it's the little things.

Online practice scenarios for trauma

2011-02-08T02:37:00.000-08:00

Worried by their dithering the last time we had an accident victim, I just took our docs through a bit of trauma training. We don't have the materials to conduct a formal ATLS course, nor does our rural Indonesian clinic have the tools to conduct full trauma care, but we can certainly review basics. So we went over the primary and secondary surveys, as well as important concepts like resuscitation and teamwork. This is their chance to learn and practice, since they tell me that all the spots in Jakarta ATLS courses are booked till 2012.

Fun with moulage will take place in a few days (my long-suffering fellow volunteer, Dr. Bobby, will play the role of victim, with lipstick or perhaps chewed-up betel nut to denote his injuries). In the meantime, the docs asked for reading material. I wish I could find a legally downloadable ATLS manual online, but no dice. Still, there are excellent basic reviews by eMedicine and UpToDate (subscription only for the latter, alas), and this collection of interactive trauma cases online. They're free of charge, courtesy Trauma.org, a website dedicated to global trauma care that is well worth exploring. The cases are written in idiomatic (and very funny) English, so they might not be ideal for non-native speakers, but they do review important basics in a painless way and might make good moulage scenarios for people teaching trauma care in a low-resource environment. I plan to create teaching cases based on some of them. It should be lots of fun, though for poor Dr. Bobby's sake I don't think we'll be strictly following the "Fingers and tubes in every orifice" rule.

Neonatal incubator made of car parts

2011-02-07T19:34:00.000-08:00

Stuff breaks.

Replace, send for repairs, or try to fix it yourself? In the developing world, choice 3 is often the only option. Unfortunately, even if you’re game to try fixing a broken machine, the parts are often all but unobtainable. And even if the parts are obtainable, modern technology has made many machines opaque.

So here's a brilliant idea: medical machinery that can be repaired anyplace where there are car parts and mechanics. The NeoNurture was invented by Design That Matters, an American NGO that creates products and services to help the poor in developing countries. This nifty incubator is made of auto components and should be transparent to anyone who understands cars. That means it can be used in remote areas (since presumably there are cars just about everywhere these days), and when it breaks or needs to be altered, it doesn't become a useless piece of junk. God knows we're glad to have our ultrasound machine and X-ray out here in our rural Indonesian clinic, but we haven't any special parts or expertise to fix them once they fail. What do we do with them then? Burn them? To borrow a quote from the New York Times, which blogged about the incubator last November:

“Every rural clinic in the developing world has a shack full of broken donated medical equipment,” said Timothy Prestero, chief executive of the Cambridge, Mass., design consultancy.

You get it, DTM! Thank you. Can't wait to see these in production.

Check out the other ideas this firm is developing: a phototherapy device, a microfilm projector, and an IV flow controller. Their past projects sound great, too. I'd like to know more about which ones have been most successful and which ones remained at the prototype stage.

A few cc's of public health are worth a liter of fluids

2011-02-06T21:39:00.000-08:00

Another child with seizures, this time without a happy ending. This little girl was 40 days old, and had been sick for several days. Her parents first noticed something was wrong when she stopped breastfeeding. Soon she began to vomit.

The family visited a traditional healer. After that they took her to the local government clinic, which advised them to go to the city hospital (hours away). They decided not to go. The baby then suffered five continuous hours of seizures, after which she remained unresponsive. The following day, when she hadn't gotten any better, they brought her to our clinic, a few minutes' motorbike ride from their home.

We examined the baby. Her breathing came in slow gasps. She made no response to painful stimuli. Her pupils were dilated and didn't react to light, and when we stroked her corneas with a wisp of cotton, there was no blink reflex. Her soft spot bulged upward, indicating dangerously high pressure in the brain, and her belly was much too firm. She died a few minutes later.

We visited the family the next morning, a couple of hours after they had buried their daughter. Her mother asked us several times how this could have happened when the child had been so healthy before. Our doctors explained to her that the child may have caught a bad germ that was "very strong." (There were other possibilities, but we couldn't be sure of any diagnosis given how short a time we had with her.)

The mother berated herself for not having come to us sooner. We told her it wasn't her fault.

And it wasn't, I don't think. It's hard to know exactly whose fault it is that this woman happens to have grown up on a remote, malarial island with only occasional visits from a midwife; that she received no schooling past age 11 and her fisherman husband little more; that they just moved here a few months ago; that they didn't know how to judge the severity of this illness. Could this death have been prevented if the baby had received treatment earlier? Yes, possibly.

What can I say? When it's too late, medicine isn't enough. Strong public-health programs and education must underlie any efforts to deliver medical care.

Refugee Medicine

2011-01-22T22:27:00.000-08:00

The medical care of refugees, which often (though not always) takes place in a low-resource setting,
has its own fellowship at Massachusetts General Hospital. Named for Dr. Thomas Durant, who won the Humanitarian Award from the United Nations in 1995, the Durant Fellowship in Refugee Medicine promises its fellows a "full and rewarding hands-on experience in the field," caring for victims of "war, disease, drought, poverty, or politics."

Please note the honesty in the brochure's wording. People who help disaster victims do it in part because it feels so rewarding to do so. But that fact should not detract from hard questions about whether what they are doing is right in the great scheme of things, and I don't see evidence in the Durant Fellowship's online materials that it teaches participants to ask those questions. (To be fair, I haven't interviewed Durant Fellowship leaders to learn more about its aims, so consider the following words to apply to humanitarian efforts in general rather than to that particular program.)

I am lucky enough to know firsthand that it feels great to help disaster victims. Last year I went off to Haiti a few months after the earthquake to work in a field hospital, and there I was surrounded by fellow volunteers who were intoxicated by the goodness of what we were all doing. It was a tremendously good experience, and we bonded over it like kids at summer camp.

Yet there were definite downsides to what we were doing. I recall diagnosing a woman with diabetes and giving her a supply of antihyperglycemic medication, only to realize that when it ran out she might not be able to access any more. Nor did I have anyone to refer her to for long-term care. There were homeless children at the hospital who bonded week after week with new volunteers, only to dissolve in tears when it inevitably came time for the volunteers to go home.* And we were doing absolutely nothing to overcome the poverty, bad leadership, and environmental devastation that made Haitians so vulnerable to disaster in the first place. Perhaps that isn't our job--but the thought should humble us a little.

I recently read Linda Polman's book The Crisis Caravan, one of a number of books that brings a critical eye to bear on the humanitarian enterprise and argues that under some circumstances humanitarian aid can actually do more harm than good. Dambisa Moyo, a World Bank economist and native of Zambia, also criticizes the effects of foreign aid on Africa. There are a number of other books in the same genre that I look forward to reading. I don't know enough about most humanitarian aid organizations to know what kind of response they have made to these criticisms, if any. But I do know that people feel a certain romance to racing off to help the poor victims, a sense (reinforced by others around them) that they are really good people for coming all this way to help--and that that emotion can be misleading or even dangerous if it remains unexamined.

