There is a severe health care workforce shortage in Africa. The solution is not to build a western-style system, rather we need to leverage new technologies and low-cost alternatives to build an African-style medical education system that will help train and retain providers and bridge gaps in access to care.
The first is to invest in tele-education given the scant resources. There are many tele-education programs in the West and there is even a trend to expand these services to developing countries. Having been a part of such a program where US health professionas teach remotely I would suggest that these models are not ideal. The best model of tele-education would be one that is based in the host country itself. Fore example, a tele-education program for East Africa could be based in Nairobi, building local capacity to teach to more remote areas of Africa. While daunting to set up, this would help build even supporting infrastructure such as IT support.
The second solution is to train more paraprofessionals. A recent McKinsey report nicely summarizes the benefits of such a model. This will minimize the brain drain, provide more providers in less time and cost less. The model of the community health volunteer has worked in so many countries – this model needs to be scaled up so that they can refer to mid-level providers who ultimately refer to secondary and tertiary centers that are staffed by physicians. These paraprofessionals would complement not replace much needed physicians and nurses.
Lastly, medical education in developing countries needs to capitalize on mHealth. In the next few years over 90% of Africa will have a cell phone. It makes perfect sense to use this technology to bridge gaps in access and knowledge. For example, geographically isolated providers could complete modules on their cell phone on topics that are relevant to their patient population e.g. HIV, TB, NTDs.
While I’m sure the solution to the health care workforce shortage is much more complicated, I do feel these three areas are worth prioritizing and funding in these areas should be scaled up.
Categories: Africa · East Africa · Medical Education · eHealth
The McKinsey Quarterly Report suggests that Africa is on the rise and in particular, Sub-Saharan Africa is a land of economic promise. The region is weathering the global downturn better than Latin America, Europe and Central Asia. The article suggests this is largely due to macroeconomic and political stability, in particular private investment into infrastructure and education. Average years of schooling are catching up to developed countries which means this growth has hopes of being sustained by an educated and progressive younger generation. Natural resources and renewable resources will be some of Africa’s most valuable assets as it is positioned well to develop solar and hydro energ.
Of particular interest to me, given my interest in eHealth is the fact that Africa’s mobile market has grown to 400 million and that 65% of the population lives within reach of a mobile phone network. I had previously heard at Med-e-Tel that by 2013 98% of the world would have a mobile phone so this number did not surprise me. The article makes an important point that despite the increased and impressive access to wireless technology, other sectors have been slow to capitalize on this access for development.
For so long we only heard of Africa in the context of civil unrest or corruption in the government. By allowing private investment, Africa is changing its reputation and prognosis, it’s exciting to hear African countries being referred to as ‘emerging markets’.
Categories: Uncategorized
I recently read an article in the New York Times about the prospects of telemedicine in the US…the future looks great now that reimbursement is picking up. Clearly the motivation behind using technology here is to see more patients and earn more money.
The driving force behind telemedicine in developing countries will be different. Not that money isn’t important because there’s no place on earth that can’t benefit from more money. The use of technology and telemedicine in resource poor setting could save the lives of pregnant women without access to adequate care, provide professional support to geographically isolated health care professionals and nurture academic environments by generating dialogue among professionals in who would otherwise not have an opportunity to discuss interesting cases.
It’s much easier to advocate for investing in a telemedicine program when you can demonstrate a robust financial return on investment. It’s much more challenging to inspire investment in educational or professional support.
Those of us interested in eHealth or telemedicine, particularly in it’s application in developing countries, need to think about how to either monetize the benefits, or find objective measures to prove their worth.
Categories: eHealth · telemedicine
I’m hoping to start a Global Health Track (GHT) in our internal medicine residency program. While many of our residents are currently doing international rotations -these are arranged by individuals and don’t incorporate any formal global health teaching. That said, we have seen year after year that there is interest from both current and prospective residents to have more global health training. With an increasing need to steer medical students towards more general practice in medicine, I think the time is right to encourage global health teaching in GME programs. Studies have even shown that international experiences do influence career choices in public health, community health and/or primary care.
I envision our global health track to incorporate some coursework in global health done longitudinally over the latter two years of training. In addition residents would complete an international rotation (considered their field work). Prior to their trip, they would complete a ‘country assessment’ which would require them to learn about the health care context of their destination and learn how to access this information on the web. Residents would be required to complete a scholarly project over the two years, something that incorporates their field work experience. The final product of their scholarly project might be a paper or a presentation. Residents would be assigned a faculty mentor from within the Dept of Internal Medicine – someone who is already active in global health and who could provide guidance on their project, help in preparing for the international experience and most importantly career guidance.
As I have spent much of the last few weeks exploring different models of global health tracks in other residency programs, it has become clear that one of the critical pieces of this program will be funding. Residents should get financial support for their international experience. Without funding, it would be difficult to envision the sustainability of such a program as only those who could ‘afford’ to go abroad would sign up.
