Once regarded by the ancient Greek geographer Ptolemy as “Happy Arabia”, the Republic of Yemen has had to endure anything but a happy wellbeing in its modern history. In a country slowly emerging from the brutalities caused by both two civil wars and a bloody uprising for independence in the south; Yemen still bears the brunt of modern warfare. Amidst all the past disparities, hope was on the horizon as in May 1994 unification was reached between both former Yemeni sovereignties, the Peoples Democratic Republic of Yemen (PDRY) and Yemen Arab Republic (YAR). Although considered a corner-stone in modern Yemeni history, unification came at a cost felt most by the everyday Yemeni. The newly formed coalition government found mergence on a macro-administrative level far from simple. With this the Republic was subsequently characterised by ongoing internal political disputes, a crippled economy and escalating violence. As a result the country’s public health sector was hastily severed most of its financially support. This forced it to discard its previous health system based on an unsustainable ideology of free for all healthcare and adopt a more financially sustainable one. Almost a decade on, to the every day Yemeni this has translated into a health system which relays 75% of the overall healthcare costs to its patients (1). Housing one of the fastest growing capital cities in the world (2), I plan to examine the Yemeni health system two decades after unification, examining how effectively it has disseminated its healthcare services towards its majority rural population.

Just over a decade before unification was finalised, in September 1978, the Declaration of Alma-Ata made its way onto the global arena at the International Conference on Primary Health Care (3). The declaration now adopted by all the World Health Organisation (WHO) member states and promoted by many non-governmental organisations such as the United Nations Children’s Fund (UNICEF) demanded a change in global healthcare systems like never before. The declaration specifically targeted at the developing world managed to successfully highlight the importance of Primary Health Care (PHC) in not only promoting the universal objective of “Health For All” but in also fostering good social and economic development nationally. Over forty years on, its importance on the global health agenda has diminished little, with the recent Director-General of the WHO, Dr. Margaret Chan, reinstating the adoption of the PHC strategy within governmental health systems as the most efficient and cost-effective way to organise developing health systems (4).

As a result of the international optimism surrounding its introduction, the Yemeni Ministry of Public Health & Population (MoPHP) has, since 1978, incorporated the PHC strategy into its health programs (5).Nonetheless I still believe the MoPHP is yet to establish itself a firm foundation on which to mature itself a successful PHC based health system. One of its main obstacles today in achieving this ideal is the illogical distribution of health services nationally. The subsequent inequality in healthcare which has been created has placed huge pressure on the country’s rural health centres, forcing these centres to provide healthcare to the almost 16 million Yemenis, with over 7 million of them being under the age of 15 (6,7). Therefore I believe it is within reason that the MoPHP considers that to achieve a stronger transition towards a PHC based health system, it must begin to seriously address ways to reduce the health inequality currently seen within the Republic.

Road through the village of Dhula’a

With this in consideration, I managed to obtain a two week work placement at a rural hospital in the village of Dhula’a. Having direct hands-on experience working with the doctors and speaking to the patients, I believe I am able to describe the extent to which the healthcare provided by the Dhula’a hospital portrays the current state of the healthcare within rural Yemen. Dhula’a is approximately 65 kilometres from the capital Sana’a, linked by a single carriage sand road. With there being no emergency services throughout the entire country (8), the Dhula’a hospital stands virtually isolated from any regional secondary or tertiary hospitals. The hospital itself, built initially to provide primary healthcare for the local villagers of Dhula’a, has now, due to the lack of sufficient health service coverage, had to undertake the burden of providing healthcare to just under a million Yemenis all from surrounding villages (9).

Early afternoon at the Dhula’a Hospital

I believe it would be foolish not to suggest or even affirm the failures of the current health system on the country’s severely underdeveloped economy, poor governmental distribution of health services and population boom. However working in Dhula’a I began to comprehend the everyday reasons, immeasurable by statistics, behind the failure of the of the PHC system in achieving its core “Health For All” objective four decades into its existence.

The early morning A&E room

Typical to Yemeni working hours, the hospital opens from 8am to 1pm; after which the on-call doctor begins his or her shift until the following working day. Consultations generally occur in rooms no more than 5 by 6 meters in area; however one department bucks the trend, boasting 1 waiting area and 3 of the best equipped rooms in the hospital. With UNICEF figures showing 52.4% of the general population to be under the age of 18, with the average age of rural marriages being just 12 to 13 years of age (10,11), I found it little to my surprise that this was the gynaecology department.

Dhula’a Admissions in 2008

Traditionally the practise of gynaecology within Yemen has always been in heavy demand, with the Dhula’a hospital registering from January to June, so far during 2009, a 17% average increase in admissions comparable to 2008 (12). Such an increase in admissions reinforces the fact that the health demands of the Yemeni public are rapidly changing. The challenge now faced for the MoPHP is not only to eliminate health inequality nationally, but to also allocate its receding resources wisely. This is crucial in allowing it to service the evolving health demands of today’s population, and forecast the health demands of tomorrow. Writing from my experiences of a hospital which had only one working telephone line and had never preformed an official patient referral, I believe rural hospitals such as the Dhula’a hospital have received poor government support and as a consequence have relayed a hugely substandard healthcare service towards their patients.

Dhula’a Admissions in 2009

It is in my opinion, that Yemen’s failure to implement the PHC strategy effectively can now be attributed more so to the government’s past and present inability in planning and administrating a demographical representative distribution of health services. I also believe its ineffectiveness in assessing and acting upon the changing landscape of health demands within its population has stunted the potential growth of its PHC based health system. In reality I believe both the above have allowed for the inequality in healthcare to exist, which from the country’s national average health statistics is almost undetectable.

Fortunately, over the past few years, UNICEF has been working closely with the MoPHP in advising and supporting the implementation of a cost-effective health system reform on a national level. Reforms such as the promotion of primary preventive healthcare have reaped early success, with the 2005 nationwide immunisation campaign to prevent the spread of an epidemic polio subsequently allowing Yemen to boast itself as officially polio free (13). As the world’s largest provider of vaccines to the developing world, UNICEF has delivered most of it’s assistance in providing awareness to the need of vaccination by distributing media publications; such as a leaflet, which I was able to obtain from the Dhula’a hospital (14,15).

A UNICEF-funded infant nutrition and immunisation leaflet

The leaflet, written in native Arabic, highlights the importance of vaccination for newborns in providing immunity against the common diseases which contribute most to Yemen’s infant mortality and malnutrition. It also highlights the importance of good nutrition in preventing malnourishment and its effects on weakening the immune system. In a country where 42% of the children under the age of 5 are malnourished, both immunisation and dietary advice are crucial in reducing the overall infant mortality (16).

UNICEF has also been instrumental in promoting nationwide health awareness by setting up educational workshops in collaboration with the MoPHP (17). One of which during 2008 managed to successfully attract a strong geographic representation of young Yemenis. Allowing the generally conservative government to open up dialogue on the experiences, ideas and preventive measures available concerning HIV/AIDS (18).

Ranking abysmally at 153 out of 175 on the latest Human Development Index (HDI) (18), for the upcoming generation of Yemenis I believe a prosperous health system must be at the heart of any administrative system they choose to elect. With estimates showing 73% of the population to be living rurally, however allocated only 25% of the countries health services (19), I believe Yemen in the long term needs to invest its resources in providing a more demographically representative distribution of its health services. However in the short term, Yemen certainly needs to assert a greater control over its escalating population boom both by reducing illegal immigration from neighbouring unstable states and from reducing its national fertility rate. Vital to the latter goal is the introduction of free nationwide educational workshops such as those previously set by UNICEF, however focusing more on family planning and contraceptive control. These workshops would be most useful in both educating and promoting sensible future family planning to both the current and upcoming generation of sexually active Yemenis. The MoPHP also needs to address the design of future policy which actually serves to reflect the current health demands of the population. I believe this can only be achieved by allowing working clinical doctors an assertive unconditional voice on the policy-making tables of government. With the above objectives taken into consideration, I believe Yemen can realistically aspire itself a stronger health system in the future, with both quality and geographic accessibility at the heart of its strengths.

Zeyad Al-moasseb is a UK student currently on a gap year
z_almoasseb(at)yahoo.co.uk

References

(1) Abdul W. Al Serouri, Dina Balabanova & Souad Al Hibshi (2002) – Cost sharing of primary health care: lessons from Yemen.

(2) Reuters: Water crisis threatens Yemen’s Swelling Population (2009). http://www.reuters.com/article/environmentNews/idUSTRE57T0HK20090830

(3) World Health Organisation: Declaration of Alma-Ata (1978). http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf

(4) Dr. Margaret Chan, Director-General of the World Health Organisation (2008).
http://www.who.int/dg/speeches/2008/20081014/en/index.html

(5) Ministry of Public Health & Population (2000) – Health Sector Reform in the Republic of Yemen: Strategy for Reform. http://www.mophp-ye.org/docs/HSR_Strategy.pdf

(6) World Health Statistics 2009: Table 9 – Demographic and socioeconomic statistics.
http://www.who.int/whosis/whostat/EN_WHS09_Table9.pdf

(7) World Health Statistics 2009: Table 9 – Demographic and socioeconomic statistics.
http://www.who.int/whosis/whostat/EN_WHS09_Table9.pdf

(8) Library of Congress Federal Research Division (2006).
http://lcweb2.loc.gov/frd/cs/profiles/Yemen.pdf

(9) Dr. Mohhamad Yehya Al-shamy, Dhula’a Clinical Director.

(10) United Nations Children’s Fund: A glance at, Yemen – Statistics (2007).
http://www.unicef.org/infobycountry/yemen_statistics.html

(11) UNICEF report on a study conducted by the Sana’a University. http://www.unicef.org/infobycountry/yemen_50331.html

(12) Dhula’a Admissions table (2008, 2009). Refer to the “Dhula’a admissions table [ENGLISH].xls”

(13) IRIN: Mohammed Osama Mere, technical advisor to WHO’s Expanded Programme on Immunisation (2009). http://www.irinnews.org/Report.aspx?ReportId=84433

(14) United Nations Children’s Fund: About (2009). http://www.unicef.org/media/media_51043.html

(15) UNICEF Leaflet: refer to “DHL-LEAF1.JPEG”

(16) United Nations Children’s Fund: A glance at, Yemen – Statistics (2007). http://www.unicef.org/infobycountry/yemen_statistics.html

(17) United Nations Children’s Fund: National peer education workshop on HIV and AIDS in Yemen (2008).
http://www.unicef.org/media/media_43545.html

(18) Human Development Report (2007/2008). http://hdrstats.undp.org/indicators/1.html

(19) Library of Congress Federal Research Division (2006). http://lcweb2.loc.gov/frd/cs/profiles/Yemen.pdf

User charges and their effect on compliance

“That’ll be 10 shillings, please.”