Anyone who wants an international disaster-aid experience should skeptically evaluate their proposed actions, and refrain from assuming that because they are headed off to help the sick and injured, they are heroes and immune from criticism. Too often, we doctors believe we're unambiguous warriors for good--what parent doesn't approve when their kid wants to go to medical school? who doesn't look with awe upon the intrepid Doctors Without Borders?--but I'm not as sure about that as I once was. For instance, if, as Polman argues, humanitarians are sometimes played off against one another by strongmen, then their presence in a war zone might perpetuate a tyranny rather than ameliorating its effects. Are doctors** thus turned into tools in the hands of leaders who use amputation as a war strategy? Does the organization they propose to work with have thoughtful leaders who are prepared to recognize and react to such a situation? There are other hard questions. Does their organization mishandle funds, elbow out more effective groups, or duplicate the work of other organizations? Does it engage in self-evaluation to see if its work is effective? Does it make mistakes like failing to provide for follow-up care after plastic surgery? Do the doctors help to train locals (capacity-building) so that expertise remains in place once they leave? And how, if at all, will their efforts prevent future disasters?

I would never argue that people with the power to help the dispossessed should refrain from doing so. Indeed, justice for everyone is one of humanity's highest goals, and it gives me hope for our species that we feel good when we pursue justice for others. But we must question our methods. We need to weigh the evidence about whether what we're doing will achieve the goal of well-being for all, and not reflexively accord too much weight to the rush we all get when we help.

* One, I'm happy to report, was adopted by a volunteer, and now lives happily with his new family in Ohio.
** I use the word "doctors" as shorthand for all professionals, including physical therapists, nurses, social workers, logisticians, architects, and anyone else who chooses to work or volunteer on behalf of disaster victims.

The road to hell and the privilege of volunteering

2011-01-11T01:44:00.000-08:00

An odd little encounter in our rural Indonesian nonprofit clinic yesterday made me think more about the consequences of volunteering.

In the waiting room, Fitri, one of our bilingual staff members, came up to me looking puzzled. Standing beside her was a young man with Asian features and a friendly, eager expression. He was strapped beneath a huge backpack with a rain cover. While curious patients looked on, he began to speak to me in poor English. I made out that he had met me and heard about our organization. He had decided to come here and offer his services as a volunteer, too.

I was as puzzled as Fitri was. I certainly didn't remember meeting him and we weren't expecting any new volunteers. I asked him if he could explain himself to Fitri in Bahasa (that is, bahasa Indonesia, the national language) rather than in English. "Bahasa?" he said, not seeming to know what I was talking about--which was astonishing, considering we were deep in the heart of Indonesia where Bahasa is the lingua franca. "Chinese?" I suggested, thinking of a doctor we have who knows that language. Finally it emerged that he was Korean. Alas, none of us could speak that to him.

He'd confused me with another volunteer. She and her husband, who soon emerged from an examining room and helped us to clear things up, had indeed met this man two days ago as they waited in the harbor for the boat to our town. Perhaps noticing their Caucasian faces among all the Asian ones, he had walked up to them and asked them where they were going. They explained that they were volunteers with this NGO, whereupon the young man announced that he would come along and volunteer, too.

"Well, you have to learn more about the organization first," John said, taken aback. He told the young man the NGO's name and its web address, and the man wrote them down before abruptly walking off. It had been that short an interaction. Forty-eight hours later, here he was. He had taken a long boat ride to this remote town far off the tourist track, then stumped around town with his backpack asking where the clinic was. Now that he'd arrived, he was ready to roll up his sleeves and get to work. "I do anything, doesn't matter," he averred.

It seemed this young man had just finished earning a mathematics degree in Korea and was now on a sort of yearlong walkabout before joining the navy. In Korea, he explained, you could just offer your services as a volunteer and they would take you on the spot. At least, he had done so once at a tutoring organization there, where he had taught math to children.

It fell to John to gently tell the young man that we couldn't use his services at this time. It's not completely unreasonable to assume that a willingness to work without pay will open the door of any struggling NGO (and aren't they all struggling?). But that's not how it works. As with most organizations that do anything more complicated than, say, clearing invasive brush in public parks, volunteers here go through an application process. They have to agree to certain conditions, sign liability waivers, perform specific duties for which they have the skills, and learn some of the language and customs first so they can responsibly represent the organization. Many applicants are turned away, and just because this young man had come thousands of miles to our door did not put him at the head of that line. As if he were a jar of unlabeled medication, no one knew quite what to do with him--he spoke neither bahasa Indonesia nor, really, enough English to talk to bilingual Indonesians. And as if he were a drug none of us had ever prescribed, we didn't know whether he was prepared to respect local customs or if he'd make a terrible cultural mistake, hurting the organization.

He was crestfallen, but seemed to understand as John explained these things to him and suggested that he inquire at the national park office. He added some kindly advice about researching volunteer opportunities in the future. (I might add that a quick study of the local language--starting with what it's called--never goes amiss!)

In the nicest possible way, this young man's mistake reminded me of the concept in disaster medicine of the "second disaster"--the wave of well-meaning but uncoordinated volunteers and supplies that materialize at the scene of earthquakes, tornadoes, and so on. Though that seems like a good thing, in fact the transaction costs of organizing that energy and stuff are high, and too much unorganized help literally creates a second disaster. On 9/11, so many volunteer fire trucks rushed to Lower Manhattan that they blocked the paths of the fire trucks whose job it actually was to get to the scene. At a Haitian field hospital where I worked last spring, there were six-foot stacks of boxes of donated clothes, all of it lovingly sent by various American groups, none of which any of the medical staff had time to sort out and distribute, and many of which (I confirmed this by poking through them) were worn out, grubby, or otherwise inappropriate. And drug companies are notorious for dumping inappropriate supplies on disaster scenes, where workers then have to make heads and tails of them, starting with figuring out what they are and when they expire. Fiascoes have taken place on many occasions, including the 1988 Armenian earthquake, the 2005 tsunami in Aceh, and Bosnia and Herzegovina in the mid-1990s, when, according to this grim WHO recitation of such failures, 17,000 tons of useless drugs had to be disposed of at a cost of $34 million. Patients have been harmed by drugs whose use was unclear. Even assuming the drug companies meant well (not necessarily a safe assumption!), this is harmful by any measure.

The point is that, the giving instinct notwithstanding, to give can sometimes be a privilege, not a right. You have to give responsibly. And those of us already volunteering are not exempt from self-examination. We can't take it for granted that our good intentions achieve good results--a topic for another day.

As for the young man, we told him about a couple of places to stay the night and suggested a swim at the beach later that evening. He asked us to call him a taxi, but we had to explain that there are none in this town, so he started off on foot. We watched him as he trudged with his backpack down the hot and sunny road. I hope he finds the right place to give of himself.

Follow-up: Child with status epilepticus, posturing--and recovery

2011-01-09T18:45:00.000-08:00

I posted yesterday about a 3-year-old girl whom we saw several weeks ago whose parents brought her to the clinic after 6 continuous hours of status epilepticus. Soon after our physicians stopped the seizure, she began posturing, a sign of damage deep inside the brain. While we treated her for malaria, viral encephalitis, and bacterial meningoencephalitis (we didn't know which of these it might have been, but we dared not do a spinal tap to check--that can be dangerous if one suspects increased pressure in the brain), she remained at our clinic for three days, comatose, unresponsive except for posturing in response to pain. Then our physicians advised her parents to take her to another hospital that has higher capabilities than our clinic. But we doubted she would recover.

We were wrong. And it's not for the first time--I must learn to be more measured in my doom-and-gloom predictions about sick kids in our clinic. Half a day after I posted yesterday's sad entry, her mother walked in, child in arms, very much awake. She was so cute and lively that I didn't recognize her, but the other doctors and I were shocked when we realized who it was.

