The "speed bump" sign to detect appendicitis

This group in the UAE did a small prospective study suggesting that, among patients presenting with suspected appendicitis, the "speed bump sign" of increased pain over speed bumps is over 90% sensitive for appy.

Again, it's small. And the pretest probability in this group of patients was very high, while the specificity was low (40%). But, as with rebound tenderness, it's another reminder that peritonitis doesn't like to be jostled.

Oh, and hi--Low-Resource Medicine is back after an extended hiatus. We'll be posting relevant tidbits at intermittent intervals and always welcome readers' thoughts. Who knows; we might even update our look.

Visual inspection with acetic acid for cervical cancer screening

In an ideal world, women would get all the Pap smears they need to prevent eminently preventable death by cervical cancer. In reality, many don't. Cervical cancer kills over a quarter-million women each year, most of them in developing nations.

It turns out, though, that painting a woman's cervix with white table vinegar is a cheap means of visually highlighting abnormal areas of the cervix and detecting possible cervical cancer. That's no small thing. Here's the BBC's take.

The vinegar method, a.k.a. visual inspection with acetic acid (VIA), has been around for some time. In one recent study, the test's sensitivity compared favorably to that of the Pap test.

Turmeric and Tumor Metastasis

From MedPage Today, a good tidbit for those of us who like yellow food.

 Curry Component Fights Cancer Spread, by Crystal Phend

'The active ingredient in the curry spice turmeric may help block tumor metastasis, German and Italian researchers found. That compound, curcumin, reduced inflammatory markers, which correlated with a lower incidence of prostate cancer metastasis in their mouse model study reported in Carcinogenesis. Curcumin has also been shown to suppress breast cancer metastasis to the lungs in prior animal studies from the group. "This does not mean that the compound should be seen as a replacement for conventional therapies," lead author Beatrice Bachmeier, PhD, of Ludwig Maximilians University in Munich, cautioned in a press release. "However, it could play a positive role in primary prevention – before a full-blown tumor arises – or help to avert formation of metastases. In this context the fact that the substance is well tolerated is very important, because one can safely recommend it to individuals who have an increased tumor risk.'

A field block for abdominal surgery

Field blocks are ways of delivering anesthesia to a region of the body via a strategically-placed injection. Say you're looking to numb up a fingertip laceration in order to suture it. Injecting lidocaine at the wound itself is not only excruciating, but can also distort the anatomy, since the lidocaine solution in itself takes up space. There's also the chance that you'll miss a spot. But you can numb the entire finger with a field block at its base (alas, not a painless injection). There are a number of field-block techniques out there--whether you're numbing up an ear, an ankle, an abscess, these techniques offer analgesia in a localized region of the body without requiring either wound injection or general anesthesia.

 An anesthesiologist recently told me about a field block for the abdominal wall. It's called a transversus abdominis plane block, or TAP block. Author Karim Mukhtar writes that the TAP block is "indicated for any lower abdominal surgery including appendectomy, hernia repair, caesarean section, abdominal hysterectomy and prostatectomy. Efficacy in laparoscopic surgery has also been demonstrated. Bilateral blocks can be given for midline incisions or laparoscopic surgery."

The TAP block would seem to be an awfully nice option for low-resource surgical practitioners. One can imagine the safety benefits in a setting where general anesthesia is impossible or risky. Mukhtar also describes an ultrasound-guided technique at the hyperlink above.

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.

Quitting smoking can be a warning sign of lung cancer

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

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.

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

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

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

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

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

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

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.