I had come to East Africa for my gap year with the rather woolly notion of “helping” the locals and yet here I was taking money off them. But as I ticked off another yellow form, I reflected on how much these Kenyan mothers were getting for their seven pence: monthly visits from the local hospital’s Maternal and Child Health unit, an Oral Polio Vaccine and the three required doses of the Pentavalent vaccine which confers immunity to Hep B, Diptheria, Tetanus, Pertussis (whooping cough) and Haemophilus influenzae type B (HiB, a leading cause of pneumonia) (1). Between them these conditions accounted for over 800,000 deaths every year(2), as well as causing thousands of debilitating and stigmatising deformities. The babies are also weighed to check they are developing at a normal rate. Food parcels are provided if the patients are showing signs of malnourishment and essential vitamins (chiefly retinol – vitamin A – which 127 million pre-school children and 7.2 million pregnant women are deficient in (3)) are given out. Pregnant women can also come for HIV checkups, counselling and testing, and malaria prophylaxis.

What struck me was not just the breadth of the programme but the efficiency of it all. All of the yellow medical records presented were kept by the patients, each was up to date and every mother attended when their children’s immunisations were due. I had seen similar schemes organised by Western NGOs with no charge for users. These had turned into a free-for-all with little organisation and demand (often unnecessary) far outstripping medical supplies. Even the low user charges introduced into the African-run programme gave the nurses time to impress upon the parents the importance of hygiene, diet and adherence to treatment. This system also endowed the patients with a sense of responsibility over their medical records and, by inference, general health.

A decade ago, this was a contentious issue in global health management. However, the international consensus has since turned against charging users for primary healthcare. Critics argue these charges prevent the worlds most needy people from accessing services, encourage reckless prescription and do not recoup costs (4).

What I saw was very different. Whilst they may not finance the entire programme (UNICEF fund the immunisations and USAID pay for the food supplements), the mothers’ 10 shillings covers the rickety minibus which allows the nurses to travel to these remote villages. When patients themselves have to travel, a combination of distance and cost (often more then user fees themselves) reduce attendance significantly (5). Transport can account for more than a quarter of medical bills (6). A personal knowledge of their patients also allows discretion and flexibility in cases of extreme hardship. At times, on the programme I witnessed, eggs were given in lieu of payment, and schemes in Cambodia combine user fees with a ‘health equity fund’ to great effect (7).

From my experience, over-prescribing did not seem evident either. As established above, these fees do little to recoup operational or administrative costs, and when not set within a command-driven economy, they do not make profit for the hospital. In my opinion, without a target-driven quasi-market (a financial incentive to prescribe or vaccinate), the fees are more likely to reduce ‘frivolous demand’ (8) than increase reckless prescription.

The advantages of the project, though, were not limited to increasing efficiency. The practitioners spent time with each mother, instructing them on the proper nourishment of their children, stressing the importance of vaccinations and counselling them to continue regularly taking medication for existing conditions. Antimicrobial resistance is a growing concern for malaria, tuberculosis and HIV, which constitute “a significant proportion of the disease burden in developing countries” (9) and the WHO cites minimising ART (Anti-Retroviral Treatment) interruption as a key to preventing HIV drug resistance (10).

Another criticism levelled against user fees are their tendancy to encourage “use of partial drug doses” (11) but this can be dissuaded with the proper education of sufferers, which the schemes facilitate. Ownership of their yellow forms, together with this extra education and the value imbued to their health services conferred a sense of responsibility to the patients to which they appeared to respond well.

Clearly, this evidence is anecdotal. Nevertheless, a whole plethora of research has been conducted into the efficiency and equity of user charges (4,12) whilst work focusing on the long-term effects of including patients in their treatment plan – such as increasing concordance – is often neglected. If these programmes can help to increase compliance to treatment and successfully reduce drug resistance, the benefits to inter-generational equity would be immeasurable, much more than just a “necessary evil” (13).

These initiatives do not stand alone. They require investment in health education and with this, the elasticity of demand may stretch to paying user fees. If by introducing these policies we can increase efficiency and add value to a service, thereby promoting adherence, then hopefully those ten shillings will be seen as a worthwhile investment.

Isaac Ghinai is a second year medical student at University College London
zaacghinai(at)hotmail.com

References

1. Medical News Today, ‘Pentavalent Vaccine Launched For The First Time In Lesotho’ (from a UNICEF press release), 22/12/2008.

2. P. Chinnock, GAVI Alliance news, ‘Vaccinating against childhoods biggest killer’, 22/06/2009.

3. K. West, American Society for Nutritional Sciences, ‘Extent of Vitamin A deficiency among Preschool children and women of reproductive age’ September 2002.

4. A. Costello, British Medical Journal, ‘Should mother and child health services in developing countries be free?’, 29/03/1997.

5. D. Hodgkin, Health Economics, ‘Household characteristics affecting where mothers deliver in Rural Kenya’, July 1996.

6. N. Brikci and M. Phillips, The Lancet (Vol 369, Issue 9555, pp 10-11) ‘User fees or equity funds in low income countries’, 06/01/2007.

7. W. Hardeman et al., Health Policy Planning, ‘Access to health care for all? User fees plus a health equity fund in Sotnikum, Cambodia’, 2004.

8. C. Griffin, World Bank Paper, ‘User charges for health care in principle and practice’, 1951.

9. Diseases Control Priority Project, ‘Drug Resistance: Disease control is threatened by rise in resistant microbes’, July 2006.

10. D. Bennet et al., Antiviral Therapy (Vol 13), ‘The World Health Organisation’s global strategy for prevention and assessment of HIV drug resistance’, April 2008.

11. L. Gilson, et al., Health Policy, ‘Strategies for promoting equity: experience with community financing in three African countries’. October 2001.

12. L. Gibson, D. McIntyre, British Medical Journal, ‘Removing user fees for primary care in Africa: the need for careful action’. 01/10/2005.

13. B. Meesen et al, The Lancet, ‘Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia’, 23/12/2006.

14. A. Sepehri and R. Chernomas, Journal of International Development (Vol 13, Issue 2, pp183-209), ‘Are user charges efficiency- and equity-enhancing? A critical review of economic literature with particular reference to experience from developing countries’, 11/06/2001.

A recent WHO report is critical of internationally funded disease-specific health initiatives in Africa in particular for unintentionally taking resources away from national health systems (1). A Canadian medical student describes another shortfall of such initiatives and the inequity in health care delivery they can cause.

I couldn’t believe the thought that was going through my mind as I sat with Steven Banja and his mother. I was sick to my stomach, wishing a little boy and his mother had HIV.

It was 2006 and I was in Uganda as a pre-med student. While helping at a medical clinic in a remote village, I had befriended eleven year-old Steven. He was the most emaciated child I had ever seen and had been sick for some years according to his mother, an impoverished contract sugarcane cutter who had five other children. Even though he had so little energy that flies would settled on him undisturbed, you couldn’t help but see the spark of life Steven still had in him.

A chest x-ray subsequently revealed the reason why Steven was so malnourished. Copious white areas in his lungs were evidence of the tuberculosis that had slowly and relentlessly been taking hold of him. The doctor at the Children’s Hospital told me that, without treatment, the infection would soon overwhelm him. And because tuberculosis is so often partnered with HIV, there was a strong chance that he was also HIV positive.

I started processing the full context of Steven’s situation: Steven lived 30 km from the publicly funded hospital to which he or his mother would have to travel to receive his weekly regimen of anti-tuberculosis medication. His mother was a strong and loving person who worked hard to provide the bare essentials for her children. But it was impossible for her to make enough money to pay for the travel to town – even though the medication itself was free. For her to have to pursue this course of action was, in effect, a death sentence for her son.

Steven lived in an area that was unusual for its comprehensive care for those living with HIV/AIDS. The local foreign funded clinic provided free anti-retroviral therapy to anyone with AIDS. People could come and pick up their medication and receive counseling at the clinic, in addition to free meals and childcare. And if patients could not afford the trip or were too sick, counselors on motorbikes would deliver the medication to their village. Diagnostic testing and medications that may be required to fight the opportunistic infections, such as TB, were also free. Hence, if Steven was HIV positive, his anti-tuberculosis medication and anti-retroviral medication would be delivered to him and he would be able to access nourishing meals that the public system could not afford. With the success of anti-retroviral therapy, he could live a long life with treatment.

So it was that I sat with Steven and his mother awaiting the results of their HIV tests, hoping that he was positive. Having HIV would allow him access to life-saving anti-tuberculosis medication, to free meals, to diagnostic tests. Being HIV negative would mean that, despite free medication, Steven would remain untreated and almost certainly die.

Steven turned out to be HIV negative. Later that year, I heard from workers of an orphanage whom I asked to check in on Steven, that they had brought him to hospital in grave condition. Steven’s mother had unfortunately not been able to pick up his anti-tuberculosis medication.

Disease-specific global health initiatives (GHIs) have revolutionized healthcare delivery in Africa and saved countless lives. There can be no mistake about this. But Steven’s plight describes one of several serious limitations of this model of healthcare delivery. Indeed this is not news to the WHO that recognizes that in some cases “access to some targeted health services has expanded faster than access to other services not targeted by the GHIs, revealing a new dimension of health service inequity” (2). Steven’s case outlines a related but distinct scenario where two diseases, HIV and TB, both targeted by GHIs, provided differing access to care for the same disease.

The scope of the particular problem of unequal access to TB treatment in Uganda is potentially huge. Of the documented 109,000 new cases of TB per year, at least 3/5 are like Steven, not associated with HIV (3). However, the true scope remains impossible to determine, obscured by the lack of epidemiological data examining access to treatment for those TB patients with and without HIV.

As disease-specific GHIs expand their model of healthcare delivery, the type of inequity demonstrated by Steven’s case will likely become more pronounced. To address emerging inequities, the WHO has recently made several recommendations aimed at synergizing the interactions between GHIs and national healthcare systems (1). In particular the WHO recommends improving “alignment of planning processes and resource allocations among GHIs, and between GHIs and country health systems” which may mitigate this type of inequity. However, how this recommendation is operationalized remains to be seen.

The larger question is whether we accept Steven and others like him as an unavoidable casualty of an imperfect but overall effective model of healthcare delivery. Or do we strive to strengthen national healthcare systems in Africa that can provide comprehensive care no matter what diseases patients have so patients don’t find themselves in a circumstance like Steven’s, where HIV negative was a death sentence.

Steven was fortunate. His charm and love of life won over the staff at the orphanage who, with his mother’s blessing, took him in. Just last month a US family signed the papers to adopt him. Next month he will start a new life in Ohio.

Peter Orth is a 3rd year medical student at the University of British Columbia in Canada
peteorth(at)gmail.com

References

1. World Health Organization Maximizing Positive Synergies Collaborative Group. An assessment of interactions between global health initiatives and country health systems. The Lancet 2009 June 20; 373(9681):2137-2169.

2. World Health Organization [Online]. 2009 June 15 [cited 2009 July 19]; Available from: URL:http://www.who.int/healthsystems/New-approach-leaflet-ENv2-p4p.pdf

3. WHO REPORT 2009 Global Tuberculosis Control [Online]. 2009 March 24 [cited 2009 October 4]; Available from: URL:http://apps.who.int/globalatlas/predefinedReports/TB/PDF_Files/uga.pdf

A personal view on the health status, major determinants and needs of rural populations in light of primary health care currently delivered in Akaroa, New Zealand.

