A Drop in the Bucket?

Today I attended a lecture on an OB/GYN physician's experience in South Sudan promoting and teaching family planning. She spent 4 weeks teaching local healthcare workers, midwives, and doctors everything from basic anatomy to how to implant an IUD. Her talk highlighted many of the difficulties in global health work such as financial obstacles, language obstacles, and cultural obstacles.

One hospital (term used loosely -- a few 1 room/1story buildings on the same property) where she worked didn't have much/any materials and medication. The hospital pharmacy and THREE small bottles of antibiotics. They didn't have sutures, speculums, or a constant source of power. If a family needed/wanted a c-section, they would somehow have to find their own supplies to bring to the hospital and hope that there is a doctor there who knows how to do it (not to mention traverse horrible, unpaved road for hours upon hours to get there)

Another barrier she faced was 1) the lack of education on why family planning is important (ex -- why can't you have 11 babies starting when you are 14?) 2) the acceptance of physical abuse as a form of aggression in households. This creates problems when you are trying to provide contraception to a women without her husband knowing (ex -- concerns about husband feeling IUD strings). She would have to start from scratch explaining how baby after baby after baby (especially at a young age) increases the maternal mortality rate and decreases the country's productive output.

Although her lecture was extremely informative and enlightening, I couldn't help feeling discouraged as I left. People like this doctor and my medishare team going to Haiti do their best to make a difference, but in the end, what is really accomplished? She left South Sudan with not a single medical professional up to competency to provide contraception (such as IUD and the arm implant). However, they are about a million miles closer than before she arrived and are continuing training in her absence. What about that hospital that can't even function due to lack of supplies? It just makes me really sad about the whole global health picture in developing countries. I know there are NGOs and non profits trying to fill the gap, but it almost seems like trying to put a bandaid over a gushing wound. What would happen if no one did anything though?

I guess I can only hope that all the drops in the bucket eventually add up to make a significant impact. I also know that I am extremely privileged to live in this country with all these resources available to me when I just as easily could have been another person born in South Sudan, seemingly without hope.

International Medicine

I returned from a medical trip to Haiti a little less than a week ago. I went through an organization called Project Medishare that aims to provide access to healthcare to the people of the rural, central plateau through local clinics and mobile clinics set up by international volunteers, like us.

I have been on a similar trip before to Costa Rica and Nicaragua, and both times I was struck by the EXTREME poverty around me. How much can sporadic primary care change the lives of people living under a faulty social structure? Although there may be a fairly constant stream of mobile clinics coming through somewhere close (and by close, I mean within 60 miles) to their vicinity, it's not like they have the same doctor who knows their history or even a different doctor that can look up their past medical history in a chart. Every time they see a new (most likely foreign) doctor, they have to start all over -- building a relationships, recounting their symptoms -- all through the barrier of non shared languages. Yes, translators help -- in fact, they are essential, but it's still not as good as being able to speak to and understand your patient.

It's an internal struggle doing international work -- am I really making a difference? Am I providing an essential service? Am I just doing this to make me feel better about myself? Am I doing more harm than good -- prescribing medicine without follow up, without knowing if the patients knows how or why they are taking their medication? I'm not the first person to face these struggles, there have been journal articles examining the effectiveness of international medical work, and even the different articles can't come to agreement-- are we doing something good or bad?

After my experience, I would say we aren't doing anything bad, and we are actually mostly doing good, AND occasionally, we're even doing something life changing. The medications we prescribe and give to our patients are mostly drugs most americans can get over the counter -- pain medication, antacids, multivitamins, etc... There is the occasional antibiotic, but honestly, antibiotic prescription abuse probably occurs more in the US than in Haiti. The doctors are very careful about prescribing anything that needs follow up --ex: anti hypertensives. And yes, it is hard to tell with a lot of the patients if they are actually sick or just describing the symptoms they know will get them the medication they need for when they really are sick and the american doctor isn't there. But when I think about it, so what if they are faking it? They are doing what they need to do in their circumstances. If I didn't have regular access to medicine, I'd probably do the same thing -- why not get some medications and get seen by a doctor while they are there? Also, I think having the doctor look at you and say "Your physical exam is normal" can provide a lot of psychological benefit.

The "life changing" patients -- the ones that have decompensated heart failure, glomerulonephritis, severe infection, early stage dementia, failure to thrive, or AIDS -- that maybe 1-3% we see, we can help them. We might not be able to be the hospitalist administering their care, but we can make sure they get that referral, that money, that transportation to get to a hospital and get taken care of.

And you know what? that 1-3% makes it completely worth it.