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Sunday, July 28, 2013

Medical Tourism--some ideas, and maybe what not to do.

There are many ways to visit exotic destinations, including cruises, tours, adventure travel, business related meetings and just plain going there. I always thought it would be most interesting to visit a place and practice medicine, since it would give me the opportunity to meet interesting people, do interesting things and maybe actually help. I first went overseas as a doctor about 23 years ago after finishing my medical residency. I traveled north from Bangkok to Chiang Mai where I found my way to the McKean leprosy hospital. There I spent a week rounding with the American physician who was the medical director, surgeon and primary doctor for all of the leprosy patients. There were also visiting dentists from Germany and other people who helped in various ways, including carrying on a religious mission for the Episcopal Church. It was one of the most memorable weeks of my life and flavored my ideas about medicine for the decades I have practiced since then.

I have looked for ways to visit developing countries in a medical capacity and learned about what seemed to me to be a disturbing development: medical tourism. For a significant chunk of change, a physician can visit some out of the way destination, be assured of room and board and expect to work as a doctor. I have nothing against paying for travel or donating money to worthy overseas medical causes, but it seemed to me that, if it cost thousands of dollars to go far away and do good, perhaps I ought to just donate that money and stay home. Also it seemed that if it was so very expensive to go ply my trade, perhaps my expertise wasn't actually very valuable in those places.

Haiti in 2010 offered me the opportunity to be a doctor in a far away place without actually resorting to a medical tourism agency. I traveled with friends to evaluate the needs of a few small communities on the island of La Gonave off the coast of Port Au Prince. My friends' projects included womens' rights, gardening and the economics of arts and crafts. I brought a suitcase full of remedies which seemed like they might be useful, saw patients, visited dysfunctional health centers and observed the work of a group of flying doctors who come in for 2 weeks every year to treat patients who lined up for hours to be seen. It turned out that what I could do medically in 2 weeks was close to nothing, since people needing acute care couldn't get to me or had died or gotten well all on their own. Many people did need help, but it was more of an ongoing need, and not something I could provide in the time I was there. There were some advanced cancers, HIV, non-healing wounds and severe hypertension. Undoubtedly there were tropical diseases which I couldn't recognize and there was chronic pain, mainly headaches and belly aches. When I made the trip a year later I brought close to no remedies and saw only a few patients in a clinic setting. I concentrated on talking to people about their existing health care and its obstacles, encouraging sanitation projects and handing out condoms. I sat in meetings with women and men in which I tried to address their concerns by blowing up condom balloons and telling stories with the help of a skilled creole translator which made them laugh and perhaps dispelled some rather physiologically implausible myths. In other meetings we talked about what they had and didn't have and what they wanted and what seemed possible and sustainable. Although I can't confidently say I did no harm, we did engage in mutually satisfactory dialogue.

The problem with going to places to help is that it can set up a relationship of dependence, especially if the help that is provided is something that is necessary and not otherwise available in that place. And that kind of help is also exactly what we would want to provide. Our natural impulse is to share our tremendous wealth with people we see as being helpless and destitute. The projects that are most successful in this capacity, I think, are projects that can be completed in a limited amount of time such as cleft palate repairs or cataract extractions, or ones that develop staffing and infrastructure in the country they serve that is at least partly self sustaining. Paul Farmer has done this in Haiti dealing with many aspects of chronic diseases in hospital/health care center settings, as has Jill Seaman in her work treating the deadly tropical disease Visceral Leishmaniasis in South Sudan. Provision of medical care in disaster settings is also a good idea, since its scope is usually time limited, supporting an overwhelmed medical system at a vulnerable time. Providing a higher level of care briefly in a setting where it is needed long term is not particularly useful and can upset the progress in healthcare that may have been developing organically.

Recently I visited Tanzania with some medical students who taught ultrasound to Tanzanian students and medical professionals (see the separate post here), kind of an introduction to bedside ultrasound class. I felt like the techniques were really powerful and the students made sure to coordinate with a school there and a radiologist who would probably continue with the teaching. Ultrasound machines are not so very expensive in the developing world, especially as newer, smaller machines are replacing older, still adequate ones. Increasing the baseline competence of people who will be delivering care has the potential to reduce suffering and improve patients' lives in a country with a staggering deficiency of doctors. The motivation for the project was beautiful in itself, medical students bringing the cool thing they had just learned to a place where it could really make a difference.

