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.

Nearsighted and farsighted

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.

Books, journals, and UpToDate for less than retail

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."

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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

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.

Statistics: How to find them

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

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

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

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

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