On Deconstructing the Discourse

March 9, 2007 at 9:54 am (AE Beacon's Posts)

“Can one divide human reality, as indeed human reality seems to be genuinely divided, into clearly different cultures, histories, traditions, societies, even races, and survive the consequences humanely? … For such divisions are generalities whose use historically and actually have been to press the importance of the distinction between some men and some other men, usually towards not especially admirable ends.”

-Edward Said in Orientalism  

 

The central mission of Global and International Health is to improve health conditions for people facing the highest burden of disease and suffering. This lot typically falls to those living in Africa, Asia and South America. However, is the discourse of this benevolent mission categorically reinforcing the social order it seeks to alleviate?

What is the utility of the phrase “developing country”? The original conception of developing versus developed countries was created as an economic method of stratifying nations by economic output. Despite having limited correlations to health status, this terminology has been subsequently adopted by health workers to define areas of supposed greater disease burden and suffering.

This transliteration fails to achieve several of its objectives. First, lumping countries into developing or developed ignores the spectrum of need between nations. Second, nation based classifications of health fail to accurately represent the internal needs of political groups such as immigrants or internally displaced persons and social groups such as religious and ethnic factions or women and children. Finally, some developing countries such as Cuba, despite having the resources and political structure that would otherwise suggest poor health, have managed to produce impressive health outcomes. Thus, the concept of developing country does not accurately evaluate how well a region or nation can deal with its health issues.

The segregation of developing and developed nations does succeed in accomplishing several things. First, it insists on the immaturity of developing countries. Inherent to this distinction is the idea that developed countries have achieved a universally attainable state of happiness and prosperity, a socio political nirvana if you will, through integrity, hard work and ingenuity. Implicitly, that developing countries have failed to reach this standard reflects more on their inadequacy than on divisive social and economic structures that keep them in poverty and disarray.

Second, this construct asserts that the methodologies of my society, capitalism and cultural exportation, are requisites of domestic success.  Despite the considerably dependence of my economy on cheap goods from elsewhere, we have maintained an equal opportunity rhetoric that doesn’t suffice to describe our domestic state let alone global economic and political involvement. Finally, the concept of “developing” demeans the intelligence, talent and efforts of (health) professionals abroad. Stripped of the comprehensive diagnostic testing equipment, auxiliary support staff and myriad pharmacological interventions would our physicians be more capable? I won’t posit an answer but only suggest that poor outcomes reflect more than the physician’s capability.

So what can we change? How can we (I) more accurately delineate differences in health outcomes without disparaging those in need?

Æ Beacon

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On Mandating Immunity

February 9, 2007 at 11:40 am (AE Beacon's Posts)

The HPV vaccine. To me this ranks along with recent developments in stem cell technology as one of the most significant medical breakthroughs of our generation. A vaccine that prevents the second leading cause of cancer in women, unbelievable. However, despite the proven life saving ability of this vaccine, I’ve still encountered quite a few people who are ambivalent about its use.

One of the chief arguments against the HPV vaccine is that it will encourage premarital or unprotected sex. First, 90% of people in the
United States engage in premarital sex, 90%. I sincerely doubt that a vaccine could in any way increase that number. Second, quite frankly I doubt that most people think about their risk of getting HPV first or even tenth when they decide to have unprotected sex (or following the decision). From AIDS to unwanted pregnancy to herpes and gonorrhea, there are a plethora of other things that come more immediately to mind (in my male biased opinion). Obviously this is unfortunate since HPV, aside from the strains that do have acute symptoms like genital warts, is one of the STIs that can kill you. Additionally, given HPV’s prevalence at upwards of 70%, it’s pretty likely that your partner will have one of the 100 strains (hopefully an innocuous version). Either way, the risks of HPV are so under appreciated that I sincerely doubt people will change their behaviors even if there’s a vaccine.

Moving on to implementation. HPV is a clear chance to save lives and save our public health infrastructure money. HPV is the cause of most cervical cancer and, through available vaccines we can prevent most types of HPV. This will definitely save lives now and in the future. Cervical cancer costs tens of thousands of dollars per person to treat whereas the HPV vaccine costs only a few hundred dollars per dose.  It is in the interest of insurers, hospitals, doctors and consumers to take advantage of the HPV vaccine.

The key words for implementation are young, national and mandatory. The vaccine is recommended for women ages 9-25 (or 26) who have not yet contracted any form of HPV. Given the prevalence of HPV, it is therefore likely that a younger age will need to be treated. Vaccinating at the younger threshold, say 9-11, not only decreases the likelihood of previous exposure but also reduces the slim chance of changing sexual behaviors since most young women aren’t sexually active yet. Second, the vaccination must occur nationally and eventually
internationally. Domestically there are about two million female nine year olds who will need to be vaccinated. Those that aren’t covered by private insurers should be covered by Medicaid. Finally, the vaccine should be mandatory. While perhaps consumers are ambivalent about whether their child should get vaccinated, savings from the eventual reductions in cervical cancer treatment costs will be passed down to them (hopefully) as costs to insurers are reduced. Oh right, and there will be vast reductions in the number of people who get cervical cancer.