Another issue with medical projects overseas concerns scarce resources. When I was in Haiti I noticed that there were lots of small, short haired, gentle dogs who barked at intruders and ate garbage. Most of them were thin, and about half of them eventually had puppies. The puppies were incredibly cute and were treated with complete indifference by most people, even as they appeared to cling so very tenuously to life. Undoubtedly most of the puppies died. Nobody but us rich white people fed the puppies food scraps because there wasn't enough food for all of the people, or even the mother dog. If all of those puppies survived, a person would not have been able to put a foot down without stepping on a dog. The human infant mortality rate in Haiti is high and lifespan is short, which results in a pretty stable population in the very resource limited island I visited. If medical care is really successful and the very young and the old live longer there will not be enough food or anything else to support everybody. In some places healthier people produce more food and shelter which offsets this problem, but we need to be very careful about how we focus our philanthropy. If babies are to survive in families that can care for them, there must also be adequate birth control and improved gardening and other industry.

Should we doctors just stay home? No. Emphatically. Unless we want to. But those of us who are motivated to go forth and help people should pay attention to the complexity of the systems we are driven to change. We should open our hearts to the possibility that it is we who are benefited most by our adventures as we meet, care for and in turn are cared for by people whose backgrounds and social contexts are very different from our own.

Tuesday, July 16, 2013

A wonderful project teaching ultrasound in Tanzania, organized by awe-inspiring 2nd year medical students from University of California at Irvine

I have just pretty much recovered from jet lag and my anti-malarial drug induced dysphoria (I will attest to the fact that Mefloquine does have side effects) and am excited to tell the story of a project that I got to be part of.

In mid-July I got on a plane and flew to Kilimanjaro airport in Tanzania with 7 medical students from UC Irvine. UC Irvine's medical school is small and encourages its students, after their first year of training, to do interesting projects in the summer, before returning to immerse themselves in massive absorption of data and passing of standardized tests. I met some of these students while doing my mini-bedside ultrasound fellowship, when I acted as preceptor to a group who staffs a regular rural health clinic in Mexico. A project to teach ultrasound in Tanzania was in the planning and not-quite-sure-if-it-would-happen stage, and I signed on, in a not-quite-sure-I-was-coming kind of way. 5 months later I got off of a plane with medical students, took a very large and unreliable bus west to the shores of Lake Victoria and dismounted in Mwanza.

Tanzania is a mostly politically stable East African country with the worst doctor to patient ratio in the world. It provides for basic medical care of children, old people, pregnant ladies and patients with HIV and tuberculosis. Medical care outside of cities is very sparse, and in cities down to the bare bones of adequacy. Or not quite. Into this setting we place 7 medical students keen to teach ultrasound and me.

UC Irvine is on the leading edge of medical schools in teaching all students basic bedside ultrasound, first as a sort of living anatomy class and then gradually adding in understanding of pathology and diagnosis. All medical students become adept at using an ultrasound machine to visualize the human body, from the eyes to the internal organs to muscles, joints and bones. An emergency room physician and well loved clinical teacher, Dr. Chris Fox,  has been a champion of this cause and it is now well established as part of the curriculum. There are other medical schools which do this, but perhaps not as well as UC Irvine. It was there that I did my ultrasound mini-fellowship at the beginning of this year which has made me basically competent in bedside ultrasound. Teaching medical students was part of the fellowship and so I met some of them who decided that they wanted to go to Tanzania to teach people what they had learned about ultrasound in their first year.

This was an ambitious project, bound to fail on some level, and yet it didn't. It also seems to me that it is an example of exactly what we should be doing in the developing world. Its goal was to teach a technology which was appropriate for its target audience and provide materials so that the teaching could be ongoing after we left. The tricky parts involved developing a curriculum that could be learned by people of unknown educational capacity who were primarily Swahili speakers. They did get most of their post primary education in English, but not the English that we Americans speak. We also needed to make sure that ultrasound machines would be available to the students after we left and we had to find the students and a setting in which to teach. Much of this ground work was done before I even joined the project. The students sent out e-mails to various contacts who had connection to medical education in Mwanza, the second largest city in Tanzania. Many were dead ends, but through a Nazarene preacher who had been a host to one of the students on a previous trip, we were introduced to a doctor and businessman who worked at several hospitals and also owned one. He had also, as part of an NGO, recently opened a medical school for clinical officers, like a physician's assistant training program.  In addition to providing access for the UCI medical students to observe medical care in the city, he also provided us with students and a place to teach them.