Apparently the parents chose not to go to the other hospital and took her home instead. That evening she began to regain consciousness. And now, several weeks later, having received only three days' worth of treatment, she is here with us, wiggling in her mother's arms, kicking at us playfully, and filling the waiting room with her chatter. She doesn't appear to be deaf. According to her mother, she's back to normal. If there is residual damage, it isn't obvious.

I don't know what to say. I thought she was done for. But it's nice to be reminded--especially as an ER doc who often sees people at their sickest--that even the sickest of the sick can recover.

By the way: I asked the patient's mother why they came to the clinic 6 hours after the seizures started, and, for the record, I was incorrect to speculate in yesterday's blog that they delayed because they didn't know they were dealing with an emergency. They knew it, all right. They spent those crucial hours raising the money and securing the transportation to get to our clinic--which is two hours from their home. We sent them home with a dose of rectal diazepam in case it should happen again--in such a remote area, the benefits of self-treatment of such a dangerous condition seemed to us to greatly outweigh the risk.

Tough life out here.

3-year-old girl with seizures

2011-01-09T00:41:00.000-08:00

Some weeks ago in our rural Indonesian clinic, we saw a small girl of about three in the late afternoon. Her concerned parents brought her in because she was having a seizure during a fever. It was a quiet little seizure, and perhaps it didn't much worry them at first. She didn't jerk or turn blue or flail dramatically. She just lay limp and insensible, left hand twitching and eyes gazing to the left.

How long has she been having this seizure? we asked them.

Since morning, came the answer. Oh, no.

A seizure that lasts longer than a few minutes--the definition varies from 5 to 30 minutes in some texts--is called status epilepticus, and it's a different ballgame from the more benign self-limited fever-related seizures that little kids sometimes get. Seizing for longer than a few minutes can cause brain damage.

Our physicians stopped the seizure quickly with rectal diazepam. But she didn't recover. Instead she lay comatose, barely responding to painful stimuli like a firm rubbing of her sternum. Basic tests found no obvious explanations of her seizure other than the fever, and no obvious cause of the fever. Treatment for the most likely bugs was begun, but within minutes of her seizure stopping, she began posturing--a sign of grave brain damage. Having reached the limit of the clinic's capacities, the physicians decided to transfer her to a nearby hospital. Her prognosis for resuming a normal childhood is grim.

Though it's a completely different situation, this tragedy reminded me of Anne Fadiman's superb book The Spirit Catches You And You Fall Down. It's about of a clash of cultures--Laotian Hmong and Western medical--and how a failure of communication between a pair of well-meaning immigrant parents and a group of equally well-meaning doctors led to a little girl's suffering a devastating and seemingly preventable seizure. It's brilliantly researched and presented. I read this book before beginning medical school and it's one of the few books in my adult life that I've reread many times, because it fascinates me that cultural differences can lead to so absolute a failure to communicate.

In our case, the failure is not one of person-to-person communication; it's hard to pinpoint and blame is hard to affix. The tragedy here is in part from her parents not bringing her in sooner because they didn't realize how dangerous an extended seizure can be. Or so I speculate, across a language barrier--there may also be factors like lack of access to transportation, concerns about expense, not realizing there was a clinic they could go to, and so on. But if I'm right and it was a simple lack of alarm on their part, then this episode underscores how much medicine a layperson in a developed nation can learn simply by having access to the media. TV dramas, radio programs, newspaper articles, storybooks, all of these over a lifetime teach people the seemingly obvious fact that things like seizures or sudden paralysis or terrible chest pain need to go to the hospital right away. We aren't born knowing these things, and in areas where this knowledge isn't floating around, maybe people don't know it. Maybe her parents didn't know it. And what looked to them like a quiet little seizure turned out to be seismic.

Review: Fabulous little EKG machine

2011-01-08T02:35:00.000-08:00

Greetings, faithful readers, from the aftermath of a long Internet outage. I want to review a nifty portable EKG machine that our clinic recently received from a generous donor.

Sold on eBay by a Chinese company called Medeshop for $239.00 plus $29.00 shipping (American dollars), this electrocardiogram machine fits in one's palm and weighs 800 grams. It arrived promptly (to a US address, after which it was hand-carried to Indonesia) and came with detailed instructions in somewhat fractured but quite understandable English. And I couldn't be more pleased with it.

For one thing, it's a snap to use. We borrowed one of our male nurses and had it on him within minutes, using its handy suction-cup and clamp attachments. After five or ten minutes' spent studying the instructions, we'd mastered all the buttons and options, each of which was close to intuitive.

For another thing, it's all but self-contained. For one thing, the suction cups and clamps mean no disposable stickers--not only are those stickers expensive and hard to obtain in remote areas, but they also generate trash. And here in rural Indonesia as everywhere in the world, trash is a big problem. The only thing this machine does need is paper for printouts--unless you decide to hook it up to your PC and view the EKGs digitally. Our clinic is Mac-based and we're not able to choose this option, but one could conceivably go completely paperless and trashless with this EKG. In a low-resource environment, all things being equal, equipment that doesn't require disposable parts and that behaves in a near self-sufficient matter should be given greater weight in purchase decisions than equipment that relies on parts that must be continually bought and replenished. Even if one has a steady supply of parts, they can go missing or be hard to store or keep track of in a small clinic.

Finally, one can operate without power--its battery lasts at least half an hour after being fully charged. That is absolutely key in an environment where the power often goes out. And you can opt for backlighting.

This machine allows the user to toggle through each lead on a standard 12-lead EKG; one can then opt to print it out. The printout isn't like a full-sized machine that prints a series of heartbeats from the simultaneous point of view of each of the leads--on this little machine, each lead is measured for three seconds sequentially. So you have to bear in mind that you're not comparing individual heartbeats across leads.

It offers various paper speeds and filters, too. I'm delighted with this thing and hope our clinic will eventually be able to obtain a few more. But if we never do, it's so light and portable that we can carry it from bedside to bedside and use it as we would any other portable equipment.

Verdict: great product.

Follow-up: Child with airway obstruction

2010-11-30T21:12:00.000-08:00

A few weeks ago I wrote about a little girl with an airway obstruction who tested our team's skills to the utmost. Well, four days after we bundled her into the ambulance with heavy hearts, she walked into the clinic, followed by her beaming relatives. We were shocked and overjoyed.

It turns out that by the time she arrived at the hospital, she was already breathing far more comfortably. The doctors there removed her breathing tube and didn't replace it, but from what I can discern across a language barrier and at third hand, she didn't need it by then. We suspect that she had an obstruction beneath the level of the vocal cords, perhaps from an unusually severe viral illness, and that the steroids our team administered kicked in to reduce the swelling just in time for her arrival at the transfer hospital. She stayed a few days there, receiving antibiotics. By the time we saw her, she had no airway trouble whatsoever. The only thing wrong with her was that she seemed a little shy. Maybe that's because the whole clinic pounced on her with hugs and kisses and exclamations.

Yeah, sometimes you love this work.

Delayed appendectomy

2010-11-04T21:31:00.000-07:00

This article reviews a recent study published in the September Archives of Surgery that suggests it may be safe to delay an appendectomy in adults, even for over 12 hours.

We're not in the US, but we can offer decent supportive care here in rural Indonesia, and from what I can discern from the article, I think this study is good news for low-resource or remote practitioners. Fluids, antibiotics, one gives those, of course, but we probably have time to safely transfer a patient to a surgeon if he presents to our remote clinic with suspected appendicitis. That's nice to know.

