Developing World's Doctor Brain Drain

From the New York Times, an article by Matt McAllester about the United States' propensity for attracting young physicians from abroad and adding them to the American work force when they're far more needed at home.

The migration of doctors and nurses from poor countries to rich ones elicits some highly emotional responses, not to mention a great deal of ethical debate. Writing in the British medical journal The Lancet in 2008, a group of doctors, several of them from Africa, titled their paper “Should Active Recruitment of Health Workers From Sub-Saharan Africa Be Viewed as a Crime?” They concluded that it should. Other critics have used terms like “looting” and “theft.”

Some of the anger is directed toward the doctors who leave. The managing director of University Teaching Hospital in Lusaka, Lackson Kasonka, suggested to me that doctors who received government financing for their educations and then left exhibited “a show of dishonesty and betrayal.” ...Peter Mwaba, the most senior civil servant in Zambia’s ministry of health, said that doctors overseas should not “hold their country to ransom” by staying away until things, in their minds, sufficiently improve.

The public health challenges in Zambia are intimidating: life expectancy is 46, more than one million of Zambia’s 14 million people are living with H.I.V. or AIDS and more than 1 in 10 children will die before they reach 5. To cope with this, there are slightly more than 600 doctors working in the public sector, which is where most Zambians get their health care. That is 1 doctor for every 23,000 people, compared with about 1 for every 416 in the United States. If Desai decides to stay here, the world’s richest country will have gained a bright young doctor. The loss to Zambia will be much greater.

The author visits an understaffed Zambian hospital with plenty of donated equipment from Japan, making it clear that more doctors are needed there to put it to use. Yes, it's clear that with those new ventilators just sitting around, more doctors would make it a much better hospital. But not all hospitals in these doctors' home countries are even minimally equipped. In my opinion, he doesn't adequately examine the difficulties a doctor faces in running a facility with extremely severe equipment shortages, of which there are all too many in developing countries.

Low-resource medicine is a noble practice, but has its limits. Too few resources and a hospital becomes a hospice--with no IVs, sterile equipment, meds, or adequate staff, it becomes essentially impossible for caregivers to do their jobs. Patients either get better or they lie around and die. Hard to blame a doctor for not wanting to walk around, much less try to work, in a place like that. If you bring doctors back to such hospitals, will even the simplest of the tools they need somehow follow them there?

Candida susceptible to coconut oil

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

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

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

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

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

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.