I came in handy on several levels. The first was that I had just recently bought an ultrasound machine from China, in order to see what Chinese technology, which is much cheaper than US technology, was like. I had thought that the machine should probably be donated to some place where it could serve patients, but since it was not FDA approved, that place was not going to be in the US. The students had been unable to convince anybody to donate a used US ultrasound machine for their project, so clearly my machine had found its home. The students had done a huge amount of work developing the curriculum, but the power point presentations needed adjustment to our students' level of understanding, and my clinical input was helpful, both in the content of the lectures and in learning better how to do and teach actual hands-on ultrasound skills. It also turned out to be nice to have an actual MD along to establish legitimacy.

The students gave 4 classes a week for 3 weeks, with two additional days for hands on practice and one day for examinations each week, a 7 day a week commitment. Each student learned and taught a specific subject area, determined what defined competence in that area and taught the other students to be teachers in the hands on part of each class. The classes started at 5:30 every evening and lasted 3 hours, with one hour of lecture followed by 2 hours of ultrasound practice. They expected to be teaching maybe 20 students, but ended up with about 140, which required having 2 sections to reduce crowding. UC Irvine and Dr. Fox allowed the students to bring 5 Sonosite Nano ultrasound machines with them, and with my Chinese machine, that made 6 learning stations. The remaining student and I acted either as models or floated to answer questions. Our students and friends also played model after some wheedling and cajoling.

Each UCI student giving a lecture first delivered the lecture to the rest, with each word examined and critiqued. They then spent the day of their first lecture polishing their slides and practicing speaking much more slowly and clearly. The results were beautiful lectures, at a level the students could understand which covered the most important points. They skillfully incorporated repetition and simple questions for the audience to make sure that at least a good number of the students understood the material. The same material was presented again during the practical sessions. With regard to our audience, there were excellent students and not so excellent students, but the majority of them became competent in the subject areas that they were taught. Some of our audience had MD and RN degrees and worked in the community. Most were students at the school for clinical officers. They all learned to ultrasound the heart, abdomen, lungs, pelvis, the shoulder and hand and learned the very basic physics of ultrasound. They learned to turn the machines on and off, change the transducers, adjust the various knobs to get the best pictures and to store patient information. They learned that the anatomy they saw in books was really, truly present inside real human bodies. They will never be afraid of ultrasound technology.

Our doctor host has bought ultrasound machines both for his classes and for a couple of the district health centers in Mwanza, which will be used by those of our students who practice in those centers and also by part time radiologists, if they are available. Although our brief course did not cover enough pathology to make the students capable of diagnosing diseases in all of their subtleties, the plan is to have a radiologist who works with our doctor host continue to teach. The ultrasound machines in the district health centers will primarily be used for basic obstetrics, identifying fetal hearts, measuring fetal heart rates, evaluating the position of the baby to identify high risk presentations. The MD students will improve at this with practice and will need to use local as well as online resources to develop competency.

In a year, barring mishap, we will go back and see what the project has unleashed, if anything. Our impression was that the Tanzanian students took to ultrasound like fish to water, and I suspect their abilities to use the technology to the advantage of their patients will progress faster than mine did. East Africa already uses ultrasound far more effectively than most of us do in the US, due to lack of other affordable technology, and it seems likely that our introductory class will feed into a knowledge base that is already becoming well established in that area of the world. One of the directions that I think we should go before returning to Tanzania is to find out where the centers of excellence are in East Africa so that our piece can be incorporated into care improvements that will develop organically.