Abstract

Rural medicine is the interdisciplinary study of health and healthcare delivery in the context of a rural location or community. While people in such areas appreciate the medical services provided, it can sometimes be challenging to provide services all year long and to attract young medical professionals to choose a career in rural health. To investigate the delivery of primary health care in rural New Zealand, a group of Otago University 3rd year medical students were sent to Akaroa, New Zealand, as a part of their medical course. This report provides a rapid participatory appraisal of Akaroa’s primary healthcare. This project had a three-fold objective: to describe the population, to analyse its disease, disability and health risks, and to evaluate the current services and policies that respond to such risks. While we report about Akaroa’s general health status and primary health care delivery, more specific health issues, such as epidemic outbreaks and sexual health, were beyond the scope of this rapid participatory appraisal, and hence not covered in this article. Indeed, most of Akaroa’s medical needs are adequately met while keeping costs to a minimum. Living in a rural area is not as big of a health risk as might have been suggested in some literature. We hope by pointing out major health risks and need s in Akaroa and neighbouring areas this paper will be taken as a first step towards changing health and non-health policies affecting the health of rural inhabitants.

Abbreviations: Christchurch City Council (CCC), Emergency Room (ER), Christchurch Public Hospital (CPH), Individual Education Plan (IEP), General Practitioner (GP).

1. Introduction: Akaroa’s population

Akaroa is a historic French and British settlement, situated in the heart of an ancient volcano (1). It is located in the Canterbury region in the South Island of New Zealand, about 75km outside the city of Christchurch (1). According to the 2006 New Zealand population and dwelling census, it is estimated that Akaroa has a permanent population of 567 people (2). However, this number increases to up to 7,000-9,000 people during summer months, and the number of summer inhabitants is increasing (3). This influx of visitors from all over the world not only provides a great source of income to Akaroa, as well as increased job opportunities and improved quality of community facilities, but also appears to have normalised welcoming outsiders into Akaroa’s small population over the years. Indeed, out group felt very welcomed and accepted into the community, by the generosity we saw from Akaroa’s people, and the deep involvement we had in discussing issues around Akaroa. Over 80% of residences in Akaroa, mostly summer-holiday homes, have absentee landowners, which accounts for the more slow-paced township seen during winter (3). Furthermore, Akaroa is believed to be one of New Zealand’s most popular retirement destinations. As a result, it is commonly the well-educated, high socioeconomic class that can afford to retire there. Thus, the population is well aware of the available health care services, and they are well adapt at seeking help. Figure 1 shows a view of Akaroa harbour (4).

The predominant ethnicity in Akaroa is New Zealand European, accounting for 85.3% of the population (2). The Māori population is relatively small in Akaroa (5.4%) and tends to be of the younger age-group (2,3). People aged 65 and older account for 29.6% of the population, whereas10.6% are under 15 years old (2). This noticeably higher number of older people relative to other rural communities, is mainly due to Akaroa’s popularity as a retirement destination, as mentioned earlier. Since these retirees are usually well-educated, Akaroa has a higher percentage of people aged 15 years or older who hold a post-school qualification (46.4%), compared to the greater Canterbury region (38.5%) (2).

A view of the volcanic-formed harbour in Akaroa (4).

Apart from the health services available (discussed shortly), other facilities in Akaroa include a bank, three churches, a school (years 1-13) with a library, a marae (a sacred place that serves both religious and social purposes in Māori tradition) and a supermarket. These are usually run by people who live permanently in Akaroa. However, employment in Akaroa is mainly in agriculture, horticulture, and tourism hospitality.

2. Disease, Disability and Health Risks in the Akaroa Population

Recent studies concerning rural health have concluded that living in a rural area is not a significant health risk, when compared to urban dwelling, as might have been suggested by previously published studies (5,6). These significant discrepancies between urban and rural health, come from differences between rural communities within a specific countryside, as well as differences in specific health risks (6). These ‘intra-rural’ differences can be attributed to many reasons including for example; the size of the population and distance to the nearest city for example. Specific health risk factors can be grouped into those related to human biology, those that are due to the environment, and those associated with the rural lifestyle.

Health risk factors related to human biology refer to general health measures, such as life expectancy, disability and health perception, and examining how living in a rural area may have an effect as a health risk factor (6). According to the 2006 Christchurch City Council (CCC) report, the Akaroa area and Akaroa harbour had the highest median ages (i.e. the point at which half the population is older and half is younger) of 55 and 50 years respectively (7). In essence, this implies that Akaroa has good mortality rates and life expectancy profiles. The overall impression we got as a group of medical students, was that the health status and health provisions of Akaroa did not appear any different from the rest of New Zealand, except in the area of mental health and substance abuse. These services have always been more difficult to provide to rural communities, not only in New Zealand, but also in other countries, such as Canada, the United States, Australia, England and Wales (6,8).

Environmental health risk factors refer to all physical, biological and chemical factors in and about a community that directly affect the health and well-being of the population (9). These include the exposure to harmful chemicals, the quality of drinking water and air, as well as the psychological effect of isolation and living in a small community. Since many rural communities, especially in New Zealand, work in agriculture and farming, many studies have looked into the effect of farm and pollen exposure on the incidence of associated allergies. Such studies, however, cannot be generalised to all rural communities, due to potential confounders, such as the type and seasonality of the allergen studied. Taking such confounders into account however, studies have concluded that lifelong farm and pollen exposure is protective against asthma and atopy in people living in rural areas (10,11). With respect to Akaroa, year-long residents do not usually face such health problems, but allergies are a concern for the summer residents of the community. The immune system of these summer residents has not ‘learnt to adapt’ to Akaroa’s farm-borne and pollen-borne allergens. This increase in the incidence of allergies was confirmed by staff in the Emergency Room (ER) in Akaroa hospital who suggested that asthma and allergy-related conditions made up the highest percentage of cases seen in Akaroa during summer, and called Akaroa “New Zealand’s allergy centre”. Furthermore, the psychological effect of isolation is substantial, especially on the youth (8). The relatively low number of activities for Akaroa youth, and fewer drug prevention programmes, has lead to an increase in prevalence of alcohol and substance abuse. Staff at the Akaroa area school, have attributed the problem to the relatively high number of pubs around the area, as well as what they called “vertical socialisation”. Since the Akaroa school is an area school, students of all years study at the same facility making it easier for a ‘bad’ habit to spread ‘vertically’ across different age groups than it is in age-separated schools.

A rural lifestyle can impose certain risks on populations. Unfortunately, our group did not get the chance to be informed on Akaroa’s official tobacco and alcohol use, and physical activity and sedentarity level statistics. Studies from outside New Zealand, however, show that rural inhabitants seem to drink alcohol less regularly than their urban counterparts (6). On the other hand, people in rural areas smoke more, are less physically active and more overweight (6). Two studies from New Zealand show that noise-induced hearing loss and back injuries were the most common lifestyle-related health risks experienced by rural farmers (12). Interestingly, most rural inhabitants expressed an interest in health-related lifestyle changes (13). Another effect on the overall health in these areas is the nature of family bonds such that when it is time to die, some individuals choose to go back to their families living in rural areas, and this must be considered when for planning health care services for rural communities (14).

3. The Current Services Available to Manage Disease, Disability and Risks to Health in the Akaroa Population

Akaroa is a small village, with a population of around 600 people. The community is small enough for people to know each other well and help out like a big family. A school staff member put it beautifully: “we take anything [problems or assaults] personally, because it affects us all as a family”. Therefore, a health issue is not always dealt with by medical professionals but rather goes in the order of: help from home/workplace/colleagues, then help from Akaroa hospital, and finally seeking medical care from the Christchurch Public Hospital (CPH). In my opinion, this system, in its entirety, is what holistic medicine is all about. It is both the art of loving and caring for each other, as well as the science of diagnosing and prescribing.

Receiving help initially from family and colleagues can prove very helpful. One impressive instance our group came across in Akaroa is how efficiently the Akaroa school deals with students with social and mental impairments. The school has developed Individual Education Plans (IEPs) for students with special needs, such as autism and Asperger syndrome. IEPs involve assigning each student with special needs to a teacher who has received special training for his or her condition. The teacher starts the student with ‘light-weight’ classes only two days a week. Gradually, the class load increases, until the student is seen as academically and socially able to return to main-stream classes. In this way, students with special needs are progressively reintegrated into main-stream schooling, without the feeling of discrimination. It was very encouraging for us to see such a challenge being independently sorted by the school community.

In terms of Akaroa’s local health services, our group was surprised by the extent and range of health-related services available to such a small population. The number of services available may be due to the increase in the summer population. Services available include:

● Akaroa hospital: a seven-bed hospital, a maternity ward, an ER and 16 part-time nurses.

● General Practitioner (GP) surgery: attached to the hospital, has two GPs, a rural medicine registrar and a district health nurse.

● Rest home: 11 beds, usually used for carer-support and respite care.

● A pharmacist, physiotherapist, health promotion coordinator and alternative therapists.

● Counselling services: an occupational therapist works part-time, a counselor visits once a week, a psychiatrist visits the hospital once fortnightly, and a sex-educator visits once a month (mainly for issues that require specialised-training beyond the expertise of the GPs).

● Visiting clinics: a dental nurse visits once every two months, a diabetes clinic reaches out Akaroa once every two years and a respiratory clinician and nurse are planning to start visiting Akaroa during summers to establish an allergy-clinic.

Studies on the health of rural areas have shown that rural residents are more likely to have a family physician than their urban counterparts. However, they are less likely to consult them (6). Our group did not have enough data to compare, but from information gathered from hospital staff, Akaroa residents seem to follow this trend in that patients only visit their GP when there is a ‘problem’. As beds in Akaroa are usually saved for medical and surgical rehabilitation as well as carer-support, hospital stays are usually shorter in Akaroa than in city hospitals (6, 15).

Some medical procedures, such as child delivery or critical-care cases, cannot be performed in Akaroa hospital, due to the lack of both expertise and facilities. When such procedures are necessary, the voluntary Akaroa ambulance service, which is run by the fire brigade, takes the patient to CPH. Factors such as weather and road congestions can hinder the provision of this service, and thus an aero-medical service to cover the Banks Peninsula area is now being considered. The combined fire brigade/ambulance service is run by around 20 trained volunteers. It has so far covered Akaroa’s demands even during the summers. However, an emergency back-up medical-helicopter can fly from Christchurch and arrive to Akaroa within 20 minutes.

4. Policies Affecting Disease, Disability and Risks to the Health of the Akaroa Population

While there are differences in the health status and determinants between city and country populations, these differences tend to be of little importance when the overall health of the population is considered. Nonetheless, specific health risks and concerns should be the focus of health-related policies. It is encouraging to hear that an allergy-clinic is being established in Akaroa for the summer when there is an increased demand for such a service.

A non-health policy that would benefit the Akaroa population is the establishment of a new road between Akaroa and Christchurch. This improved infrastructure would make ambulance travel easier between the two areas, reducing the effects of adverse weather and traffic conditions on the transport of patients to Christchurch.

5. Conclusion: An Outsider’s Insights

For such a small community Akaroa’s, primary health care providers (i.e. GPs, district health nurse, dental nurse, pharmacist and physiotherapist) provide most of the necessary medical services. This can be clearly seen in the context of oral health in Akaroa; the dental nurse is the first health professional to be and more complicated and demanding cases are referred to a dentist. In this way, such medical needs are adequately met while keeping costs to a minimum.

