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.

First-person accounts from MSF docs in India and Zimbabwe

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.

Animals as diagnosticians and treatment aids

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.

Traffic injuries and trauma care

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

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

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

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

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

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

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

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