Pediatric airway nightmare

2010-11-04T21:10:00.000-07:00

I'm trained in emergency medicine, and in my field we live in dread of the "difficult airway." Many lectures and articles and textbooks are devoted to preparing us for it. What's an airway? When patients have trouble moving air between the outside world and their lungs, they may need some sort of secure tube to be put there. After all, without an airway, you can't even get started breathing. ER docs put in these tubes all the time, and it generally goes okay, but there are certain people who for one reason or another are extremely hard to tube. This can include people with obese necks, trouble opening their mouths wide, cancers or swelling down there, and so on. These kinds of distorted anatomy can prevent us from seeing what we need to see in order to stick the tube down the trachea instead of just poking around blindly.

There are all kinds of ways to conquer the difficult airway. You can use a newfangled fiberoptic laryngoscope or an old-fashioned bougie, or you can throw in a handy LMA to buy time. You can do a needle cric and then transtracheal jet ventilation for a few minutes, or you can resort to a retrograde intubation using a Seldinger technique. You can even call for your surgical backup to come do a trach. And so on.

Last night in our clinic here in rural Indonesia our doctors faced the most difficult airway I have ever seen. Yet there was nothing about the patient herself that made it so hard. Let me explain.

A ten-year-old girl arrived, limp and gasping, draped in the arms of two people, though she only weighed about 20 kg. An IV snaked out of her arm. The history was of a couple of days of fever and worsening trouble breathing followed by a visit to a remote clinic, where they'd placed a line.

Almost from across the room, it was clear from the way she was breathing that this was an airway problem rather than a lung problem. So, some sort of infection blocking the airway. Oxygen levels low. Almost no lung sounds because so little air is getting in. Whatever the diagnosis, she needs an airway immediately. That simple thing might save her life and give her time to get over the infection. Without it she will die in minutes, right in front of us, this previously healthy little girl with a blocked airway.

Then followed long minutes of professional misery, wherein items one desperately needed were found to be absent, dirty, too big, or too small. I love our clinic, but we're not a hospital; we aren't equipped for intubations. (I'm looking forward to building a bigger facility here, with the tools we need to care for sicker patients. Plans for this are in the works.) Someone happened to have donated us a beautiful case of laryngoscope handles and blades, all nestled in red velvet; but the few tubes we had were the wrong size. We don't stock airway medications, though we had diazepam, which our doctors gave her in huge quantities to try to keep her from fighting the lifesaving tube. Let us breathe for you, baby. Normally, one uses paralytic drugs to keep (unconscious) patients still so we can carefully insert the tube and secure it safely. We had none such here. No stiffening rod to keep the tube from flopping limply; one of the nurses found some sort of wire in a back room. No bite blocks to fit her. As we scrabbled around, temporizing, trying this and that, we pushed air into her lungs, barely, with a bag-valve-mask assembly sized for an adult.

After a long saga, and as the bag-valve-mask method was beginning to fail, her O2 dropping despite optimum technique, our team got a tube in. In a way, it was easy. Her little epiglottis and vocal cords, though swollen and patchy, were perfectly visible, and the tube slid in without difficulty. In another way, it was a nightmare. Without the right drugs and equipment, these were bad intubating conditions, to say the least. She coughed and clawed and gasped. She regurgitated and bit and struggled. And the tube itself was precarious because far too small, and the end was half-buried inside her mouth. Though we carefully taped it to its connector, it pulled away on one occasion, whereupon she inhaled the tube and it had to be fished out of her throat before it disappeared down her trachea. That wouldn't have happened with a tube that fit.

Still, she had an airway. That was what she needed. She calmed down. Her oxygen levels rapidly normalized, her lungs finally whooshed as lungs should, her speeding heart slowed a bit.

Now she needed a ventilator machine, complete sedation and more thorough diagnostics. Possibly she would need an abscess drained. We aren't equipped for any of that here. But it seemed worth it to try to obtain those things for this child, who after all had what amounts to a simple plumbing problem.

To say "We then transferred her to the ICU" would be technically accurate, but it would be inadequate to describe our difficulty in so doing (for example, a doctor held that faulty connector pinched between his fingers the whole way), as well as our disappointment on arrival. I am told that "ICU," which is hours away by ambulance, had no working suction, no ventilator machines, and evidently no airway management capability, as they removed her tube and did not replace it. Her oxygen levels began to drop again, and that was that. I hope the steroids and antibiotics we gave her will work in time. But I doubt she will survive this illness. Maybe all that diazepam means she's not suffering.

And so, my ER colleagues, I submit to you that the most difficult airway is not that of the large-tongued or the cancerous, not that of the obese or the swollen. It is the airway you try to secure without the tools you need.

Doorway diagnosis, but to what end?

2010-10-26T03:56:00.000-07:00

Our clinic recently saw an 18-year-old man who had had seizures for most of his life. It seems that they had been well-controlled on a three-times-a-day seizure medication, but his mother had recently tapered it off, and his seizures resumed and did not stop even when she restarted it. One of my Indonesian physician colleagues asked me to join him in the examining room.

The patient had a peculiar facial feature: crowded, shiny papules scattered across his nose and cheeks, as well as some larger, fleshier patches on his forehead. There was another on his lower back. And there was a pale, depigmented patch of skin on his belly. All of these had been there since early childhood.

From this telltale skin features plus his seizure history, it was all but certain that he had a genetic disease called tuberous sclerosis. Most cases arise spontaneously, and indeed there was none in his family, but because of dominant inheritance, each of the patient's own future children will have a 50% chance of inheriting it.

We explained this to him and his mother. She told us she had taken him to specialists in the city since he was little and had never gotten any kind of diagnosis, only a great many expensive and unhelpful tests and therapies. She said the family had sold everything it owned to pay for these trips and consultations.

Though it was gratifying to make that interesting diagnosis in this low-resource setting, the intellectual victory was Pyrrhic. The patient had been hoping for a cure for his seizures and skin problems, and there is no cure for tuberous sclerosis. Still, there's a lot that can be done. If he were lucky enough to be born in the developed world and possessed of good health insurance--or if he were the son of someone very, very rich here--he could have the lesions lasered off, which our textbooks informed us can give excellent cosmetic results. He could consult an experienced pediatric neurosurgeon about possibly removing the growths in his brain which are probably causing his seizures. He could see an eye specialist as well as receive the special education that many TS patients need. He could get a session of genetic counseling, too. With reliable Internet access, he could meet other TS patients online and get a little psychological support.

He has access to none of the above. In fact, he dropped out of school as a child because of his seizures. He is unemployed. His mother told us very frankly that she doesn't think any woman would marry him. The patient looked miserable to hear all this.

One of my American physician colleagues angrily pointed out to me later that it wouldn't be all that big a deal to at least get the boy's facial lesions lasered off--that alone would make a tremendous difference in his life. That is, it wouldn't be a very big deal if he were in a developed country that allowed for such things. As it is, though, what we had to offer were adjustments to his seizure medications and a suggestion to see a neurosurgeon who is hundreds of thousands of rupiahs' worth of travel from here.

I'm left wondering what good this diagnosis will be to him and his family. Is there ever a time when one might as well not know?

Follow-up: Patient with infected stone

2010-10-21T01:30:00.000-07:00

On October 18 I wrote about a very sick patient with an obstructing, infected kidney stone who underwent a dramatic transfer via boat to the nearest hospital with urologic capability. I will report what we learned about happened next. The patient underwent ultrasound there by the urologist, who noted that the kidney was indeed obstructed but who could not see a stone. He decided his involvement was no longer needed. The patient was begun on dialysis.