Living in a rural area is not as big of a health risk as might have been suggested by some literature. However, we hope this paper will be taken as a first step towards changing health and non-health policies that affect rural healthcare, by pointing out major health risks and needs in these areas.

Exploring Akaroa’s health system made me feel nostalgic about my Arabian background where everyone takes care of one another, just like a big family. Sometimes this type of care can easily be overlooked or ignored in larger communities where everyone is busy with his or her own life, or taking care of the health of close family members. However, I believe that it is important not to forget that medicine is all about healing, both the body and the mind, and this trip to Akaroa was a big reminder of this for me.

Yassar Alamri is a 3rd year medical student at the University of Otago Dunedin School of Medicine in New Zealand.
yasao(at)hotmail.com

References

1. Welcome to Akaroa. Akaroa official website. [cited 2009 Jun 27]. Available from: http://www.akaroa.com/fpnew/fastpage/fpengine.php/templateid/204

2. QuickStats About Akaroa. Statistics New Zealand, 2006. [cited 2009 Jun 27]. Available from: http://www.stats.govt.nz/census/census-outputs/quickstats/snapshotplace2.htm?id=3596800&tab=PopulationDwellings&type=au&ParentID=1000013

3. Ashmore-Price J. Scoping Exercise and Needs Analysis Study for the provision of Akaroa Primary Health Care Serves/Facilities. Akaroa, Wairewa Community Board, 2008.

4. Akaroa. Wikimedia Foundation, Inc. [image on the internet], c2001 [updated 2009 Jun 06; cited 2009 Jun 27]. Available from: http://en.wikipedia.org/wiki/File:Akaroa-ViewOfHarbour.jpg

5. Anwar I. Perceptions of quality of care for serious illness at different levels of facilities in a rural area of Bangladesh. Journal of Health, Population and Nutrition. 2009 Jun;27(3):396-405.

6. Pampalon R, Martinez J, Hamel D. Does living in rural areas make a difference for health in Québec? Health and Place. 2006 Dec;12(4):421-435. Epub 2005 Jun 13.

7. Christchurch City Council. Age, gender and ethnicity: median age by area unit, 2006. Statistics New Zealand: Census of Population and Dwellings.

8. Gamm LD Mental health and substance abuse services among rural minorities. Journal of Rural Health. 2004 Summer;20(3):206-209.

9. Environmental health. World Health Organisation. [cited 2009 Jul 04]. Available from: http://www.who.int/topics/environmental_health/en/

10. Naleway AL. Asthma and atopy in rural children: is farming protective? Clinical Medicine and Research. 2004 Feb;2(1):5-12.

11. Douwes J, Travier N, Huang K, Cheng S, McKenzie J, Le Gros G, et al. Lifelong farm exposure may strongly reduce the risk of asthma in adults. Allergy. 2007 Oct;62(10):1158-1165.

12. Firth H, Herbison P, McBride D, Feyer AM. Health of farmers in southland: an overview. New Zealand Medical Journal. 2001 Sep 28;114(1140):426-428.

13. Raeburn JM. Expressed interest in health-related lifestyle change in three communities. New Zealand Medical Journal. 1985 Apr 10;98(776):242-244.

14. Welaga P, Hosegood V, Weiner R, Hill C, Herbst K, Newell ML. Coming home to die? The association between migration and mortality in rural South Africa. BMC Public Health. 2009 Jun 18;9(1):193. [Epub ahead of print].

15. Akaroa Hospital. Canterbury District Health Board, 2003. [cited 2009 Jul 04]. Available from: http://www.cdhb.govt.nz/ash/hospital.htm

“Do not inquire the name of him who asks a shelter of you. The very man who is embarrassed by his name is the one who needs shelter.” (1)

As medical students in Israel, we were privileged to volunteer in an open clinic for refugees and asylum seekers in Tel-Aviv during the past year. The clinic is operated by Physicians for Human Rights (PHR), a non-governmental organization (NGO). This article will review the clinic’s activities, and within this framework we have conducted an interview with Iman Aghbariyya, the manager of the open clinic. Let us first understand the background of the current situation.

Refugees in Israel

The UNHCR’s (UN High Commissioner for Refugees) annual 2008 Global Trends report shows the number of people forcibly uprooted by conflict and persecution worldwide stood at 42 million at the end of last year. The total includes 16 million refugees and asylum seekers and 26 million people uprooted within their own countries (2).

Since 2007 there has been a dramatic increase in the number of refugees and asylum seekers arriving to Israel, mainly from Africa, following regional conflicts and humanitarian crises. Nowadays, about 17,000 reside in Israel (2), coming mostly from Erithrea (7000) and Sudan (5500), and the rest from other countries like the Ivory Coast and Congo. Nearly all asylum-seekers come to Israel through Egypt. Israel’s southern border is over 230km long and porous, only a low fence separating the two states. Asylum-seekers pay Bedouin guides hundreds of US dollars to get them to the frontier where they risk getting shot at by Egyptian border guards. According to UNHCR and NGOs in Cairo, in recent years hundreds have been wounded and detained while attempting to cross the border, several have been deported to their countries of birth, while others have been shot dead (3).

In Israel, under certain circumstances, regulations can allow asylum-seekers to work, and grant temporary protection and non-refoulement (a commitment not to force people back to where they came from). However, getting non-private medical treatment is a more complicated problem. Until their legal status is regulated, asylum-seekers are entitled to get emergency medical treatment but not to use the public healthcare system. Therefore, once in Israel, they are forced to receive their medical assistance from UNHCR and local NGOs, including Moked, Assaf, the African Refugee Development Centre (ARDC) and Physicians for Human Rights (PHR). Last year, the Israel medical association opened its own clinic, providing free primary treatment for refugees.

The Clinic

PHR-Israel was founded in 1988 with the goal of struggling for human rights, in particular the right to health, in Israel and the Palestinian territories. Today PHR runs five projects: the Palestinian territories project, the prisoners and detainees project, the migrant workers and refugees project, the project for the unrecognized villages of the Negev, and the residents of Israel project. In addition, PHR runs a mobile clinic in the Palestinian territories, and an open clinic in Tel Aviv that provides services for all within Israel who have no legal status and therefore no health insurance.

The entrance of the open clinic in Tel-Aviv

Since its foundation in 1998 about 20,000 patients have been treated by the open clinic. The clinic is run mostly by volunteers and operates on two levels. On the humanitarian level, the clinic aims to provide the best possible health services to all in need, including migrant workers, refugees, asylum seekers and other status-less persons lacking medical insurance; On the ideological level, the clinic leads the struggle to change policies and to apply the national health insurance law to the populations treated by the clinic.

For the thousands of refugees and asylum seekers arriving in Israel in 2006-2007 from Africa, the only address for medical treatment was PHR-Israel’s Open Clinic. The large number of refugees and asylum seekers made a significant impact, as the Open Clinic received over one hundred patients each evening, some with severe physical and emotional trauma.

Iman Aghbariyya has been running the open clinic for the past year. She first started to work at PHR 10 years ago, as application coordinator. She is very excited and proud of her work at PHR, managing a full time job alongside raising her 4 children. Over the years she served in different positions and before running the open clinic she ran the mobile women clinic, which promotes women health issues and provides medical care for women in villages with limited access to medical services.

Iman Aghbariyya during her work in the open clinic

Iman tells us that the clinic was founded after a migrant worker who suffered from an infected wound, died because he was afraid to seek medical care:

“About a year before the Clinic opened, a migrant worker from Ghana came to the ER suffering from a morass in the anal region. Due to his fear of seeking medical attention he had waited for almost two weeks, and only sought help when his situation became very serious. On intake in the ER he was suffering from severe infection and underwent surgery on him the same night, as well as ostomy surgery due to the severe compromising of the anal area. He was subsequently treated in the intensive care unit, and over the following two weeks underwent several operations due to worsening of his situation.

“He eventually died as the result of multisystem failure and the uncontrolled infection. The doctor treating him was horrified by his death. He met a friend who was active in the Association for Civil Rights in Israel and told her about this case, saying it was intolerable that in an advanced society someone should die from a minor illness just because they were too scared to seek medical attention in case they were deported. After calling several organizations, they were referred to PHR-Israel, which agreed to take up the challenge”.

The clinic is operating five days a week, three afternoons as a general clinic, once a week as a specialists’ clinic (gynecology, orthopedics and more) and one morning as a pediatric clinic. The clinic relies on volunteers who include about 160 family doctors, pediatricians, gynecologists and other specialists, 27 nurses, 54 medical students assisting with the triage, 50 translators, and 50 non-medical volunteers who assist with reception. In addition to the doctors coming to the clinic, about 30 doctors with a broad range of specializations receive patients in their own clinics, free of charge or with only a symbolic fee. Physiotherapy, acupuncture and dietician services are also provided.

In principle, each visit in the clinic costs the patient 10NIS (~2 Euros) but in fact, no charge is collected since even this sometimes can’t be afforded by the patients. Practically, no other choice is available to them because a similar visit in private clinic would cost around 500NIS (~100 Euros).

Funding is provided by many organizations, as well as private donors. The medicines are supplied by pharmaceutical companies (mainly drugs near expiry date), and from patients who no longer need the medications they have purchased.

The clinic cooperates with hospitals and other voluntary organizations in Israel. It is connected through agreements with various medical institutions that allow the patients to receive a variety of examinations, and other services, sometimes including surgery, free of charge or with significant discount. Tel-Aviv Sourasky Medical Center (Ichilov) donates a large amount of laboratory work, Assuta hospital provides discounted surgery and Sheba hospital at Tel Hashomer provides discounts for both examinations and treatments.

The Profile of the Patient Population

Until 2007 the most prominent group among those seeking help from the clinic were migrant workers, coming to Israel from developing nations to secure a future for their families. Since 2007, due to both local and global reasons, the profile of the patient population has changed. Along with activation of a deportation campaign against unauthorized migrant workers in Israel, the number of patients began to rise. The reason was mainly an increase in the number of asylum seekers and minors, arriving in Israel as a consequence of the political situation in their countries. Refugees and asylum seekers had accounted for a small proportion of patients in 2006, but during 2007 their relative weight rose steadily (3).

A detailed examination of the statistics for 2007 showed the increase in the number of refugees and asylum seekers, along the decline in number of migrants (taken with permission (3))

The patient population is comprised mainly of young and basically healthy people (ages 20-40). Many patients suffer from seasonal illnesses such as upper respiratory infections. Others suffer from other “simple” conditions such as urinary tract infections, but also from trauma following street fights. It is not all that surprising that many patients also suffer from psychological co-morbidities when you consider traumatic experiences they may have undergone on their way to Israel, and their life circumstances that entail much uncertainty and insecurity.

