global health

Things I don’t believe in #18 – Bringing people to the US for medical treatment

By Alanna Shaikh | | 0 Comments |

I know it’s heartbreaking when you see children on the news with cancer or serious injuries that can’t be treated at home. I have a two-year-old and if, god forbid, he ever got seriously ill, I guarantee I would take him anywhere it took to save him. I have profound empathy with the families of sick kids. But sending one child to the US for care uses resources that could help an awful lot of kids in-country. It is the job of a parent to care for their own child first and foremost. It is the job of donors, governments, and NGOs to care for as many children as possible with the funding available. In my opinion, it is not an ethical use of limited resources to transport one child for health care.

When you bring a child to the US, you need to bring at least one relative as well, to look after the child in a strange place. If the relative is a parent, siblings at home will probably suffer emotionally and economically in their absence. If the relative is not a parent, they may have trouble making difficult decision about the child’s care. Assuming your medical care is donated, you still need to pay for their plane flights, housing, and food. For a long period, since they will need to stay in the US for all necessary follow-up appointments. The child and relative will need translators so they can talk to doctors. They’ll need a lot of help with informed consent to risky procedures. Often, at the end of it all, neither the child nor the relative want to go home. There is generally no way for them to stay.

Assume the medical treatment is successful, assume everyone goes home happy. What happens to the next kid with the same problem? If she’s lucky, the same effort that was generated for the last child. Expensive transport, a long time away from home and family, frightening and unfamiliar doctors who don’t speak her language. If she’s not so lucky, nothing. The next child with the same problem probably won’t get as much media attention because it’s not a novelty. There will be donor fatigue – finding donated care will be harder. Probably she is stuck in her home country with medical care she may or may not survive.

How do we do it better? It’s not very realistic to argue that you should just ignore seriously ill children and spend the money on public health interventions. No human can do that. On a practical basis, you probably have people willing to donate money for that one compelling child. You can’t just take that cash and save fifty children from malaria or helminths. But you can fly in a team of specialists or oncologists. You can most likely talk them into donating their time for the chance to help someone in a faraway location.

Team up your foreign doctors with local specialists. They can train the local physicians in how to treat the illness or perform the necessary surgery. They can train local doctors in how to provide the follow-up care. You may have to bring the sick child to the capital where facilities are available, but he is still in his own culture, speaking his own language. His relatives can alternate who stays with him so his siblings are not neglected. You’ll need translators for the foreign doctors, food and housing, but that’s still a lot less than sending people the other way. Yes, there are lots of complications; you may need to purchase, or find, donated equipment and drugs.

But now consider the next kid. She’s received a scary and terrible diagnosis, which requires sophisticated treatment. She travels no further than her own capital for care. She is treated by doctors who’ve been trained by American specialists, and her doctors can contact those American colleagues if they have questions. She can go home right after her treatment, and come back as needed for follow-up visits.

Things I believe in #1 – Positive Deviance

By Alanna Shaikh | | 10 Comments |

In every village, there is at least one woman (usually a few) whose children are healthier than the rest. For whatever reason, that woman is better at navigating the complexities of village life and child nutrition. That woman has knowledge and skills which can be taught. You find her, you learn from her, you support her to teach her peers. That is positive deviance. Find the people who deviate from the norm by being more successful. Learn from them.

The original positive deviance programs were nutrition programs, with a specific structure and methodology. These are some nice examples. Positive Deviance remains one of the most powerful tools we have for improving nutrition in the developing world. You can also, however, use the ideas behind positive deviance for more than just nutrition.

Every systems has its positive deviants. People who are better at surviving within it. You don’t need a bunch of outsiders to or foreign experts to find ways to improve your system. Most of the knowledge you need is already there. It’s a profound and powerful idea. It means you improve education by learning from the teachers and principals of high-performing schools. It means you make childbirth safer by talking to maternity nurses and ob/gyns. It means you value the knowledge and experience of the people in the developing world.