We would love to be able to put in stents here in our clinic. What does that involve? Might it be possible in a low-resource setting like ours, if were were able to get good equipment?

Some of the reasons why it's hard to treat TB in rural areas

2010-10-20T00:03:00.000-07:00

Here at our clinic in rural Indonesia, we send an ambulance out with doctors and nurses twice a week to run mobile clinics in remote villages. This morning, one of my fellow American doctors told me with frustration that many of the patients she saw yesterday clearly had TB, but that she wasn't able to prescribe DOTS ("directly observed treatment short course," for tuberculosis) because there is no DOTS worker in that village.

Turns out it isn't quite that simple. That village has had DOTS workers in the past, but there have been bad logistical barriers to them doing their jobs. For one thing, the roads to that village are bad at the best of times, and sometimes well-nigh impassable. For another, that village isn't covered by cell phone service, so our clinic's DOTS coordinator can't easily communicate with them. And many of the villagers leave for weeks at a time to work on palm oil plantations, where they are out of reach of even the most dedicated local DOTS worker.

Lack of infrastructure is largely to blame here. But it also seems to me to be a clear example of how environmental devastation (in this case, the clearing of rainforest for palm plantations) can erode public health.

The road to a village in rural Kalimantan, Indonesia.

One of the bridges along the way.

A middle-aged man with flank pain

2010-10-18T20:01:00.000-07:00

A moderately obese middle-aged man with a history of treatment for kidney stones presented to our Indonesian village clinic with a history of severe left-sided flank pain for several days. He was febrile, and writhing with what appeared to be classic renal colic. Though we didn't detect blood in his urine, given his history and presentation, we still suspected he had developed another stone. Given the fever, we also wondered if the kidney was infected (pyelonephritis). More worrisome still was the possibility that he had both an infected kidney and an obstructing stone. That's a surgical emergency and beyond our capacity to care for at the clinic.

We began aggressive fluids, antibiotics, and antiemetics, and gave him the pain meds we have--Tramadol, paracetamol (Tylenol), and ibuprofen. Then we took a look at his kidneys with the portable ultrasound, hoping it would help determine whether we needed to worry about obstruction or whether this was just pyelo. The news was grim. The left kidney showed clear evidence of blockage in the form of hydronephrosis, while the right kidney looked normal. It looked like he did have pyelo and an obstructing stone. We discussed transfer options with the family.

They happened to be relatively wealthy, and they decided to take him to the city where he'd been treated for stones before. The five-hour speedboat ride was arranged to take place the following morning. We were worried about the delay, but it appeared to be the soonest they could arrange for.

Just after midnight, my colleagues and I were called to his bedside. He had become tachycardic, hypotensive in the 70s, and delirious. He had developed snoring respirations as well, though his lungs didn't sound fluid-overloaded. In short, he had developed septic shock, and his life was in immediate danger.

We stepped up our supportive care, but were now faced with several hard decisions. Do we attempt to get this patient to the city sooner than his scheduled 7 AM departure? Does the family have the money to make this happen? Is he stable enough to ride in a bouncing speedboat for hours on end? What about a plane flight? The planes that leave the nearest airport (about two hours away by car) don't have a first-class section, and the aisles are only two seats wide--that's not enough to lie down across a row of seats. In any case, it was hard to imagine putting this man into a wheelchair, let alone manually lifting that chair up the steep flight of stairs from the tarmac into the airplane cabin. And once he finally arrives at the hospital, is there a urologist there and an ICU bed?

Worst of all, if his breathing deteriorated, should we place a breathing tube? This is no small matter even in the highest-resource setting, because once you place a breathing tube you are committed to "bagging" the patient by hand, giving breaths, until he is connected to a respirator. Giving breaths manually is far from ideal--it is much too easy to give them too fast, too slow, or at the wrong volume. There are no respirators here, nor anywhere nearby.

Faced with these problems, the family swiftly chartered a boat to leave at 4 AM. They expected to be treated there by the same urologist he'd seen in the past. As we discussed treatment options, they told us they were prepared for the worst, but asked us to give "the best care" in the meantime.

What is the best care in this instance? Does it include placing a breathing tube if he goes into respiratory failure? That would generally be the right choice in a high-resource setting in a previously relatively healthy man like this. But here? Is it the best care to intubate someone out in a village, with no X-ray to confirm correct placement, no continuous monitoring available, no respirator to regulate the depth and volume of breaths? What if someone overinflates a lung during the journey and it collapses? What about the lack of easily-titrated sedative and pain medications to keep the patient comfortable? And, given that we are trying to save both lives and livelihoods out here (a trip to the city can completely ruin a family's finances), are we sending these people on a futile errand? Sometimes our job here is to advise against escalating care.

In this case, the family had the means to travel. And we were spared the intubation decision, as the patient's blood pressure improved with increased fluids and his breathing didn't worsen. Soon he and his family had sped away in the clinic's small ambulance, headed for the docks, an Indonesian doctor at his side with a bag full of fluid bottles and extra medications. And a bag to provide temporary breaths, just in case. We wait to hear how he did.

On low-resource medicine in Indonesia & elsewhere: Much to admire.

2010-10-18T02:17:00.000-07:00

Greetings from rural Borneo, Indonesia. Indonesians call their portion of this magnificent island Kalimantan, and it is both richly endowed and gravely endangered. Until recently the island was covered in rainforest; since the 1980s, it has been so heavily logged that only a fraction of the original forest remains. Illegal logging, fires, and the clearing of forests for palm-oil plantations are among the reasons why the ecosystem here is being devastated. Through flooding, drought, and changes in disease patterns, hat has led to adverse health consequences for many people here.

I'm in Kalimantan with an organization that provides health care for people living amongst this destruction. Since I'm not writing for them in an official capacity, I will withhold identifying details about them, as I wouldn't wish to bring even the possibility of unwanted publicity through anyone taking offense at what I write.

Some Indonesian readers may be offended, for example, at the term "low-resource medicine." I hasten to reassure them that no slur is intended. On the contrary, I am here because I admire this kind of medical practice. At its best, low-resource medicine has the capacity to surpass medicine as it is practiced in developing countries, in terms of wise stewardship of resources and of providing patient care that is both medically effective and cost-effective. I greatly admire the practitioners of low-resource medicine and of all that they do for their patients, and I firmly believe that medical practitioners in developed nations like the United States have much to learn from their colleagues who work in low-resource settings.

It has often been remarked upon, for example, that physicians who do lack access to a near-infinite array of tests and studies develop sharper physical examination skills and may well grasp a patient's clinical situation than their American colleagues would. And few would dispute that medical care in the United States is becoming unsustainably expensive even as it still doesn't reach as many people as it should. It makes no sense that we spend vast resources pursuing treatments that might give people a few weeks' more life, but that many people with hypertension remain undertreated. It is as if we Americans continue to pour into some glasses while other glasses remain empty--and we're running out of water. That policy isn't reasonable and it isn't fair. Practitioners in lower-resource settings, on the other hand, have experience in making sure that the largest number of people get good, sensible, and sustainable medical care, and I want to learn more about how they do it.