A question that arises in connection with this project and also with the increasing use of ultrasound at the bedside in the US, by non-radiologists, falls in the category of "is a little knowledge a dangerous thing?" Radiology technicians spend thousands of hours learning how to image the human body, and radiologists then interpret the images that the technicians record. Radiologists are MDs, with 4 years of medical school and often a rotating internship year prior to spending years in dark rooms peering at images of human anatomy in health and disease while being mentored by teaching radiologists in their residency programs. Cardiologists read echocardiograms obtained by echo technicians and look at these images with eyes that are informed by years of familiarity with the human heart. The three dimensional knowledge of anatomy that my colleagues the radiologists and radiology technicians have is truly inspiring. They are able to see things in images that I can't and interpret them in the light of years of experience. Still, when I can see inside a person with an ultrasound as part of my examination, that is extremely powerful, and improves my ability to make a diagnosis and to choose which official imaging tests will be most useful. In Tanzania, the medical students, with only one year of training, were able to help the Tanzanian doctors identify a pregnant woman whose baby was in distress and a few women who, at term, had babies in the breach position, which were not identified on physical exam. These women did not have the advantage of a fully trained radiologist to evaluate their pregnancies, and the limited information we were able to give them was profoundly helpful. In the US and Europe there is active research about how bedside ultrasound can be useful. A few studies have shown that it can diagnose small bowel obstruction when used by resident physicians in emergency medicine, with a few hours of training. Despite the difference in backgrounds, radiology residents were no better at it than ER residents. Medical students with handheld ultrasounds were significantly better at making cardiac diagnoses than cardiologists with stethoscopes, in one study at the Cedars-Sinai School of medicine. Ultrasound is much more sensitive for pneumothorax than x-ray, which is the present standard of care, and requires very little training to perform accurately. There are lots of other examples.

My experience has been that it is very possible to miss important diagnoses with ultrasound as a beginner and to over-interpret findings, and that learning to be more accurate is a constant part of the process of using it as a tool. I think the little knowledge that the Tanzanian students got as part of our course will probably be very helpful, and more so if their training with ultrasound is ongoing and supervised by a radiologist at their school. Ultrasound is a natural extension of the physical exam in this setting and can cost nothing after the purchase of a machine. As more medical professionals become comfortable with the technology, they will be likely to use an ultrasound for answers to clinical questions, just as they might pick up an otoscope to look in an ear, or a pair of glasses to more accurately see a skin lesion. This will never replace the skill of an official radiologist, but in most of Tanzania these are few and far between.

Friday, July 12, 2013

The State of our Health 1990-2010, the very brief version

I was interested to read the recent article in the Journal of the American Medical Association entitled The State of US Health 1990-2010, the Burden of Diseases, Injuries and Risk Factors. It is a vast compilation of data from various surveys and data banks using the methods of the Global Burden of Diseases, which has been performed for 50 countries, allowing comparison on a variety of measures. The article is a clear presentation of that data, and I won't repeat that, at least not much.

In the last 10 years the US has had a significant improvement in life expectancy, from 75.2 to 78.2 years. This is a good thing. Other countries, though, had more significant improvements, so we dropped in ranking among these countries from 20th to 27th, behind Chile and just ahead of Poland. We also spend much more money on health care than they do. We are the very top country in terms of percentage of gross domestic product spent on health care, at over 16%, and Chile spends about half that.

The years of life we spend with disability is actually about stable, at about 10.5 years, and we rank only 6th on that metric, which surprised me. I see so many patients treated with life sustaining hi-technology interventions toward the end of life that I thought this would mean that the US would have a higher proportion of walking wounded than the rest of the world, but that isn't true. At least not as it is measured in this study. We have moved down a point from 1990, at which time we were in 5th place.

We die mostly of heart attacks. Our health is significantly worse because of increasing obesity, diabetes and inactivity since 1990, which increase heart attacks. These are things we could change without spending more on health care. It is interesting that we have figured out how to live longer even though we are less active and fatter. Medical science is full of miracles.

Tuesday, July 9, 2013

Medical Care in Tanzania--How does this East African republic take care of its people?

I just got back from Tanzania, where I supervised 7 medical students who were doing a couple of really awesome ultrasound projects in Mwanza, the second largest city in this East African country. I will write about the projects in a different blog. Mwanza is right on the shores of Lake Victoria, a huge but relatively shallow body of water which Tanzania shares with Kenya and Uganda. Tanzanians are friendly, and the weather in Mwanza was perfect. We were at the tail end of the rainy season, but saw almost no rain, and the temperature was perfect, in the mid 80s during the day and cooling off at night. Because of the lake, there are huge numbers of birds, egrets, cormorants, storks, kingfishers, brightly colored starlings, and lots of frogs who became vocal at night. Tourists do not come to Mwanza, probably because there are more jaw-droppingly amazing places nearby, including Mt. Kilimanjaro, the island of Zanzibar and the Serengeti. People speak English and Swahili, but mostly Swahili, which makes getting along a little complex. We had wonderful hosts who helped with the language issues, and we all picked up a working knowledge of Swahili, mainly stuff like "hello" and "thank you" and "your liver is fine."