One of the programs I found particularly inspiring was the one at University of Pittsburg – the structure is similar to what I envision and the curriculum provides a good balanced approach to global health.
As I look for options for coursework in global health, one obvious resource is our School of Public Health but another option is online material. To this end, I found a document entitled “Developing Residency Training in Global Health” published by GHEC to be very helpful.
My goal is to have this track, or at least a more formal experience in global health, established for the next academic year.
Categories: Uncategorized
February 5, 2010 · 1 Comment
I went to a seminar at the Woodrow Wilson Center last week on Eritrea’s external relations. As well, I’m reading a book called “I didn’t do it for you” which talks about the history and events that have shaped Eritrea. It is indeed a fascinating country. I have not yet been there but the more I read, the more I am intrigued by the impact that the country’s history has had on the psyche of the people. While other countries have statues of people whom they revere, Eritrea has a giant sandal in the middle of the capital Asmara which represents their victory over Ethiopia, which they won in sandals. The country’s leader President Isais is intent on building a self-sustaining country which is why he is not afraid to make enemies or rather why he’s not concerned with building allies. The fact that the UN has imposed sanctions is likely not a source of stress for the President, rather the political isolation allows him the independence he desires.
I worry about the people of Eritrea who may suffer hardship by the lack of international support especially for economic development. One point that was made during this session was the need to ‘engage’ with President Isais. This was one aspect of Obama’s foreign policy that I found particularly encouraging and unfortunately find myself disappointed by the lack of it. That said, I can appreciate that Eritrea probably doesn’t make the top of any list of foreign policy priorities…but using sanctions as a means of punishing the country is just not going to accomplish anything good.
After World War II, Eritrea fought Ethiopia for 30 years and despite being one tenth the size, they eventually won. They spent a few years enjoying that victory and once again another war broke out with Ethiopia over the border. The small population of Eritrea has sacrificed an unnatural proportion of their men and women to these wars and as a result, the Eritrean people carry a lot of luggage in their national culture and identity.
My other work in East Africa has focused on Kenya and Tanzania – countries I have ties to since my parents were born there. I thought Eritrea would be a natural extension of my other East Africa work but the more I learn about this small, but unique country in the horn of Africa, the more I realize this is likely to be a unique, educational and challenging experience. Since most of the world is looking away from Eritrea, it leaves me with the feeling that our project to start a residency program in internal medicine may actually have a significant impact on the plight of the nation.
Categories: Africa · Eritrea
Given that HIV, Malaria and TB are the three infectious diseases we need to tackle most, here are a couple of interesting finds:
Daktari is a company that makes an interesting gadget that would provide better access to CD4 counts using a handheld device that’s simple to use. The CD4 count helps decide when a patient should be started on antivirals and subsequently helps determine if the treatment is working – hence, a hand-held device to provide this number would be enormously helpful in the trenches.
Another company just got funding for to work on similar diagnostics for malaria and bovine TB – point-of-care diagnosis for both of these conditions would lead to better outcomes in treatment and with TB would be critical in reducing the spread…hopefully the bovine testing will translate to humans!
I’m sure there are many other potential point-of-care solutions. Their impact on global health issues is obviously huge…an interesting trend to follow.
Categories: eHealth
For a small country, Eritrea has recently been getting a lot of attention in the news – issues surrounding the quality of life of it’s citizens, UN sanctions and the disappearance of it’s national soccer team in Kenya. On a much more optimistic note, despite it’s reluctant to work with external partners, the government has now been working for years with George Washington University (GWU) and Physicians for Peace (PFP) to address the severe physician shortage in the country. This month, the Orotta School of Medicine graduate it’s first class of 31 physicians and 8 pediatricians. A result of a collaboration between Physicians or Peace and the George Washington University, the medical school and three residency programs have been established over the last three years to address the severe physician shortage. Plans are now underway to start an internal medicine program – a challenging and very exciting undertaking that I am leading at GWU. As I embark on this journey to learn about this country in East Africa I am reminded of the similarities in the region, yet the unique culture, history and challenges of each individual country.
Some background on the country, Eritrea is only slightly larger than Pennsylvania, on the east coast of Africa between Djibouti and Sudan. Having separated from Ethiopia in 1997, it is a small country with a population of just over 5.5 million, 97% of whom are under the age of 65 years (the median age is 18years and life expectancy is just over 61 years). 20% of the population lives in urban areas (the capital of which is Asmara), therefore, the majority live in rural areas. The fertility rate is 4.7 which is high for western standards but puts it behind many other sub-Saharan African countries. Interestingly, the rate of HIV infection is just over 1% (much lower than other parts of eastern and southern Africa). That said, they are at risk of other infectious diseases such as the Neglected Tropical Diseases, Hepatitis, Malaria and Typhoid Fever.