A closing note on gender equity and the HPV vaccine. I’ve heard quite a few complaints, that there isn’t a vaccine for men. Right off that bat I will admit men are equally as responsible for the spread of HPV as women and ostensibly should share the responsibility of eradicating the virus. However, women bear the brunt of the disease and the strong majority of the costs. Men can get genital warts and this alone is a good reason to develop a vaccine for men but for now it only makes sense to focus our resources on getting the vaccine into the hands of women. Additionally, given the huge costs associated with developing a drug, often estimated at around $100 million, making the existing treatment cheaper seems a better investment than creating a new vaccine.  

Æ Beacon

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Perspectives on NGOs Abroad: Critical care or colonial enterprise?

December 20, 2006 at 1:23 pm (AE Beacon's Posts)

    Non Governmental Organizations (NGOs) including foundations, non profits, individual donors and multi national organizations (to a lesser extent in this essay) have all seen unprecedented increases in healthcare sector influence abroad particularly in the last twenty to thirty years. As these groups extend their international influence, it is important that we consider the pluses and minuses of their work.

            From a practical perspective, NGOs are often the most nimble health providers available. Able to rally resources quickly around an initiative they can represent the sole provider of services in emergency situations where a government system is either non existent or debilitated. With their increasing budgets and on the ground staff, NGOs are rapidly becoming semi-permanent facets of the health infrastructure in many developing countries.

            However, the growth of NGOs abroad presents a new and hereto underappreciated threat to the autonomy of developing countries. Are international health workers the 21st century missionary? Particularly in Africa the conditions are certainly ripe for the subjugation of locale governance. Decimated by disease, inter ethnic war, famine and poor infrastructure, the western world has once again arrived with a self righteous hubris reminiscent of the 17th, 18th and 19th centuries. Touting medicine and food we’ve resurfaced in virtually every area of health (not to mention other aspects of education, agriculture, defense and countless others) to “save” the day.  Ironically, the most capable of these aid workers are often members of the colonial powers many African countries fought so bloodily to overthrow (see most of Sub Saharan Africa).  

The international health NGO has seen staggering growth in power in influence abroad throughout the past decades. Unbridled by bureaucracy, these players have shown their potential to enact change quickly and unilaterally even in the face of chaotic situations. However, NGOs simultaneously represent a growing threat to local governments. Their inherently undemocratic infrastructure, fervid staff, blossoming budgets and medical capabilities combined with low resourced and under structured health systems set the stage for the unfettered subjugation of local powers.  As we continue to insist on stepping in, do we even know when to step out? Perhaps that time is going to come sooner than we think.

A final note. A few months ago many around the world were outraged when Madonna adopted a small Malawian child. For many the concept of a western woman (undoubtedly exacerbated by Madonna being Madonna) removing a child from a developing country and, what later appeared to be an unwilling father, conveyed a disgusting sense of culturally imperialism. And yet this same image adorns the cover of countless international health books, webpages and brochures. Would we find her actions more acceptable if she was wearing a stethoscope? Conceptually we do. As we move forward whether on the ground, in our writing or even in checkbooks with international aid, it is important that we are as self critical as we are compassionate. Don’t get me wrong, people are suffering and need care, but let’s just make sure we’re creating history reminiscent of Achebe and not Conrad.

 Æ Beacon

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On medicine abroad

November 8, 2006 at 8:50 pm (AE Beacon's Posts)

Liberal doctrine has increasingly disparaged the concept of the Western actor in developing world medical settings. Utilizing phrases like “sustainability” and “development”, the idea of an American or European physician entering an impoverished area as a first line health worker or a medical administrator has become a frowned upon concept. However, with most of the world’s medical resources and biomedical research capacity, what role should the developed world play in low resource and low access settings?

Brain drain, while one of the worst contributions of developed countries to health abroad, offers an interesting example of medical exchange. In many hospitals around the US and certainly around Europe there are doctors who immigrated from Africa, South Asia and
Latin America. These doctors undoubtedly face a variety of cultural and logistical problems upon their arrival and likely for a prolonged period thereafter. However, I find no indication that Americans (or Europeans) are particularly ambivalent about being treated by these physicians despite the supposed boundaries that we proclaim foreign medical personnel bring to clinical settings.  

I believe that health workers can successfully make people better in any setting regardless of cultural background. We have put so much emphasis on liberalized health goals like local capacity building, development initiatives and training programs that we have forgotten the brutal arithmetic of human suffering that is daily putting more patients in the hands of fewer doctors. Our enormous capacity to help through physical resources, health personnel and medical training is being handicapped by an ostensibly righteous drive to avoid (vague) concepts of medical colonization and imperialism.  This rhetoric is perpetuating inaction and diverting crucial resources to peripheral efforts. Are we so misguided that we think a sick patient in
Harare would prefer no doctor to a Western doctor?