Our projects involved visiting several hospitals in Mwanza and talking to many healthcare professionals. I was able to go on ward rounds with some of the doctors we met and wandered around one afternoon in the very large public hospital, Bugando Medical Center, which has a medical school and is loosely affiliated with Cornell. There were many hospitals, of varying sizes and capabilities. There were district health centers which were publicly funded and provided care to outpatients and had wards for patients who were too sick to return home.  There were dispensaries, which despite their title, did not just act as pharmacies, but also offered clinic services such as doctor appointments, birth control, prenatal care and HIV monitoring. There were also private hospitals which were a little less crowded than the public ones, a little more cushy and required that the patient pay for their own care completely, except in rare cases such as having health insurance (usually only government employees) or having any of the conditions which the government pays for in full. Doctor visits were both by appointment and drop-in, and there was 24 hour availability of doctor care, though doctors were pretty scarce on nights and weekends. The big hospital, Bugando, had a cafeteria and would serve food to the patients, but that was a rarity, and generally families were expected to bring the patient food and drinks.

In the private hospital the rooms were semi-private, 2 beds to a room, 1 person per bed, with a mosquito net. In the public hospitals the wards were open, with 10 or more beds per room, and no curtains between patients. Some had mosquito nets, some didn't.  Usual necessities in US hospitals, things like blood pressure cuffs, oxygen and suction, which are attached to the wall, were absent. Most facilities had the ability to do a chest x-ray, some could do an ultrasound, but usually just for female problems and obstetrics. There were very few CT scanners and no MRI in the city. Basic surgery was available, but more complex issues had to go to the largest city in Tanzania, Dar Es Salaam, which was over an hour away by airplane and 10 hours away by car or bus. The nicest hospital room I saw was a cement floored 2 bed room that was about 200 square feet with a window, a door, mosquito net, bedside table, sheets and an ancient plastic covered pillow.  It wasn't dirty, but neither was it scrupulously clean. There was no electrical outlet or fan, though the temperature was comfortable.

The physicians I saw interact with patients were mostly polite, but clearly didn't spend much time either in examining the patients or taking a history, and it was rare to find any evidence that full vital signs were taken after the patient was admitted, though abnormal ones, such as blood pressure and temperature, were repeated at least daily. Almost everyone got a blood smear for malaria, a urine test, a stool examination for worms and sometimes an antibody screen for typhoid, which was often false positive. Chemistry testing was only rarely done, and not always available, and blood counts were available but not often used. HIV testing was available, and most hospitals had the ability to test CD4 counts to evaluate patients with known HIV.

Prenatal care is available to patients free of charge, as is birth control. Patients are tested for HIV when they first present for prenatal care and receive peripartum prophylaxis to prevent vertical transmission. Vaccination for measles, mumps, rubella, polio, BCG for tuberculosis, hepatitis B, diptheria, pertussis and tetanus are all available and encouraged. There were always lines of mothers with babies at the health centers we visited, there for vaccination. There is no cost to the patient for care for children under 5, pregnant women, patients over the age of 60 and patients with HIV/AIDS or tuberculosis. Women are required to receive prenatal care and deliver their babies at hospitals, though this is far from universal in practice. Since there is very little access to blood tests or ultrasound, it appears that the primary purpose of prenatal care is to identify patients who are clearly at high risk of birth complications and to treat and prevent the spread of HIV.