When you want to make things better, look inside first. Learn from the people who know it best. After that, bring in your outside experts. See of they have anything add. But most of what you need to know is already there.

Reader Question #2

By Alanna Shaikh | | 0 Comments |

So, my reader questions are nothing like I expected them to be. Which probably makes them more fun to answer. This question has to do with sexual identity, so skip it if it’s not something you are comfortable reading about.

Q: Why did we begin using the term MSM? I thought it was because not all men who have sex with men consider themselves to be homosexual or bisexual. I thought there was a trend of allowing individuals to determine his/her own sexual identity.

I have had an argument with 3 friends, 2 liberal, about this exact conversation. In my head, a man having sex with men does not make him homosexual or bisexual. In the head of my friends, it does. Am I crazy? Am I being overly sensitive and picky about the wording that we use? Is this not a personal descriptor that can only be determined by the individual? Does it actual “make” someone gay? Is this just something that I should get over because it is never going to change? I am not ready to say I am wrong. One friend threw wikipedia and the oxford dictionary out.

A: I think you are exactly right. There are a whole host of emotional and cultural reasons a man might have sex with another man and yet not be homosexual or bisexual. I think we use the term MSM because sexual identity is so fluid and complex that it’s a lot more useful to just describe the situation than to try to apply a label that serves no diagnostic or risk-management purpose. As health professionals, it is useful to know if a man has sex with other men; his reasons for doing so are a lot less important in any immediate calculation.

There are plenty of reasons a man himself might want a more specific label for his sexuality, but that’s not our business. We just want to provide the best services possible.

Physician training has very little impact

By Alanna Shaikh | | 0 Comments |

Jishnu Das writes about research on physician training in low-resource countries. His disheartening conclusion is that the training has very little impact on improving quality of care.

The research was as follows:

Our approach has been to try and decompose the quality of medical advice into two components—what doctors know and what doctors do. What doctors know—measured by testing doctors—represents the maximum care that a doctor could provide. What doctors do—measured by watching doctors—represents the care they actually provide to real patients. We call the first “competence” and the second “practice quality”.

And the depressing conclusion:

In Tanzania we find that two additional years of school and three additional years of medical school buys an increase of only 1 point in the percentage of essential tasks completed. Results are similar for other countries.

Training doctors has been a standard way to improve the quality of health care for years. It’s a major shock to discover this minimal impact. I wonder if the quality of training make a difference? Perhaps competency based training would make a difference.

While this is depressing research, it’s not necessarily telling us things we didn’t already know. If you want to change a physician’s behavior, you don’t just give her training. You change the system she is part of. Good projects health projects recognize that, and so do American HMOs.

Lesson: Don’t try to change individuals, try to change the system they are part of.

Health care quality is extremely difficult to teach and maintain

By Alanna Shaikh | | 0 Comments |

Nearly 40,000 Endoscopy Center of Southern Nevada Patients Asked Hepatitis C Testing. What struck me about this story is how much it sounds like something you’d expect in the developing world. The clinic in question was reusing single-use medical supplies. In the developing world, of course, the reason is usually resource scarcity and not pure greed.

Either way, the fact that this happened in Nevada is reminded that even sophisticated licensing systems have flaws and fail sometimes. Medical care needs to have a constant focus on making quality better or it actually gets worse.

Mental health in the rest of the world

By Alanna Shaikh | | 0 Comments |

Psychotherapy for All: An Experiment – New York Times. The NYT looks at an Indian experiment in providing mental health treatment at Indian clinics. A lot of people believe that illnesses such as depression and anxiety are first-world luxuries. Anyone who’s spent time abroad can tell you that’s not the case.

This is interesting to me because while donors and NGOs are starting to pay some attention to mental health in emergency situations, it’s still very rare to look at mental health in ordinary life. Like dental care, it tends to be low priority. This Indian intervention may mean that is changing.