Currently, there is only one political party – The People’s Front for Democracy and Justice. The economy of Eritrea is largely based on subsistence farming with 80% of the population involved in farming and herding. A May 2000 offensive by Ethiopia affected a large portion of land and homes in Eritrea and the government has since been trying to stabilize the economy and make improvements to infrastructure. Unemployment, illiteracy and low skills are challenges that need to be addressed for Eritrea to make economic strides.
With the news of UN sanctions on Eritrea being approved, and given the backdrop of the political and economic challenges within the country, the collaboration between GW, PFP and Eritrea provide a ray of hope for at least better access to care, better health and utlimately a better life.
Categories: Africa · East Africa · Medical Education · Neglected Tropical Diseases · Uncategorized
There are new guidelines published by the USPSTF to start screening women (at average risk) for breast cancer at the age of 50 (not 40 as is currently done). If we were to establish a set of screening guidelines for developing countries would we start at age 40 because the disease appears to be aggressive in this context or would we use data on cost effectiveness from the developed world and create a more conservative program that started screening at age 50?
The Lancet recently published an editorial on Breast Cancer in Developing Countries which describes the increasing burden of this disease on people in resource-poor settings. The article states that currently only 5% of global spending on cancer is aimed at developing countries. This is worrisome given that “an estimated 1·7 million women will be diagnosed with breast cancer in 2020—a 26% increase from current levels—mostly in the developing world.” Yet the article explains that the WHO Commission has determined that most current strategies for breast cancer treatment and prevention in the developed world are not cost effective in the developing world.
In contrast, an article by the Breast Health Global Initiative states that “breast cancer outcomes in low- and middle-income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion.
There is clearly a major challenge that lies ahead – we have a growing problem in resource-poor setting and we won’t be able to export our solutions from the developed world to solve these issues. We will need to dig deep by chanelling research dollars to understand the nature of the disease in this context and develop a customized set of guidelines for the developing world.
Categories: Breast Cancer · Evidence-based public health · Uncategorized
A recent article in the Lancet claimed that global mental health needs attention. It’s not hard to imagine - if 40% of the world lives in extreme poverty on less than $2 per day, with limited access to basic health services, mental illness then sits at the bottom of the stack of future priorities. As this article states, “the lives of individuals with mental illness exist under the worst of moral conditions.” The author, who has been involved in global mental health for four decades describes depressing scenarios …”appalling, dreadful, inhumane – the worst of words pile on each other to name the horror of being shunned, isolated and deprived of the most basic human rights…hidden by families, stoned by neighborhood children, treated without dignity, respect or protection by medical personnel.”
One of the major issues in dealing with mental health (in any part of the world) is the stigma associated with most psychiatric disorders. In fact, mental health professionals and family members often promote these stigmas making it even more difficult to break the cycle. Addressing the issue of global mental health, the article argues, will require a moral transformation – giving social legitimacy to people suffering from a mental illness.
The article goes on to claim the state’s responsibility for protection of its citizens (under international law) which arguably should protect against this human tragedy.
Regardless of who we want to blame, addressing this global and tragic situation will require both civil and state response. Those of us who are physicians, nurses or global health experts should advocate to bring more attention to mental health issues.
For example, we can advocate for a more robust, creative and effective curriculum to train health professionals. In my medical training, I remember finding it particularly boring, tedious and difficult to memorize the DSM IV criteria for the many psychiatric condition that ultimately I could barely tell apart. In fact, I have subsequently found that the most effective way to teach the real impact of psychiatric disease is through narrative medicine – poetry, stories, or movies – that depict the mentally ill and bring the human spirit into the experience of these diseases.
We don’t need to tolerate the apparent apathy toward global mental health. For those unfortunate enough to live in poverty with a mental disorder, we can give them a voice by advocating to improve their moral conditions. Improving medical education is just one small step we can take towards improving the global mental health crisis.
Categories: Mental Health · Uncategorized
October 24, 2009 · 1 Comment
The Lancet recently reported that South Africa has established the Traditional Health Practitioners Act which provides registration and training of traditional practitioners and serves to protect the interest of those who use the services. While traditional medicine is still unregulated, this is a step in the right direction toward building a bridge between allopathic medicine and traditional healing.
According to this article, in South Africa, patients often seek care from both systems assigning the task of diagnosing and treating the pathology to the doctor while relying on the traditional healers to establish what is wrong with the mind-body connection.
In fact, collaboration between the two systems could potentially lead to better outcomes than either one alone. One example is the use of traditional practitioners as supervisors for TB treatment programs. In one study, conducted in South Africa, over 3000 patients were registered and assigned to either DOT (Directly Observed Treatment) program supervisors or traditional practitioners and there was no difference in results – indicating a potential role for traditional healers in ambulatory DOT programs.
Especially in developing countries, where access to physicians and providers of allopathic medicine may be geographically or financially beyond reach, traditional healers are more frequently sought and more often trusted. It is exactly for this reason that steps to standardize the training, licensing and therapies of this parallel system would go a long way towards improving the quality of care and health outcomes in developing countries.
Categories: Africa · Traditional Healers · Uncategorized