As an example of the cases the clinic deals with nowadays, Iman tells us about the following case:

“A 28 year old refugee from Erithrea, who arrived in Israel a few months prior to his visit, came to the clinic due to rectal bleeding, and abdominal pain. He was referred to the ER (which is obliged, by law, to attend to emergency cases). In the hospital, after a comprehensive workup, a malignant rectal tumor was diagnosed. He needed chemotherapy to reduce the size of the tumor before surgery. He would need further chemotherapy and radiation after surgery. The oncology ward refused to admit him for this expensive and long lasting treatment without a sponsor. Application for financial help to the UNHCR got a negative answer due to the high cost. Consequently he did not get the chemo treatment. The emergency treatment he finally received in the hospital included surgical resection of the tumor, and a stoma surgery. The patient is in need of stoma bags, costing over 1000 NIS (200 Euros) a month, and the clinic is trying to raise the money for his treatment.”

Similar stories of refugee patients can be found worldwide. According to Dr, Hadas Yaron, coordinator of the refugee project in AMNESTY Israel, UN agencies and human rights organizations share the opinion that the solution for the problem should be a joint action by the international community. The issue needed to be solved is not a war ending after several years, but a chronic situation of unending wars.

When we asked Iman what she wishes for the clinic, she answered that she wishes there will be no more need for it, and it will close. We join her in that wish.

Eyal Lotan and Eleana Meyers-Earon are medical students in their final year at Sackler School of Medicine, Tel-Aviv University, Israel.
elotan(at)post.tau.ac.il
eleana_m(at)hotmail.com

References

1. Victor Hugo, Les Miserables.
2. Data taken from United Nation High commissioner for Refugees (UNHCR). http://www.unhcr.org
3. Under your wing, refugees and asylum seekers at physicians for human rights-Israel’s open clinic. January 2008.

Introduction

An Emergency Medical Service (EMS) can be defined as ‘a comprehensive system that provides the arrangements of personnel, facilities and equipment for the effective, coordinated and timely delivery of health and safety services to victims of sudden illness or injury’ (1). EMS can be simplified into four main components including, accessing emergency care, care in the community, care en route and care on arrival to receiving health care facility(2).

Today’s EMS has advanced so much that it contributes widely to the overall function of health care systems. Furthermore, emergency medical service providers have an extended role to deal with medical and trauma emergencies utilizing very advanced clinical technology. Currently, providers can administer controlled medications (eg: morphine, epinephrine), perform invasive procedures (eg: endotracheal intubation, intravenous line) and make clinical judgements and even pronounce death. The rapid development of medical technology has also reformed international EMS systems with the introduction of multifunctional compact monitoring systems making the task of monitoring patients manageable in the often uncontrolled environment of the pre-hospital setting.

Models of EMS:

Since the 1970s, the mode of emergency health care delivery in pre-hospital environment evolved around two main models of EMS, both with distinct features. These are the Franco-German and Anglo-American models:

Franco-German model:

The Franco-German model of EMS delivery is based upon a “stay and stabilize” philosophy (3). This approach means the attending health care provider stays at the scene longer and stabilizes the patient intending to bring the hospital-level of care to the patient’s side at the scene. The service is usually run by physicians who have an extensive scope of practice with very advanced technology. The model utilize a number of methods of transport such as helicopters and coastal ambulances alongside the traditional land ambulance (4). This model is usually a considered and closely allied with the health care system. In many European countries, a speciality of ‘emergency medicine’ exclusively rarely exists and instead is considered a supra-speciality. This means that a core speciality must first be obtained and then emergency medicine can be considered in addition to this (for example, being a specialist in surgery and emergency medicine or anaesthesiology and emergency medicine)(5). Most emergency physicians provide advanced field medical care on scene and en route. The EMS personnel practice clinical judgement extensively and treat patients both in their homes and at the scene. The very few transported patients are usually directly admitted to hospital wards bypassing the emergency department. The countries that follow this model include: Germany, France, Greece, Malta and Austria (6-10).

Anglo-American model:

In contrast to the Franco-German model, the Anglo-American model is based around a “scoop and run” philosophy (4). This approach means minimal stabilizations and rapid transport to nearest health care facility. Thus, its aim is to rapidly bring patients to the hospital. It is usually allied with public safety services such as the police or fire departments rather than public health services and hospitals (11). Trained paramedics and Emergency Medical Technicians (EMTs) run the system. It relies heavily on land ambulance services and less so on aero-medical or coastal ambulances. In countries following this model, emergency medicine is generally recognised as a separate speciality. Training programmes are hospital-based rather than field based as in the Franco-German model. All patients within the Anglo-American model are transported by EMS personnel to developed Emergency Departments rather than hospital wards. Countries that employ this type of delivery include: the United Kingdom, the United States, Canada, New Zealand and Australia (3, 11-13).

Table 1: A Comparison between Franco-German model and Anglo-American model.

Conclusion

While both systems have the same principal mission when delivering emergency care, they differ when delivering non-urgent care and scheduled transport. The conventional European style is to consider primary care options other than transporting patients to emergency departments. In this model, patients are frequently escorted directly to an appropriate hospital floor as opposed to the emergency department should this be more appropriate for the patient. This decision is determined by the attending pre-hospital physician (14-17).

Many studies have attempted to compare the two systems or assess whether one is superior to the other in terms of outcome or cost-effectiveness. However, it seems that the systems cannot be compared as they tend to operate in different contexts with different demands to meet. Furthermore, the lack of unified standards between the two models makes comparison a difficult task. Thus, there is no evidence that one model is better than the other and a number of conducted studies show conflicting conclusions (4, 14, 16, 18-20).

There is a recent movement to advocate a mixed model between the two systems. In essence, combining the European health model and the American public safety model of EMS to create a ‘hybrid’ system. However, this opinion is not without drawbacks. One potential negative is that such an approach has the potential for a lack of funding as it may be considered neither public safety or health oriented (17). However, there are some promising results from countries that have tried a ‘hybrid’ system such as the Paramedic Practitioner Scheme in the UK (1, 2).

In conclusion, traditionally there are two models of EMS care delivery: Anglo-American which is based on “load and go” and Franco-German which is based on “delay and treat”. No model appears to be superior than the other and ultimately improving patient’s outcome is the target for both systems. In my opinion, the emergent of the two models was politically driven rather than a result of robust medical evidence. A hybrid system between the two models will probably dominate the future of international EMS. For medical students, EMS is an example of an atypical branch of medicine which is rarely taught in a typical undergraduate medical degree. Perhaps it is time to integrate this interesting field into medical education.

Sultan Al-Shaqsi is 3rd year medical student at the Dunedin School of Medicine in New Zealand currently studying an intercalated degree in EMS
veen2004(at)hotmail.com

References

1. Moore L. Measuring quality and effectiveness of prehospital EMS. Prehospital Emergency Care. [Review]. 1999 Oct-Dec;3(4):325-31.

2. Razzak J, Kellermann A. Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization2002;80:900-5.

3. Huiyi T. A Study on Prehospita Emergency Medical Service System Status in Guangzhoa. Hong Kong: University of Hong Kong; 2007.

4. Dick W. Anglo-American vs. Franco-German emergency medical services system. PREHOSPITAL AND DISASTER MEDICINE2003;18(1):29-35.

5. Fleischmann T, Fulde G, Fleischmann T, Fulde G. Emergency medicine in modern Europe.[see comment]. Emergency Medicine Australasia2007 Aug;19(4):300-2.

6. Adnet F, Lapostolle F, Adnet F, Lapostolle F. International EMS systems: France. Resuscitation2004 Oct;63(1):7-9.

7. Roessler M, Zuzan O. EMS systems in Germany. Resuscitation2006 Jan;68(1):45-9.

8. Papaspyrou E, Setzis D, Grosomanidis V, Manikis D, Boutlis D, Ressos C, et al. International EMS systems: Greece. Resuscitation. [Review]. 2004 Dec;63(3):255-9.

9. Weninger P, Hertz H, Mauritz W. International EMS: Austria. Resuscitation2005;65(3):249-54.

10. Spiteri A. EMS systems in Malta. Resuscitation2008 Feb;76(2):165-7.

11. Pozner CN, Zane R, Nelson SJ, Levine M, Pozner CN, Zane R, et al. International EMS systems: The United States: past, present, and future. Resuscitation. [Historical Article]. 2004 Mar;60(3):239-44.

12. Symons P, Shuster M. International EMS Systems: Canada. Resuscitation2004;63(2):119-22.

13. Trevithick S, Flabouris A, Tall G, Webber C. International EMS systems: New South Wales, Australia. Resuscitation2003;59(2):165-70.

14. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide.[see comment]. Annals of emergency medicine1999 Jan;33(1):97-103.

15. Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G, et al. Emergency Medical Service (EMS) systems in developed and developing countries. Injury. [Comparative Study Multicenter Study]. 2007 Sep;38(9):1001-13.

16. Roudsari B, Nathens A, Cameron P, Civil I, Gruen R, Koepsell T, et al. International comparison of prehospital trauma care systems. Injury2007;38(9):993-1000.

17. Pan American Health Organization W. Emergency Medical Services Systems : lessons learned from the United States of America for Developing Countries. Holtermann K-e, editor. Washington D.C: PAHO HQ Library Cataloguing-in-publication; 2003.

18. Dib J, Naderi S, Sheridan I, Alagappan K. Analysis and applicability of the Dutch EMS system into countries developing EMS systems. Journal of Emergency Medicine2006;30(1):111-5.

19. Riediger G, Fleischmann-Sperber T. Efficiency and cost-effectiveness of advanced EMS in West Germany. The American journal of emergency medicine 1990;8(1):76.

20. Zieziulewicz T TW. Effectiveness and Efficiencies in Emergency Medical Services, NHTSA Technical Report,. 1982 1982.

21. Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, et al. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial.[see comment]. BMJ. [Randomized Controlled Trial Research Support, Non-U.S. Gov't]. 2007 Nov 3;335(7626):919.

22. Woollard M. The role of the paramedic practitioner in the UK. Journal of Emergency Primary Health Care2006;4(1).

Background

Child health status in Pakistan is below acceptable levels, with 0.4 million under-five deaths each year and more than 500 children die every day before reaching age of one month [1-2]. The majority of under-five deaths are attributed to vaccine-preventable diseases, pneumonia, diarrhoea and under-nutrition [1-4]. [Table 1] Furthermore, progress in child health has been patchy and strategies must focus on cost-effective and practical interventions [5-7]. Evidence to support interventions in existing health system infrastructure, aimed to improve maternal and child health, is well documented [8-9] and these can be effectively incorporated into a child health and sanitation week.

1. Child Health and Sanitation Week

Child health and sanitation week was piloted in 2007 in two districts of Pakistan’s Punjab province. During the week, children were immunized and de-wormed; pregnant women vaccinated with tetanus toxoid; and health education sessions on exclusive breastfeeding, pneumonia and hygienic practices were arranged.