A recent WHO report noted a deficit of 4.3 million health workers in developing countries. According to some estimates, there are almost 4 million health workers in the US and millions more in
Europe. If even a fraction of this highly trained, highly resourced workforce were to spend a few months or a year abroad, we could make a huge difference in the lives of many sick people. While perhaps they wouldn’t be able to perform many specialized procedures, simple interventions against diseases like pneumonia, diarrhea, malaria and the measles would drastically reduce the number of deaths in developing countries. In addition to contributing positively abroad, I anticipate that upon their return, these physicians would be better equipped to deal with patients from culturally disadvantaged backgrounds. Indeed a win-win situation.

Do not mistake this essay as anti-development. We are all aware of the need for local governments to arrange a successful and self sustained infrastructure. However, in the interim, we must shun our facile philosophical leaning towards inaction and don our personal and collective responsibility for making sick people healthy again.

Æ Beacon

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Reflections on Pandemic Illness: Practical preparedness for here (and abroad)

November 1, 2006 at 11:44 am (AE Beacon's Posts)

Over the past fifteen years the federal government has spent billions of dollars on something that does not exist; bird flu. Despite less than 20 known human to human transmissions, none of which having occurred in the wildfire fashion envisioned by public health experts, considerable funding has gone into fighting this supposed menace. At this very moment several million doses of Tamiflu, the supposed cure for bird flu, are parked in warehouses outside of several major US cities awaiting distribution. Further, a half dozen manufacturers have promised the ability to ramp up production in case of a large scale outbreak.

Unfortunately these solutions neglect the dynamics of disease spread and our ability to respond to widespread public health emergencies. Recent successes with polio, mumps, measles and a variety of other illnesses have perhaps contributed to an overwhelming sense in our culture that we can triumph over illness through medicine. Though successful in certain instances, modern diseases like HIV/AIDS have proven to be more divisive and adaptable than we are prepared to handle through drugs alone. Even if we had a cheap vaccine tomorrow, how long would it take to inoculate the millions infected and the billions at risk? Ask any of the millions of men, women and children living with polio right now and they will tell you it takes a long time.

So what can we learn from HIV/AIDS? Perhaps the most important lesson is that medicine, while perhaps the ultimate cure for a given illness, is only part of the answer. The effective control of any pandemic illness requires the simultaneous action of medicine and public health. Through public health the spread of disease can be slowed enough to provide researchers with the time to develop medicines that either cure or dramatically reduce the spread of disease. This approach gives the added advantage of providing health officials with the crucial medico-demographic data that will later enable medical interventions to effectively target sick and at-risk populations.

What does a public health intervention entail? Good public health includes four main tenants: rapid medical reporting, centralized outbreak analysis, locally accountable health personnel and public awareness. Our current system lacks reliable rapid response reporting or personnel, our infrastructure is divided into a host of semi overlapping uncoordinated provider networks and Americans are armed with all the fear of pandemic disease but none of the tools to protect ourselves individually or communally.

Back to bird flu. In reality whether bird flu hits or not is irrelevant. A pandemic illness is bound to strike and I predict strike within our lifetime. The sheer number of people (and animals) combined with the rapidly evolving nature of viruses guarantees that one of the trillions of latent and perhaps low impact disease strain already in existence will mutate into a fatal, easily transmittable killer.

Evolution, however, is not the only factor competing for our health. One need not watch Twelve Monkeys to realize the realistic and disastrous potential of bioterrorism. A genetically engineered virus will likely have a long infectious but symptom free latency and resistance to most if not all known therapies. In the event of a bioterrorism attack drug research and development will not be the determining factor in who lives or dies. If we cannot manage to get people out of harms way quickly during an infectious disease emergency, in three to six months there will be few left to inoculate.  

Our public health infrastructure demands immediate practical and ideological change. First, we must decentralize healthcare. Illness happens at home, at school and at work. We must have our health workers as close physically and mentally to where illness occurs as possible. Increased connectedness between these spheres through in house, in school and at work contact with health workers will increase the likelihood of obtaining rapid and relevant care. Second, we must implement electronic reporting. This should be done through a private-public partnership. Currently we have a variety of reporting systems at several hospital systems around the country. This is great but community or even regional systems lack the tremendous benefits of a national system. The government must step in to standardize electronic reporting, make it affordable for small practices and ensure that people use it. Tax incentives, grant support and fines will directly ensure that health workers are providing the best in care for patients locally and nationally. Further, rewards to private companies for developing a suitable technology must also be implemented. A million dollar DOD grant initiated a few years ago resulted this year in a car that could drive for hours without any input from a person. Let’s challenge industry to come up with the same innovation in electronic healthcare reporting. Finally, integrate public health education into elementary school education. I doubt a fourth grader in San Francisco can tell you anything about plate tectonics but she certainly knows what to do during an earthquake to save her own life. Pandemic disease is frightening but, by providing simple information on what to do during an outbreak to our future generations, each of us will be able to act against disease and panic. By taking these steps we can offer ourselves the best chance to survive a natural or malicious outbreak.

When a pandemic disease finally does emerge, it will be able to affect most countries in the world in a matter of days. It will affect most major cities and it will affect the human way of life. However, pandemic illness will not kill us all. By pairing medicine with public health, vaccine research with systemic and cultural preparedness, Ho with Gerberding, we offer ourselves a chance to survive. Pandemic disease requires our immediate attention and our immediate preparation. Let’s act.  

Æ Beacon

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