Sick patients who presented to a hospital would not be denied care, even if they had no money to pay for it, though if they arrived less than dangerously ill, they would be expected to pay for care if they did not fall into a group for whom care was free. Often, regardless of symptoms, patients were treated for one of the top ten diagnoses, based on the few lab tests that were done, and sometimes were treated based on the most common diagnosis associated with their primary complaint, without confirming lab tests, imaging or examination findings. The top ten diagnoses were malaria, typhoid, ascariasis, urinary tract infection, sickle cell disease, pneumonia, pelvic inflammatory disease, HIV, infectious diarrhea and diabetes. I also saw patients who had been identified with hypertension and renal failure (one 90 year old patient), cirrhosis and hepatoma (a young woman who probably had congenital hepatitis B), measles (an unvaccinated baby) and severe iron deficiency anemia. It is interesting that in the fast food stalls they sell little sticks of clay for pregnant ladies to eat. Eating clay (and laundry starch and dirt) is called pica, and is strongly associated with iron deficiency in pregnancy. I do wonder if there may be a significant under recognized prevalence of iron deficiency in pregnancy.

Malaria appeared to be the most common diagnosis in the patients who were hospitalized, and also was a pretty common diagnosis in the outpatients. A thick blood smear was examined in most of the patients who presented with any one of a number of vague complaints, including headache, weakness and low grade fevers. If parasites were seen, they were treated with appropriate medications, but many people in Tanzania harbor malaria parasites and are not sick with malaria and probably don't require treatment. I'm not sure if the inpatients getting their intravenous quinine actually were suffering from malaria, though I'm sure at least some of them were.

IV fluids are generally available as are appropriate drugs for HIV, malaria and serious infections. There is very little choice in medications for hypertension and even a patient with lethargy due to extremely high blood sugars did not warrant an insulin drip since there was no accurate way to deliver it. I saw one older woman whose blood pressure was 250/120 who had run out of her medications because they weren't available at the health center due to government shortages. She was sent to a pharmacy with a prescription which she may or may not have been able to afford to fill. HIV medications and some of the expenses for the health care centers which provide both the meds and HIV testing are funded by the United States Agency for International development (USAID.) This organization also helps fund maternal and child health and tuberculosis treatment, which has improved numbers like prevalence of HIV and death rates. USAID also is involved in promoting use of condoms for prevention of HIV, which is unfortunately not terribly effective in Tanzania. Birth control with pills or the intrauterine device (IUD) are enthusiastically accepted, but in the clinics I visited I heard that condoms were not very popular, and outside of clinics were rather expensive.There has been a huge increase in the number of people being tested for HIV, which may decrease spread of the disease, and treatment will also reduce transmission.

Tanzania has the lowest ratio of doctors to patients in the world, which may be due to a large refugee population since it is one of the most stable countries politically in East Africa. In Tanzania a person can be called doctor if he or she has completed any of 3 different medical education programs. After 3 years of medical education, after the equivalent of high school graduation, a person can become a clinical officer and can provide medical care in a clinic with some supervision. After 3 more years that person can become an assistant medical officer, with more autonomy. The MD program is a full 5 years, and includes an internship year. If a person starts with a clinical officer degree, he or she can work as a doctor while finishing an MD degree. The education being offered to clinical officers appeared to me to be pretty rigorous, including anatomy and physiology as well as practical skills that would be part of the work of a hospital nurse in the US. My Pocket World in Figures put out by the Economist magazine says that Tanzania has 145,667 patients for each doctor, but it is unclear if they include clinical officers and assistant medical officers in this count. It has a prevalence of HIV/AIDS of 5.6% in people between the ages of 15 and 49, 12th in the world, but far better than Botswana in which 25% of this population is infected. There is very little smoking and drug abuse is uncommon, though there are alcoholics. There is no concept of drug treatment programs or even mental health care. Pain is treated only with acetaminophen or oral or parenteral nonsteroidal anti-inflammatory drugs. There are no opiate pain medications in the hospitals I visited, even though physicians recognize that these would be merciful in many circumstances.

I am very impressed by the level of basic medical care provided in Tanzania, and people do have a kind of safety net should they become very ill or injured. Many of the big-ticket, costly items of medical care are heavily subsidized by the US which pretty much bypasses the government, assuring ongoing care of high risk individuals even when government budgets get tight. Still, Americans would definitely rank their own health care system far above Tanzania's. Availability of technology such as imaging and blood tests is vital to making correct diagnoses, given the huge variety of treatments we have to offer in the US, and we have come to expect at least some level of a doctor/patient partnership in making decisions about our health care. Americans expect basic comforts, including appropriate and individualized diets as well as clean and comfortable beds and rooms, which are not at all basic in Africa.