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.