Our organization runs a village medical clinic in a converted house. Indonesian physicians fresh out of medical school spend a year with us doing something akin to a family practice internship; they see patients, then present cases to volunteer physicians from the United States. Then we work through what to do and the Indonesian doctors put a plan into practice alongside the clinic's trained nurses. There is much that the clinic can't do, such as surgery in an aseptic environment; the nearest hospitals are hours away by car, plane, and/or boat, and transfer is frequently not an option. Still, there are a great many tools in our toolbox, including a good array of medications, an ultrasound machine, microscopy, and IV capabilities. It is striking how much we can do from our little house.

I'll post about some of the cases we've seen.

Medical education in Nigeria

2010-01-31T19:02:00.000-08:00

Gentle readers, forgive me for not writing more about Haiti. Though I volunteered, I have not yet been asked to deploy. Those of my colleagues who have done so, and who are in a position to comment on low-resource medicine in Haiti after the earthquake, are understandably busy and not yet able to do so.

Let's turn instead to Nigeria. Dr. U.V. Okafor teaches at the University of Nigeria Teaching Hospital in Enugu. (Famed author Chinua Achebe taught at the same university.) He has written about critical care in sub-Saharan Africa and commented on the dire shortage of nurses there. He kindly agreed to answer my questions about medical education in Nigeria; what follows is a lightly edited version of what he had to say. His words reveal a great deal about the issues that face practitioners in low-resource countries, including the emphasis on teaching the physical exam; the lack of a strong emergency medicine paradigm; brain drain; payment problems for physicians; the need to attract and retain only medical personnel, but also allied professionals like engineers; and the use and misuse of federal and international funds.

Italics and hyperlinks are mine.

A little background? Basically, medical education in the country is patterned after the British system. Nigeria is of course a former British colony, attaining independence in 1960. Physical examinations are greatly emphasised in our medical education because of a large rural population without access to tertiary care centres with modern equipment. Nigeria’s Human Development Index (HDI) progressed from low to medium in 2009. And that is good news for us, and credit must go to the rural-based doctors (they will get rural posting allowances in the new salary scale).

How do you teach students? I am a senior lecturer in anaesthesia and intensive care. Medicine is a 5-6 year programme in Nigeria, and the medical students undertake a four-week posting in clinical anaesthesia, in addition to classroom lectures. Usually I use PowerPoint presentations for my lectures to medical students. As a member of the curriculum committee of the medical school, I tried to include more credits in emergency medicine, but it is still a novel concept in the country.

A word on residents' training? I also train residents in anaesthesia. The residency programme usually takes 4-7 years, depending on one’s progress. The final examination of the programme involves a dissertation or a case series, and that usually prolongs the training. Successful candidates become Fellows of the Medical College of Nigeria, or Fellows of the regional West African Postgraduate Medical College....[The WHO surgical safety checklist is] not currently in use [at UNTH]. I got it from the WHO website and hope it will be standard practice soon.

Where do residents go to train? Though [UNTH is] one of Nigeria’s premier teaching hospitals and its centre of excellence for cardiothoracic surgery, her best graduates usually pursue postgraduate training overseas, in the US or Britain, and mainly for economic reasons. Most of the first-generation consultants were UK-trained with a sprinkling of US and Canadian fellows. I think the North American-trained specialists rarely return to the country. To reverse this sad trend, the Nigerian government recently increased the salaries of medical workers, buoyed by the increased oil and gas revenue. The country is the world’s sixth largest producer of crude oil. The new emolument will take effect this year.

What kinds of resources are at your disposal? In early 2007, the hospital moved to its permanent site where the theatre was well equipped by VAMED, an Austrian health care service provider. They installed multi-channel monitors (pulse oximetry, non-invasive blood pressure monitor, temperature, electrocardiography and capnography), and modern anaesthetic machines with low-flow systems. MRIs are avaliable in some federal government-funded hospitals, but maintenance is a problem due to a paucity of biomedical engineers. To the best of my knowledge, PET scanners are not available, being quite expensive for a developing country like Nigeria, which has no health insurance for most of her citizens. Besides, the problems of infectious diseases means funds are diverted towards these areas, and their treatments are greatly subsidized (about seven dollars a month for HAART).

A word on your position as an academic physician? The major problem for those of us in academia is a lack of grants for research work, and we still depend on Western organisations like Wellcome Trust for assistance. When a nation has made billions of dollars from oil revenue, it certainly got into some hands, but funding education doesn’t seem to be on their minds. With a former university lecturer as President, we hope that will change soon.

Haiti: Vodka and hacksaws

2010-01-18T04:36:00.000-08:00

Sixty Minutes (video, 12 mins long); doctors explaining how they are amputating without adequate supplies. Civil War medicine indeed.

Of note: the United States has evacuated 4 patients for treatment. The country of Martinique has reportedly accepted 200. Why this large discrepancy? Is Haiti's and Martinique's shared relationship with France somehow greasing the wheels? Are the patients able to go to Martinique because they are bypassing the congested airport (it's an island as well)? Has the US chosen to focus on on-site treatment and infrastructure rather than evacuation--is that a better long-run strategy? Are there immigration difficulties?

Haiti

2010-01-15T18:59:00.000-08:00

With moderate supplies, we can try to practice low-resource medicine. Without supplies, doctors and nurses don't matter. No real medicine takes place, and a hospital becomes a mere gathering of medical personnel. Or a morgue.

* Outdoor amputation with local anesthesia (video).

* Underequipped field hospital whose physicians are doing what little they can (video).

* Logistical nightmare for Doctors Without Borders (article).

No one could have prevented the earthquake, but Haiti was especially vulnerable because of shoddy infrastructure and lack of health services. The historic reasons for this are many and wretched. Tracy Kidder points out that there are 10,000 aid organizations established in Haiti, yet it remains obscenely poor. Educate yourself about Haiti and about Partners in Health's medical efforts there in his unforgettable book Mountains Beyond Mountains.

OF NOTE: Going to Haiti? Need some Creole? As of 1/15/10, Transparent Language is offering their "Byki Haitian Creole" software for free on iTunes, as their way of helping. And Pimsleur offers its first ten lessons of Haitian Creole free as well.

Nearsighted and farsighted

2010-01-12T13:01:00.000-08:00

The price we pay for want of eyeglasses is steep: $269 billion a year. That number, published in a 2009 WHO-affiliated study, is an estimate of worldwide lost productivity due to refractory error--a kind of vision problem, like nearsightedness, that glasses can fix. But, though eye exams and eyeglasses don't cost much, they require lens-grinding equipment, an optometrist, and a machine into which to trustingly settle the chin. All of those are in short supply in many countries. Who's tackling cheap vision correction?

Gadgeteers, it turns out, are drawn to eyeglasses just as they are to cookstoves. The holy grail of low-resource eyeglasses are the kind you just hand to a person--he puts them on, adjusts them, and sees. Such glasses exist. The New York Times wrote recently about high-tech eyeglasses that allow untrained wearers set the focus themselves, some using a sliding-lens system and others an injectable liquid. The companies developing this technology, which include AdSpecs in England and Focusspecs and U-Specs in the Netherlands, plan to drive down production costs and send millions of eyeglasses to poor countries, thereby helping many of the 145 million people who have bad vision from uncorrected refractive errors (but not with astigmatism--those people still need optometrists). The website of an organization affiliated with AdSpecs, Centre for Vision in the Developing World, explains how the glasses work; it's well done and worth a visit.

