NOTES FROM DR. Mary




The Downside to Public Health


February, 2017
Public health is promoted to prevent illness, and so it does. But there are down-sides to it. Your practice in Timbuktu is more difficult because of public health practices in the West.

Immunizations: When I was growing up in the 1940’s, measles, mumps, rubella, and chicken pox were rites of passage through childhood. Not anymore. If your child becomes ill with measles, most likely your doctor won’t recognize it, since he never saw a case. If he does recognize it, you will be in trouble for child-neglect. So how does that impact what you are doing in Timbuktu?

Modern textbooks don’t adequately describe these diseases. So it will be hard for you to know what to look for when there is an outbreak in your remote, rural allocation. When you send a panic email to your doctor-friend in the States, he or she may be less than helpful.
Whereas industry has developed rapid blood tests for blood sugar as well as for diagnosing strep, HIV infection and mononucleosis, there are no rapid tests for immunizeable diseases.
Local docs in Timbuktu will be better than a Stateside physician in diagnosis, but they too will be deficient. They read standard medical textbooks. These textbooks are written in the West for the most part (India being an exception). Authors don’t write about diseases they don’t see, or at least they don’t write well. Hence the clinical manifestations of immunizeable diseases are not adequately described in modern medical texts, aside from those produced in India. The bottom line: get your hands on old medical textbooks, those from the 1950’s and before. Get your hands on textbooks from India.

 

STD clinics: All over the world, as promiscuity becomes more acceptable, STD clinics are popping up. Sometimes they offer free medical care. At times patients have to pay, but the cost is very reasonable.  So how do STD clinics in the States negatively impact your ministry in Timbuktu?

Whatever training you might get in the States, its relevance in your remote rural location, while not negligible, is minimal. Why? First of all the spectrum of disease—what is common—is very much different. Consider the 6 classical STD’s: During a Stateside STD clinic internship, you will see a lot of gonorrhea and chlamydia, some syphilis, and maybe a very rare lymphogranuloma venereum, chancroid, or donovanosis. The latter three will likely all be imported cases. In developing Africa chancroid is most common, followed by syphilis. Yet there are 10 cases of syphilis for every one case of gonorrhea. In the South Pacific donovanosis is most common. The factors causing this are not altogether clear. But it is clear that your Western-supervised education will be skewed.
Since medical care for STD’s is relatively easy for Americans to access, both congenital syphilis (in newborns and older children both), and the late consequences of untreated syphilis are very rare. The increasing numbers of syphilis cases currently reported in the West are almost all in male homosexuals. Pregnancies with subsequent infected newborns are not a public health issue for that population. Likewise, with routine syphilis blood tests being part of all prenatal care and most physical exams, it is only rarely that untreated syphilis is allowed to advance to the tertiary stage.

 

Food sanitation: Brucellosis and abdominal tuberculosis have just about been eliminated from the food chain in the West. Milk is pasteurized. Cattle are tested and quarantined or slaughtered if they are infected. The food industry has sanitation standards for both equipment and workers. This also negatively impacts your practice in Timbuktu.

The Western-textbook deficiencies are also relevant here. Authors don’t well describe conditions they have never seen. Neither brucellosis nor abdominal TB is adequately described in any Western text. Brucellosis literature from Turkey and Iran can be helpful, but these journals are hard to access.
Since these diseases occur mostly in impoverished contexts, industry has not developed rapid tests for diagnosis. There is no money in expediting their diagnosis and treatment. However, clinical diagnosis, from history and physical exam alone, is extremely difficult.
In particular, with these two diseases, the manifestations of each are legion. The most that can be said is that with brucellosis there are usually joint pains, and with abdominal TB there are always abdominal symptoms. Beyond that there are no rules. The diagnoses are elusive. Also, in both cases, adequate treatment takes months, so compliance and follow-up can be problematic.

The bottom line is that you should get your hands on old textbooks, those written before the 1970’s, and newer ones from India. When some old doc goes out of practice, see if you can acquire the books that he inherited from his grandfather. These are worthless in the general book market--someone will thank you for taking them--but they are priceless for those in Timbuktu or aspiring to go there. Ignore the treatments they propose, such as drinking hot kerosene, but use the text to enhance your diagnostic armamentarium. Antibiotics do wonders for treatment in Timbuktu, but only if the diagnosis is correct.

In subsequent months I will try to present cases involving some of these rare-in-the-West-but-common-in-Timbuktu diseases.

Mary Vanderkooi
vanderkooim@gmail.com

 

  Update on the Ebola outbreak
September, 2014 From Dr. Mary: The Ebola disaster is unfolding, the numbers of cases growing exponentially. By the end of September it is projected that there will be 10,000 cases. If so, and absent effective intervention, it will be a million well before the end of the year. Tom Frieden, head of CDC, said some time ago that if it is not contained in West Africa it will go worldwide and we will be dealing with this for years. This past week MSF said that in order to contain the epidemic Canada and the States need to deploy military field hospitals and personnel. They need 800 beds (that is, in a field hospital, complete with personnel) NOW in Monrovia alone. Both Canada and the States declined to send their disaster response teams; I understand they are just sending beds (frames and mattresses).  Hospitals are turning away patients because there is no more room on the floors. These are people who are infectious, sent back out into the community to fend for themselves; they necessarily will infect others. People are dying from treatable, non-Ebola conditions because of the collapse of the health care system. Since children tend to survive Ebola better than adults, a huge orphan problem is developing. Food prices are rising rapidly. Because of transport restrictions aid supplies are delayed. The main need is medical personnel, but few will volunteer to go, particularly since 3 Americans became ill with Ebola. Most medics will go only under some compulsion. That means military. A decision by the US government to send their disaster response team would not be popular; however the US military has the discipline and isolation resources to deal with infection in its own members. Some military-context cases would not cause a general epidemic. Failure to send the military now will just increase the likelihood of an eventual Ebola outbreak among the Stateside civilian population. A recent scientific paper states there is a 28% chance of an Ebola outbreak in the UK before the end of September; for the States that number is 18%. As the pandemic unfolds these numbers will increase. Hong Kong is doing Ebola drills; the rest of the world is still in denial. I'm personally preparing protection equipment and planning with our mission board to at least send the relevant information (list of supplies, directions for using them, recipes for disinfectants, and patterns for the protective suits) to all their missionaries around the world. If Ebola strikes me my husband will be protected, and won’t need to commit suicide when providing me with food and water until transportation can be arranged. 

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