The author was with Department of Health District Nankana Sahib on volunteer medical student rotation during November 2007 and was involved in the implementation, operation and evaluation of first ever Child Health Week in Pakistan – piloted during November 2007 in two districts of Punjab province including Nankana Sahib – having 1.8 million habitants and located in central Punjab. Child health and sanitation week was piloted for first time with all available resources and every effort was made for its successful implementation by over 6000 health personnel and volunteers. A high level of commitment and ownership by one and all – in particular the district department of health– was the driving force behind the successful implementation of the project. Immunization and deworming were most successful parts of the activity. Backlogs in immunization coverage were successfully covered and almost all target children were de-wormed. However, health education during the event was not up to the expectations, the main reason being the lack of knowledge among health workers about communication skills. Haphazard supply of logistics, ineffective training and insufficient funds for field work were the other constraints. The week was again celebrated in two pilot districts in April 2008 and health education regarding diarrhea was imparted along with exclusive breast feeding and hygiene. In November 2008, the week was implemented in three districts of Punjab. Keeping in view the success of the project, the week was held in nine districts of Punjab in March 2009; and sanitation part of the project was focused by involving local governments and community development department and improving the health education sessions.

The week was again celebrated twice in 2008 focusing on immunization; deworming; and behavioral change regarding diarrhea, pneumonia, exclusive breast feeding and hygiene. Keeping in view the success of project, it was held again in 2009 and sanitation was also focused. The government plans to hold the weeks biannually and gradually increase number of districts.

2. Issues focused on in Child Health and Sanitation Week

Immunization and de-worming

Vaccine-preventable diseases remain the most common cause of childhood mortality with three million deaths each year and immunization can therefore significantly reduce mortality and morbidity among children [4, 10]. Diphtheria-Pertussis-Tetanus vaccine 3rd dose (DTP3) coverage is used usually to indicate coverage of immunization services [11]. Multiple doses of a vaccine are usually required to develop full immunity in a child against a particular disease and a high drop-out rate between first and last dose of a vaccine indicates low immunity. In Pakistan, DPT3 coverage is 83% and drop-out rate between DPT1 and DPT3 is 7% [12]. Protection from neonatal tetanus at birth in Pakistan via maternal immunization against tetanus is 80% [12-13]. Routine services under Expanded Program on Immunization are essential to maintain immunization coverage, in addition to which mass campaigns can play an important role [11, 14]. However, such campaigns have been used for polio and measles only at present. To fully vaccinate all children in appropriate age would require significantly increased effort [11, 14].

Large reductions in wasting, malnutrition and anemia world-wide that followed deworming contributed significantly to child survival and development [15-17]. A World Health Assembly resolution in 2001 set the goal of achieving 75% deworming coverage of population at risk by 2010 [18]. Although soil-transmitted helminthiasis is endemic in Pakistan, yet no deworming or helminth control program currently exists [19]. Implementation of any helminth control program requires strong links with existing interventions that are already in place to reach women and children [20].

Child health and sanitation week provided an integrated platform to cover backlogs in immunization, improve routine immunization coverage and carry out mass de-worming – it was the first ever large-scale effort for helminth control in Pakistan.

Behavioural changes

Breast feeding – in particular exclusively in first six months – is associated with reduced child mortality, morbidity and improved development [21-22]. Studies have shown that community interventions such as health education, peer counseling and support groups can promote breast feeding [23]. In addition, evidence suggests that behavioral change interventions in pneumonia and diarrheal disease, and family practices can significantly improve child survival and development [13, 24].

Community health education imparted by health workers regarding exclusive breastfeeding, pneumonia, diarrhoea and hygiene practices during child health and sanitation week provided an opportunity to encourage behavioral changes using existing infrastructure.

Sanitation

Around 10% of total disease burden worldwide could be prevented by improving water, sanitation and changing hygiene-related behaviors [25]. Viewing the importance of issue, UN General Assembly declared 2008 as international year of sanitation [26]. Pakistan made rapid progress in sanitation despite formidable odds and 40% of population gained access to improved sanitation source between 1990 and 2006 [26]. But still 68 million people have no access to an improved sanitation facility and 50 million practice open defecation; demanding an extra level of effort [26].

A special focus on sanitation was given during the recent child health and sanitation week by involving local governments and community development departments to provide resources, and spreading key hygiene messages for public awareness.

3. The Future

Child health and sanitation week provided a package for integrated delivery of health and nutrition interventions using the existing health system. It cost only 0.33 US$ per child per year [2] and was well-supported by government and donor agencies. In the future it could be made integrated into district annual plans with budget allocation from health sector.

The government plans to hold the weeks biannually and gradually increase the number of districts. Although most objectives of the project were successfully met but the following recommendations may help to get the better results in future:

· To increase validity of immunization coverage, vaccination cards should be provided to all the eligible children; and parents, especially those with poor socioeconomic background, should be motivated to keep the cards safe and accessible. If vaccines could be provided, TT immunizations should be given to all women of child-bearing age.

· Supervisory staff, especially mid-level health managers, should receive trainings for evaluation and use of data for action. Focused training programs should be organized for all the relevant health workers in communication skills and use of print material to motivate clients. The provincial and district health development centers can be utilized for that purpose.

· Logistics should be at hand at least fifteen days prior to child health week. The Information, Education and Communication (IEC) resources should be decentralized to district level and the promotional material should be tailored according to local needs.

· Sanitation wing of district health departments should be reorganized to make it fully functional and coordination with other departments should be increased at district level.

Child health and sanitation week appears to be an effective way to deliver interventions to improve child health with ultimate goal to prevent early childhood diseases in author’s view. Viability of project depends upon planning at district levels and sustainability of funding by donor agencies. To meet Millennium Development Goal (MDG) target to reduce under-five child mortality to two-thirds between 1990 and 2015, many countries will have to implement similar projects. Feasibility of conducting child health and sanitation week in Pakistan can serve as model for developing countries with similar infrastructure.

Umair Mushtaq is a final year MBBS student at Allama Iqbal Medical College in Lahore, Pakistan
umairmushtaq_aimc@yahoo.com

Acknowledgements

The author like to acknowledge the efforts of Erica and Mohsin Zia for their valuable comments on earlier versions of this article. I am highly grateful to Prof. Arif M. Siddiqui, MBBS, MD, MRCP, FRCP (London), FRCP (Edin), FRCP (Glasg) Chief Coordinator, Student Research Society and Professor of Medicine, Allama Iqbal Medical College, Lahore, Pakistan; Dr. M. Ashraf Majrooh, MBBS, DCH, MPH, FCPS Coordinator, Student Research Society and Associate Professor of Community Medicine, Allama Iqbal Medical College, Lahore, Pakistan; and Dr. Mushtaq Ahmad Shad, MBBS, DCH, MSc (Med Admin), FRSH (London) Executive District Officer Health, District Nankana Sahib, Punjab, Pakistan for their support and guidance.

References

1. United Nations Children’s Fund (UNICEF). The State of the World’s Children 2009. New York, NY: UNICEF, 2008.

2. United Nations Children’s Fund (UNICEF). Annual Report 2008: UNICEF Pakistan. Islamabad, Pakistan: UNICEF, 2009.

3. World Health Organization (WHO). World Health Statistics 2008. Geneva, Switzerland: WHO, 2008.

4. World Health Organization. The world health report 2004: changing history. Geneva, Switzerland: WHO, 2004.

5. Bhutta ZA, et al. Maternal and child health: is South Asia ready for change? BMJ, 2004, 328(7443): 816-9.

6. Haines A, Cassels A. Can the Millennium Development Goals be attained? BMJ, 2004, 329: 394–397.

7. Nullis-Kapp C. The knowledge is there to achieve development goals, but is the will? Bulletin of the World Health Organization, 2004, 82: 804–805.

8. Jowett M. Safe Motherhood interventions in low-income countries: an economic justification and evidence of cost effectiveness. Health Policy, 2000, 53: 201–228.

9. World Health Organization. The world health report 2002 – Reducing risks, promoting healthy life. Geneva, Switzerland: WHO, 2002.

10. Centre for Global Development. Making Markets for vaccines: from ideas to actions. Washington DC: Centre for Global Development, 2005.

11. Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child survival, growth and development: a review of the evidence. Geneva, Switzerland: WHO, 2004.

12. World Health Organization and United Nations Children’s Fund. WHO/UNICEF Review of National Immunization Coverage 1980-2007: Pakistan. Geneva, Switzerland: WHO & UNICEF, 2008.

13. Griffiths U, Wolfson L, Quddus A, Younus M, Hafiz R. Incremental cost-effectiveness of supplementary immunization activities to prevent neo-natal tetanus in Pakistan. Bulletin of the World Health Organization, 2004, 82: 643-651.

14. World Health Organization. State of the world’s vaccines and immunization. Geneva, Switzerland: WHO, 2002. (WHO/V&B/02.21).

15. Stoltzfus RJ, et al. Effects of the Zanzibar school-based deworming program on iron status of children. American Journal of Clinical Nutrition, 1998, 68: 179–186.

16. Stoltzfus RJ, et al. Malaria, hookworms and recent fever are related to anaemia and iron status indicators in 0- to 5-y old Zanzibari children and these relationships change with age. Journal of Nutrition, 2000, 130: 1724–1733.

17. Stoltzfus RJ, et al. Low dose daily iron supplementation improves iron status and appetite but not anemia, whereas quarterly anthelminthic treatment improves growth, appetite and anemia in Zanzibari preschool children. Journal of Nutrition, 2004, 134:348–356.

18. World Health Organization. Schistosomiasis and soil-transmitted helminth infections. Resolution WHA54.19. Geneva, Switzerland: WHO, 2001.

19. World Health Organization. Progress report on number of children treated with anthelminthic drugs: an update towards the 2010 global target. Weekly epidemiological record 2008, 83: 237–252. (http://www.who.int/wer)

20. World Health Organization. Report of the third global meeting of the partners for parasite control: Deworming for Health and Development: Geneva, 29–30 November 2004. Geneva, Switzerland: WHO, 2005. (WHO/CDS/CPE/PVC/2005.14)

21. Leon-Cava N, et al. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington, DC: Pan American Health Organization, 2002.

22. World Health Organization. The optimal duration of exclusive breastfeeding: results of a WHO systematic review. Geneva, Switzerland: WHO, 2001.

23. Green CP. Improving breastfeeding behaviours: Evidence from two decades of intervention research. Washington, DC: Academy for Educational Development, 1999.

24. World Health Organization. The World health report: 2005: make every mother and child count. Geneva, Switzerland: WHO, 2005.

25. World Health Organization. Safe water, better health: costs, benefits and sustainability of interventions to protect and promote health. Geneva, Switzerland: WHO, 2008.

26. World Health Organization and United Nations Children’s Fund Joint Monitoring Program for Water Supply and Sanitation. Progress on drinking water and sanitation: special focus on sanitation. New York, NY and Geneva, Switzerland: WHO & UNICEF, 2008.

Lady Health Workers are vital in providing primary health care to marginalised women and communities in Pakistan. For my Intercalated BSc in International Health project, I visited Pakistan to research why some Lady Health Workers leave their job soon after training.

Pakistan is a male-dominated society which restricts women’s opportunities and rights. This culture radically impacts upon the general health status of Pakistani women and restricts their access to health care (1). Prominent gender norms limit most women’s mobility and interaction with male health personnel, creating a nationally recognised demand for health care that will addresses female and child health needs (2).

The National Programme for Family Planning and Primary Health Care was created in 1994 to address Pakistan’s inequity in health provision and is now the world’s largest Community Health Worker programme, serving 70% of the population. Commonly referred to as the Lady Health Worker programme, the 98,000 female workers aim to ‘bridge the gap between the community and health facilities’ and ensure the whole population has effective access to health services (3). It especially caters for women who face social or physical barriers to healthcare by using Lady Health Workers who can reach all family members.