But as a former U-Specs executive pointed out in the Times article, the real cost is not in the nifty glasses themselves, which will be a few dollars or less once economies of scale are in place, but in their distribution. After all, many donated pairs of eyeglasses already make their way to poor countries through organizations like New Eyes for the Needy. That group claims to distribute hundreds of thousands of pairs each year, a number that dwarfs what the gadgeteers have yet accomplished--and demonstrates that powerful built-in networks for distributing glasses already exist. Are all these parties talking to each other?

Similarly, Vision 2020, the cleverly-named partnership between the WHO and the International Agency for the Prevention of Blindness, is tackling all forms of avoidable blindness, with an emphasis on developing better infrastructure rather than passing out post-optometry eyeglasses. As with so many low-resource problems, solutions to preventable blindness are many and partial. The best one may remain to be seen.

Speaking to your patient: medical phrasebooks

2010-01-06T05:30:00.000-08:00

Pocket guides to help clinicians speak a foreign language to their patients are hard to find for most languages. But there are a few on offer. The trouble with speaking from phrasebooks and dictionaries, of course, is that the person who painstakingly mouths syllables then has to brace for a fluent and incomprehensible reply. So a human translator is invaluable. But I like to make an effort to speak in the language myself,* if only because my patients' laughter at my attempts makes for good medicine.

You can get medical Spanish, French, and Russian resources by Russell K. Dollinger on Amazon, and some come with audiotapes or CDs. There are other Spanish-language resources besides his, but I mention it because it's a nice series and because Dollinger is developing a gadget to allow for more inter-language communication. (Read more about his Interphraser here.)

A Swahili book is available to English speakers.

The British Red Cross mails a free copy of a 36-language phrasebook for emergency conversations to British physicians. It can be ordered and downloaded online. I can't wait to print out those PDFs and give Pashto and Turkish and Amharic a try.

A book called Medical Translator contains phrases in languages commonly used in the US, including Spanish, Chinese (they don't specify which on the Amazon page), Italian, French, German, Creole (again, which creole they mean is not specified), Korean, Vietnamese, and others. Unfortunately, it seems only to be available in a German edition.

And here is the mother of all bibliographies for foreign-language medical glossaries, compiled by Jacquelyn Coughlan at SUNY Binghamton.

*I recommend Pimsleur audio programs to get you comfortable wrapping your tongue around foreign syllables.

First-person accounts from MSF docs in India and Zimbabwe

2010-01-03T16:03:00.000-08:00

I'd like to call your attention to three blog entries at the British Medical Journal's website, in which three physicians write about their work in low-resource settings with Médecins Sans Frontières (MSF, a.k.a. Doctors Without Borders).

Joseph Jacob discusses working in Kashmir and Chhattisgarh, India, where he and his colleagues are treating malnutrition, scabies, leprosy, TB, mental health disorders, malaria, and obstetric conditions. They also responded after Cyclone Aila hit India and Bangladesh in July '09.

Caroline Forwood writes about Bihar, where kala azar is endemic. This vicious disease, also known as visceral leishmaniasis, is transmitted by the sandfly, a creature 3 millimeters long that bites. Treatment options for this disease are few, though two new drugs were approved for use in India in the last decade. The MSF docs are using amphotericin B, which is expensive and carries serious side effects but is highly effective and readily available.

Philipp Du Cros gives the reader a look at his job improving or starting tuberculosis treatment programs, and focuses on MSF's efforts in Zimbabwe. What's striking about this and so many other accounts of work in low-resource areas are the descriptions of the distances patients must travel to obtain the most basic care. Add transportation to the list of problems (it includes sanitation, electricity, security, and many more) that are integral to the practice of low-resource medicine.

Stoves and disease

2009-12-22T11:06:00.000-08:00

A blessing of modern life that feels decidedly mixed is the need to accept that seemingly pleasant old-fashioned ways are untenable and even dangerous. Tiresome safety-conscious reformers have long had a way of pointing out that, say, the elegant horse and carriage brings with it piles of horse shit; the classic car's glossy dashboards are blindingly so; and the delicious all-American meal of burger, fries, and pop has abhorrent ingredients. You'd almost rather not know, but there it is.

So, too, I'm sorry to say, must go the open fire, with its beauty, its simplicity, its utility, its potent symbolism, and its many chemicals and particulates that lead to childhood pneumonia and a host of other diseases, both respiratory and otherwise.* I'm stretching the analogy, of course: a fire for s'mores is worlds apart from a fire for flatbreads.

Built fires are, in fact, a scourge. People suffer and die prematurely, as do forests and ecosystems and the climate, when fire is used for everyday cooking and warmth. In a recent New Yorker article (available by subscription only, alas) "Hearth Surgery," Burkhard Bilger describes it thus: "Clean air...contains less than fifteen micrograms of fine particles per cubic metre. Five times that amount will set off a smoke alarm. Three hundred times as much--roughly what an open fire produces--will slowly kill you. Wood smoke, as sweet as it smells, is a caustic swirl of chemical agents, including benzene, butadiene, styrene, formaldehyde, dioxin, and methylene chloride....Indoor smoke kills a million and a half people annually." Not to mention heats the atmosphere with terrible efficacy.

Seems like a low-hanging fruit, no? Get people cheap, powerful, clean stoves; prevent suffering, deforestation, and global warming. But it turns out that designing and introducing good cookstoves present knotty engineering and cultural problems. As Bilger explains, it's hard to come up with a stove that's simultaneously efficient, cheap, clean, durable, and easy to use. And many people accustomed to their usual way of cooking aren't eager to change. (As the New York Times put it in a recent article, can you imagine asking a traditional Italian cook to make risotto in a microwave?)

But stove development is hot. It has attracted organizations and passionate hobbyists who like the technical challenge and the idea of saving lives and the planet. To learn more, check out the blog Improved Biomass Stoves for discussions of stoves and stovers (as developers of stoves often call themselves). BioEnergy Lists and Rocket Stoves are resource sites for stove developers. The journal Indoor Air reports on these issues (free access to developing-world institutions). Then, too, there are GTZ; Stove Camp; ETHOS; Darfur Cookstoves; and the Ashden Awards, among many other sites. Lists of relevant links much more comprehensive than mine can be found here and here.

Let's hope that good stoves spread everywhere and make open fires a matter of misguided nostalgia.

*Carbon monoxide poisoning, pneumonia, lung cancer, bronchitis, chronic obstructive pulmonary disease, heart disease, high blood pressure, low birth weight, cataracts...

UpToDate's grant program: free software and information.

2009-12-14T16:36:00.000-08:00

Information wants to be free, or so say the hackers. And while good medical information has long been expensive, some of it will soon become free for some of those least able to afford it.

On December 4th I mentioned that UpToDate, the eponymous medical-article service, has rolled out a grant program. Today I talked to Drs. Ellie Baron and Denise Basow--respectively, UpTo Date's Deputy Editor for Infectious Diseases and Editor-in-Chief--about the service's plan to give away free subscriptions to its giant article database for low-resource practices.

"We've been providing donated subscriptions for several years," said Dr. Baron, who told me that they get about 20 requests a year, many of them from UpToDate authors who are doing medical work abroad. "What's changed is that recently the application process has become more formalized." To wit, they've formed a partnership with a group called the Global Health Delivery Project (GHD), which was started by low-resource godfather Paul Farmer and colleagues. If you run a medical organization in a low-resource setting and can't afford the pricy subscription to UpToDate, you can fill out an application, whereupon GHD doctors will decide whom to grant subscriptions to. This is the first year of the program and Dr. Baron wasn't able to say how many subscriptions they plan to give. It may depend in part on the number of applications they get. One hopes there will be a lot more than 20.

On the other hand, since most of UpToDate's articles are written by and for physicians in high-resource settings, it's worth asking what good they are to our low-resource colleagues. Does it help to read about the latest chemo recommendations for breast cancer when all your hospital has to offer is a surgeon? To UpToDate's tremendous credit, they are studying this. Low-resource sites affiliated with Partners In Health (also a Farmer organization) are using UpToDate and recording which articles and what kinds of information seem to be most useful. Their ultimate goal, said Dr. Basow, is to publish this information. For the moment, Dr. Baron told me, though people may not have access to the most costly resources mentioned in an article, they can adapt what they do have to the article's recommendations (which, in my experience, often offer multiple suggestions ranging from the simple to the complex). And I would submit that all health-care workers are entitled to the best information, period. If they don't have the ideal chemo cocktail, at least they will know something about how to use it if their clinic does gain capacity in the future. Which it would seem more likely to do if its leadership has a clear idea of what the clinic needs.

Also to be applauded is the fact that UpToDate is developing more content geared toward low-resource practitioners. Baron told me that the company is gradually adding authors and articles to the existing database, and once they have enough, they plan to make it a dedicated section within their contents. With the subscriptions and the articles, she said, "We're trying to get at [low-resource medicine] from more than one angle." Bravo, UpToDate.

Animals as diagnosticians and treatment aids

2009-12-09T15:41:00.000-08:00

Ants' interest in urine can be used to see whether the urine contains sugar, a marker of diabetes. (If the physician prefers, he can taste it himself.) The use of ants for urinalysis comes up in tropical medicine and historical references, but there appear to be zero articles in PubMed about it. So I remain in the dark as to which species of ant should be used, how long they should be given to show an interest in the urine, or whether more ants mean more sugar is present. Ants have also been studied in arthritis, though it's not clear from the abstracts I can find whether the ants are eaten, encouraged to sting the sufferer, or what. (Interestingly, a friend who has studied traditional medicine in Morocco tells me that bee stings are used to treat arthritic joints. Perhaps Order Hymenoptera contains an antiinflammatory agent.)

Maggots can clean the dead tissue from wounds. So-called larval therapy is used in the U.K. Here's a free fulltext review. (Dermestid beetles can clean carcasses for museum display, too. The idea is that many tiny sets of jaws can scrape off flesh better than human hands can.)

Leeches secrete a blood thinner that can keep wounds from becoming engorged, which is useful when attaching severed body parts and in other such plastic surgery needs. There are a number of articles about this in PubMed, many of which are free. These creatures have been used to treat priapism as well, though this is poorly documented in the medical literature (there's a 1960 Russian-language article about the topic, but no reviews more recent than that to my knowledge).

Also of interest:

* Zootherapeutics (the use of animals in medical treatments) in Brazil and India.

* An insect formulary of sorts, drawing upon Indian folk remedies. I don't know whether studies have been done, and if so how rigorous they've been, but as long as information about such things continues to be published in periodicals like International Chickpea and Pigeonpea Newsletter, low-resource practitioners are not going to have access to it.

* Some articles from Chinese journals are cited here regarding ants and their uses in China. Again, these are buried in journals that aren't easy to find online.

Many of these remedies remain completely unstudied by science. There are probably a lot of safe and effective medicinal uses of insects, but until they're subjected to scientific scrutiny we may never take full advantage of them in either low- or high-resource medicine.

Books, journals, and UpToDate for less than retail

2009-12-04T11:29:00.000-08:00

Until recently, most physicians consulted the kind of medical journals that stand bound in hundred-year chunks on the towering metal shelves of medical libraries. Those journals not only make for meaty browsing, with their retro advertisements and dated syntax, but also hold a wealth of valuable medical information, much of which remains unarchived on electronic media. Still, going to such shelves to look up a journal article is like knitting your own socks: it would be nice, but nobody has time. We find journal articles online instead.

Most of the journals I've needed to consult in my medical career are available online by subscription. Already pricy as physical copies, the journals can be grievously expensive in their electronic forms, even with tiered pricing. In some cases, caregivers in poor countries get a price break. The New England Journal of Medicine, for example, allows free access to URLs from 119 low-income countries.

The WHO has seen to it that many such journals are accessible to low-resource clinicians who have the bandwidth. HINARI is a WHO project to allow some institutions* in developing countries to read medical journals in the medical literature either for free or for $1000/year, depending on level of poverty of their countries. It was started in 2001 with six publishers: Blackwell, Elsevier Science, Harcourt Worldwide STM Group, Springer Verlag (Bertelsmann), John Wiley, and Wolters Kluwer International Health & Science. The site comes in seven languages, and the journals in 22. So far there are 6,458 journals thus accessible.

Despite Wolters' involvement with HINARI, one resource I haven't found on either HINARI or Free Medical Journals is UpToDate, Wolters' immense evidence-based and physician-authored article service that is the first place many American doctors turn with questions on the job. It has plenty of international subscribers, but they are charged full price. I filled out their subscription form as a theoretical internal medicine physician from the United States. The cheapest option is one for trainees at $195 a year, plus $15 for shipping and handling. A standalone subscription is $1,495. I also filled it out as the same physician from Botswana--same prices, except higher S&H.

That looks to be changing, though. Though their home page and subscription form don't signal this, UpToDate recently rolled out a donations program that allows institutions in poor areas of the US and poor countries to apply for "a limited number" of free subscriptions. It's administered through the Global Health Delivery Project, a brainchild of Paul Farmer, Jim Kim, and Michael Porter (if you don't know who these guys are, read this first). Institutions can apply to a January or May 2010 deadline for the first round of grants. It's not clear how many grants will be awarded or how applicants are judged, although an UpToDate spokeswoman has promised (12/3) to get back to me on this. In any case, it would seem to be a welcome development for low-resource medicine.

* A small-town clinic doesn't quality under its rules, which state that access "applies only to bona fide academic and research institutions."

_____

Other links to free medical information online:

* The WHO Formulary (pdf).
* Pubmed.gov allows the searcher to specify that searches return only free fulltext hits.

* HighWire's list of free full-text journals, some offering only older content for free.

* Excellent list of online resources compiled by a nursing informatics specialist. The most helpful links are toward the end of the page.

* FreeBooks4Doctors and FreeMedicalJournals' eponymous offerings are apparently accessed by thousands of readers around the world, though some of its journals are only free after a one-year paid subscription. This and the preceding site are maintained by the efforts of a man named Bernd Sebastian Kamps, who also offers a prize to the best medical textbook created to be freely available online. Good idea--there is nothing like a contest to maximally leverage effort.

Traffic injuries and trauma care

2009-11-30T20:13:00.000-08:00

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

2009-11-24T16:41:00.000-08:00

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

2009-11-23T13:38:00.000-08:00

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.

2009-11-22T10:15:00.000-08:00

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

2009-11-20T09:03:00.000-08:00

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

2009-11-19T07:31:00.000-08:00

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

2009-11-18T05:36:00.000-08:00

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

2009-11-17T09:16:00.000-08:00

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

2009-11-16T07:58:00.000-08:00

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

2009-11-11T18:34:00.000-08:00

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

2009-11-11T08:26:00.000-08:00

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

2009-11-11T08:05:00.000-08:00

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.