However, the environment which creates strong need for Lady Health Workers also challenges the function of the programme. Lady Health Workers must work in a male-dominated health system and often must work around strict, socio-cultural norms (4). Unsurprisingly, recruitment and retention of Lady Health Workers is a complicated task but essential for the sustainability and effectiveness of the programme.

Recent Findings

My qualitative study in May 2008 aimed to discover and explore factors that cause workers to leave the Lady Health Worker programme through 12 semi-structured interviews, a focus group and participant observation with workers from Rawalpindi who had resigned. The findings shed light on problems faced by female health personnel in the gender-restrictive societies typical to South Asia.

The Lady Health Workers I interviewed had resigned no earlier than January 2007, they had worked for a minimum of 2 years, and came from various rural and urban locations. Thematic analysis was performed on the interviews, and findings were triangulated with findings from discussion with key actors, the participant observation and focus group discussion.

Lady Health Workers

Lady Health Workers must be a long-term resident of and recommended by their community, with at least 18 years of age and 8th grade education. On completion of 3 months full-time and 12 months part-time training they become civil servants with an annual contract and monthly salary of Rs2990 (approximately £25).

The routine work of Lady Health Worker includes family planning, health education, maternal and child care and vaccination. She must visit approximately 150 homes within her community, liaise with the local Basic Health Unit and open her home as a ‘health-house’. Other tasks include setting-up and facilitating health committees and women’s groups and attending 15 days refresher training annually (3).

Annual attrition of Lady Health Workers is estimated at 5% which requires an extra 5,000 Lady Health Workers to be trained annually (5,6). This wastes precious resources, disrupts the programme’s function and destroys community and Lady Health Worker relationships, yet little enquiry has been given to why certain newly qualified Lady Health Workers leave their jobs. This must be examined if Pakistan wants to meet its recruitment target of 110,000 Lady Health Workers by 2010 (7).

A Lady Health Worker marking a house as part of her door-to-door Polio vaccination work

Results:

Unfortunately, limited and poor quality data did not allow the attrition of Lady Health Workers in Rawalpindi to be reliably determined but the evidence available suggests increasing loss of workers. Improved record keeping and an effective staff complaints procedure are needed to investigate complaints and to correct or minimise problems. Recent plans to computerise the programme’s human resources records should make this task easier and allow for cross examination of data (7).

Two thirds of the reasons for Lady Health Workers leaving the programme are within the programme’s control and 40% of these internal factors relate to the demanding nature of the work and inadequate or delayed pay. Polio work was seen as particularly demanding and distressed to the Lady Health Workers and their families as “women have to go far away and door-to-door which is not right.”

Unfortunately, even a small salary increase is extremely expensive due to the large size of the programme and making the work less demanding may compromise its effectiveness. However, ensuring that pay is regular and making the job a fixed position would be provide greater financial security for Lady Health Workers. Likewise, making polio work optional and additionally salaried would introduce flexibility in workload and salary. Lady Health Workers with dissatisfactions could opt out of the service and others, who need extra money, could benefit.

Poor community respect or difficult relationships with other health personnel was the next major reason for Lady Health Workers leaving. As one Lady Health Worker noted: “the problem is with our society, with men. They talk about her (the Lady Health Worker) badly and this gives Lady Health Workers a bad reputation. Men make a bad impression for ladies’ work; they call them ‘the equipment of family planning’. ” Changes that would improve Lady Health Worker respect among the community and health professionals include ensuring medical supplies are regular, increasing health personnel’s understanding of a Lady Health Worker’s job and providing Lady Health Workers with identity cards.

Reasons for leaving that are outside of the programme’s control include illness, family needs or family dissatisfaction with a relative being a Lady Health Worker. As a father of a Lady Health Worker explained: “they (the Lady Health Workers) go there and go far away and I won’t permit this. The area needs to be smaller and based at home. Then it is okay”. Single Lady Health Workers are more likely to be stopped from working by their families than married or widowed Lady Health Workers. As with Bangladesh’s female health worker programme, the job could be limited to married or widowed women whose family must give consent (8). Yet, tightening the selection criteria risks decreasing the availability of women able to work as Lady Health Workers in areas where recruitment is difficult, and the requirement of marriage could be seen as discriminatory.

Inadequate training and limited promotional options were dissatisfactions mentioned by many of the participants, regardless of their reason for leaving. An increase in the volume and frequency of training and providing certificates for such courses are ways to improve job satisfaction. Similarly, wider promotional choices and better safety were thought to be important.

Table 1: Suggestions that may help address Lady Health Worker attrition.

Further research is needed to examine this topic in different districts so that it is clear whether the findings can be generalised. Likewise, research is needed to determine why some women find the work so demanding and others appear to have no problem as this is the major factor associated with women leaving their employment. Only with greater understanding in these areas will the programme know how to improve the work and pay conditions to satisfy the majority of Lady Health Workers.

The full-text of my project is available on the University of Leeds’ Intercalated BSc in International Health website here.

Harriet Burn is a 4th year medical student at the University of Leeds

REFERENCES

1. Sen G, Östlin P, George A. Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why it exists and how we can change it. Final Report to the WHO Commission on Social Determinants of Health Women and Gender Equity Knowledge Network 2007.

2. Ministry of Health, Prime Minister’s National Programme for Family Planning and Primary Health Care. 1996, Islamabad, Government of Pakistan.

3. National Programme for Family Planning and Primary Health Care: Ministry of Health: Government of Pakistan. [cited 12/12/07]; Available here.

4. Mumtaz Z, Salway S, Waseem M, Umer N. Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy and Planning. 2003; 18(3):261-9.

5. Oxford Policy Management. Lady Health Worker Programme External Evaluation of the National Programme for Family Planning and Primary Health Care Final Report. Oxford Policy Management, Oxford 2002.

6. Ministry of Health. National Programme for Family Planning and Primary Health Care. The Lady Health Workers Programme 2003 – 2008. Government of Pakistan.

7. PHC Wing, Ministry of Health. Annual Report: National Program for FP and PHC – August 2005 – September 2006. 2006. Government of Pakistan.

8. March 2007: BRAC at a Glance. 2007 [cited 12/12/07]; Available here.

Guidelines are a series of recommendations and strategies which aid practitioner and patient decisions about appropriate health care for specific clinical situations (1). Produced routinely by medical organisations, guidelines are crucial tools in the delivery of effective care. Often based on large-scale clinical trials, they define optimal goals for the diagnosis and treatment of disease, set standards for medical practice and education, promote critical appraisal of current literature and highlight inequalities in care delivery (2).

Despite the huge wealth of knowledge on which they are based, guidelines often fail to influence health care in parts of the world where they are most needed. The majority of guidelines are currently produced by medical organisations in Western countries. By focusing on ‘gold standard’ diagnostic and treatment options, guidelines assume unlimited access to resources and funding and so are irrelevant in large areas of the world where the lack of fundamental infrastructure poses a severe limitation to medical practice. As such, many guidelines are ‘resource-blind’ and exclusive to Western countries. Moreover, guidelines may be particularly important in developing countries, where patients often have less input into their care and so doctors must be fully aware of all management options (2).

As an example, the American Gastroenterology Association (AGA) 2007 guidelines recommend the use of computerised tomography scanning to diagnose and manage acute pancreatitis; however, this technology is unavailable in the majority of hospitals in resource-poor countries. AGA 2007 algorithms also suggest the use of angiography and capsule endoscopy for the diagnosis of occult gastrointestinal bleeding, techniques unlikely to be used outside Western nations (3).

Professor Suliman Fedail, a gastroenterologist based in Sudan, deals daily with oesophageal varices caused by high levels of chronic hepatitis B infection. He highlights the impracticality of the recommended treatment in this setting: “Vasoactive drug therapy is unrealistic in most developing countries. These drugs are not available in district hospitals and in Khartoum vials of Glypressin (1mg) cost the equivalent of 25% of the salary of a house-physician”.

Guidelines may imply an ‘all or nothing’ approach which may cost lives and prevent the dissemination of knowledge by only publishing optimal goals for diagnosis and treatment, rather than a list of ‘next best’ options. Focusing on evidence rather than resources renders guidelines theoretical rather than practical (3). Furthermore, the varying patterns and presentations of disease in the developing world may not be accounted for in Western-orientated guidelines (4). Finally, different cultural values are often not considered, limiting the acceptability and applicability of guidelines.

In response to these limitations, the World Gastroenterology Organisation (WGO) has recently developed the concept of ‘cascades’ in order to increase the implementation of their guidelines in developing countries (2,5).

Cascades are ‘a collection of related diagnostic and treatment options arranged hierarchically in terms of conditions and available resources, aiming to achieve the same outcome’ (2). They provide realistic alternatives to preferred practice, taking into account local conditions such as available technology, infrastructure and training. Involvement of local experts in the development of global guidelines is crucial to ensure appropriate topics are addressed and recommendations take into account local conditions. Hence, the WGO guideline review teams include clinicians from developing countries (4). Guidelines are thus made relevant to many more clinicians worldwide, who can work productively at the level best allowed by their immediate environment.

The WGO aims to include cascades in all of its new guidelines, which include the management of acute diarrhoea, colorectal cancer and bleeding oesophageal varices. For example, the WGO provides six therapeutic options for the management of acute diarrhoea which range from the gold standard (intravenous fluids, antibiotics and diagnostic tests such as stool microscopy) to a home-made rehydration solution, an effective, life-saving treatment (3). (Figure 1)

The World Gastroenterology Organisation cascade for acute diarrhoea with severe dehydration. The treatments are arranged in a hierarchy depending on available resources. Level 1 represents the ‘gold standard’ treatment and Level 6 is the most basic management, but it is preferable to no treatment at all. Taken from (9) with permission.

Professor Eamonn Quigley, president of the World Gastroenterology Organisation, comments: “The primary mission of WGO relates to education and training with a particular emphasis on emerging and underserved regions. Though the burden of digestive disorders is considerable in these regions as evidenced by the high prevalence of digestive cancers and ongoing toll of childhood diarrhoea and hepatitis, scant attention has been paid to promoting relevant training in the care of digestive disorders. Guidelines prepared in the West both ignore certain diseases that occur in poorer nations and fail to acknowledge the personnel, infrastructure, technology and therapeutic shortages and deficiencies that will preclude the application of a Western guideline. Thus our development of the cascade approach, which we hope will alleviate this imbalance and promote greater recognition of different working conditions”.

The Breast Health Global Initiative (BHGI) is another scheme which includes cascades in its guidelines. Founded by the American breast surgeon Ben Anderson, it has defined evidence-based but resource-sensitive guidelines for the early detection, diagnosis and treatment of breast cancer, the leading cause of female cancer-related death in the world. Despite more than 55% of breast cancer deaths occurring in low and middle income countries, previously developed guidelines have focused on resource-rich environments and are irrelevant in economically constrained nations (6).

The BHGI guidelines stratify resources into four levels (basic, limited, enhanced and maximal) and suggest different diagnostic and management options for each. For example, in nations with ‘basic’ level resources, early detection methods for breast cancer include improving breast health awareness and clinical examination, whilst in countries with ‘maximal’ resources, population screening using mammography is optimal (6,7). In addition, the BHGI recommends single film rather than double film mammography in economically disadvantaged countries which cuts costs without significantly limiting image quality (3). By matching management options to resources, guidelines can therefore be applied to countries of varying wealth.

The BHGI has hence been identified by the Institute of Medicine as an innovative model for developing economically feasible alternatives for the diagnosis and treatment of other cancers and chronic diseases in low and middle income countries. These conditions are likely to become more important in developing countries as life expectancy increases and lifestyles become more westernised.

Once cascades have been established as ‘best practice’ for global guidelines, the next challenge will be to ensure that guidelines developed in one country can be applied to the disease presentation of another country. For example, in a nationwide study on irritable bowel syndrome in India, researchers found a contrast between patient demographics and presenting symptoms defined by European-generated guidelines and the Indian population studied. Guidelines such as the 2006 Rome III Criteria (8), which assume a constellation of symptoms based on a Western model, may be misleading for physicians treating populations in other countries.

In conclusion, guidelines are a vital tool in medicine and they should always publish the evidence-based gold standard. However, in order to impact healthcare in the developing world, it is important for them to incorporate clinically proven, financially feasible and culturally acceptable alternatives.

Kylie Beale is a sixth year MB PhD student at Imperial College, London
kylie.beale04@imperial.ac.uk

The author wishes to thank Kate Mandeville, a clincial fellow in public health, for her assistance in writing the paper.

References

1. MF Field, KN Lohr. Institute of Medicine Clinical Practice Guidelines: Directions for a New Program. National Academy Press 1990: 38.

2. Fried M, Quigley EM, Hunt RH, Guyatt G, Anderson BO, Bjorkman DJ et al. Are global guidelines desirable, feasible and necessary? Nature Clinical Practice Gastroenterology and Hepatology 2008 January; 5(1): 2-3.

3. Fried M, Krabshuis J. Can ‘Cascades’ make guidelines global? Journal of Evaluation in Clinical Practice 2008 October; 14(5): 874-9.

4. Fried M, Quigley EM, Hunt RH, Guyatt G, Anderson BO, Bjorkman DJ et al. Can global guidelines change health policy? Nature Clinical Practice Gastroenterology and Hepatology 2008 March; 5(3): 120-1.

5. Quigley EM, Fried M, Krabshuis JH. Use of evidence in WHO recommendations. Lancet 2007 September 8; 370(9590): 824-7.

6. Anderson BO, Jakesz R. Breast cancer issues in developing countries: an overview of the breast health global initiative. World Journal of Surgery 2008 December; 32(12): 2578-85.

7. Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A et al. Guideline implementation for breast healthcare in low-income and middle-income countries: overview of the Breast Health Global Initiative Global Summit 2007. Cancer 2008 October 15: 113(8 Suppl): 2221-43

8. Rome Foundation diagnostic questionnaire and criteria for Irritable Bowel Syndrome

9. World Gastroenterology Organisation practice guidelines: Acute diarrhoea. March 2008.

This article has been written as part of the partnership between The Lancet Student and Asian Medical Students’ Association International. The 30th Asian Medical Students’ Conference will be held next week in Taiwan on the theme of ‘Stigmatised Illnesses: To understand, to accept, and to change’. We look forward to hearing about the conference, look out for the conference blog and podcast next week! Alistair Hustig, the Secretary of Academcis – Asian Medical Students’ Association International, has written this fantastic article on the theme.

‘Stamping out Mental Health Stigma’, NHS.

Stigma. This one word often represents the most crucial element effecting people living with a wide range of illnesses. It negatively impacts efforts to treat and prevent disease, and adversely affects individuals’ quality of life. Many illnesses have a high prevalence of stigma including mental illnesses, cancer, leprosy, and sexually transmitted diseases. However, the type of stigma varies with different conditions. This article highlights some causes and differences of stigma associated with mental health and HIV, as well as successful strategies of reducing its impact.

Definitions of stigma encompass social identity (deviance from what is normal), power discrepancies (that allow discrimination), and discrediting attributes that result in devaluation of people living with illnesses, such as those above (1,2,3). This often manifests itself in an external sense as discrimination, hatred, intolerance, rejection, and exclusion. However what is often under-recognised is the internal aspect of stigma. Internal manifestations can include self-loathing, shame, and self-blame, all of which are preyed upon when someone stigmatises (3,4). Stigmatisation can also extend to family, friends, and even to institutions and clinics which themselves perpetuate stigma. As a result anyone associating with patients, or visiting centres, can be dragged into the net of stigma.

People living with Mental Illness
People who have depression, schizophrenia, and other mental illnesses, commonly report stigma from both community and health professionals. Depression is a leading cause of disability effecting 121 million people worldwide (5). Schizophrenia affects millions of people. Of these, only 25% of those with depression, and 50% of those with schizophrenia who are in need of treatment are receiving appropriate therapy (5). These figures suggest that stigma, at least in part, may be having an affect on treatment of mental illness. The perception of depression as a weakness rather than an illness (6); or people with depression are dangerous, and ‘schizophrenics’ are violent (6,7) remains embedded in public opinion. These views are less shared with other common illnesses for example cardiovascular disease. Unlike mental illnesses, cardiovascular disease is less stigmatised at least in part because the aetiology, pathophysiology, and successful treatments are well known. The fear of the unknown may therefore contribute to stigma being ingrained in an illness. As a result people with the illness are afraid of disclosing to family and friends, and do not seek help where it would be of benefit (6). Health practitioners, even those in the field of mental health can also stigmatise through intensive use of language and labelling. Some are more empathic and understanding of the nature of the illnesses, but some practitioners continue to define their patient by their illness. The difference in language is powerful – a ‘schizophrenic’, whose behaviour defines them, versus a ‘person living with schizophrenia’, whose illness causes altered behaviour (7). This labelling may plague the patient as a ‘life sentence’ (7) reducing self-esteem, withdrawing social opportunities, and creating ongoing employment difficulties (8), ultimately ruining any chance of normality.

People living with HIV
It is estimated that around 33 million people worldwide are infected with HIV, with the majority in low- and middle-income countries (9). Of these, only 3 million were receiving appropriate anti-retroviral therapy as at December 2007 (9). Again one of the biggest issues preventing uptake is stigma. However, the stigma signature associated with people living with HIV is different to that explained for mental illness. Bos and colleauges (10) propose a model for stigmatisation of people living with HIV. They describe how perceived contagiousness (everyday contact, not just sex), perceived seriousness (life-threatening), personal responsibility (unsafe sex) and norm-violating behaviour (e.g. male-to-male sex, and intravenous drug use) contribute to increase fear and anger while decreasing pity for people living with the disease. Stigma also surrounds certain groups at increased risk, such as homosexuals, intravenous drug users, and sex-workers. This further stigmatises people living with HIV leading to amplified discrimination and negative social responses. As a result, people living with HIV have a decreased quality of life and are less likely to seek testing, treatment, and counselling, or disclose their status to potential support providers. This can result in advanced presentations with high viral loads, low CD4 counts, and opportunistic infections.

Strategies for Reducing Stigma
The need to address stigma is paramount in order to reduce prevalence and thus burden of illness (e.g. curbing the HIV epidemic), and increase treatment uptake. For mental illnesses, in particular depression, Barney and colleagues (6) suggest that blaming, avoiding, and labelling people living with mental illnesses must be addressed. Accurate knowledge and portrayals of survival and recovery, as well as the true risk to the community for these health conditions needs to be expressed by all means possible, especially the media.

Public disclosure of HIV status has been shown to have a beneficial impact to both the individual and the surrounding community (11). Individuals are often very scared and describe this as the most difficult and dangerous thing to do. Post-disclosure they feel empowered, released from a heavy secret, and less isolated and withdrawn, taking back control of their lives (11). To help facilitate this appropriate training and support needs to be given before disclosing to prepare for potential negative reactions from community members. However, public speaking regarding one’s positive living helps to make the community more aware and dispel myths around HIV, thus reducing stigma. This is echoed by studies involving public speaking by people living with HIV (11) and mental illness (12), which have shown improved attitudes among high school students to those living with the illness. Uniting all people with stigmatised illness would provide a voice that would be far too loud to ignore.

Access to relevant treatment that communities understand is effective and essential in any stigma reduction programme. The case of universal access to HIV therapy in Botswana (which has the 2nd highest prevalence), implemented in 2002, provides clear evidence of reducing stigma (13). Wolfe and colleagues (13) demonstrated pre- and post-implementation that only 31% of people had disclosed positive HIV status to family, and 5% to friends in 2001, compared with 90% and 55% respectively in 2004. Other examples of reduced stigmatising attitudes include an increase in the number of people that would care for a person living with HIV, accept them as a teacher and buy food from a shopkeeper with HIV.

Conclusion
Stigma and its consequences affect the course of illness for many millions of people worldwide. It provides an enormous barrier to all attempts to help people living with stigmatised illnesses. Stigma affects all, it endures, and it compromises survival and recovery of those most in need. We must strive to find new ways to abolish stigma, and thereby allow access to treatment and empowering positive living.

Alistair Hustig, hust0007@flinders.edu.au
Secretary of Academics – Asian Medical Students’ Association International
Australian Medical Students’ Association Councillor
Graduate Entry Medical Programme Year II – Flinders University, Adelaide, South Australia
Bachelor of Medical Science – Flinders University, Adelaide, South Australia

References
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). Reducing HIV Stigma and Discrimination: a critical part of national AIDS programmes. [Online]. 2007 [accessed 20 June 2009]. http://data.unaids.org/pub/Report/2008/JC1521_stigmatisation_en.pdf.

2. Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociology of Health & Illness 2005; 27(4): pp. 468-489.

3. Courwright AM. Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics 2009; 23(2): pp. 90–96.

4. Cameron E. Witness to AIDS. Cape Town: Tafelberg Publishers Limited; 2005.

5. World Health Organization. Mental Health: Disorders Management. [Online]. 2009 [accessed: 21 June 2009]. www.who.int/mental_health/management/en/.

6. Barney LJ, Griffiths KM, Christensen H, Jorm AF. Exploring the nature of stigmatising beliefs about depression and help-seeking: Implications for reducing stigma. BMC Public Health 2009; 9(61).

7. Flanagan EH, Miller R, Davidson L. ‘‘Unfortunately, We Treat the Chart:’’ Sources of Stigma in Mental Health Settings. The Psychiatric Quarterly 2009; 80: pp. 55-64.

8. Corrigan P. How Stigma Interferes with Mental Health Care. American Psychologist 2004; 59(7): pp. 614-625.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). Report on the global HIV/AIDS epidemic. [Online]. 2008 [accessed 20 June 2009]. http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp

10. Bos AER, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: The importance of theory- and evidence-based interventions. Psychology, Health & Medicine 2008; 13(4): pp. 450-460.

11. Paxton S. The paradox of public HIV disclosure. AIDS Care 2002; 14(4): pp. 559-567.

12. Spagnolo AB, Murphy AA, Librera LA. Reducing Stigma by Meeting and Learning from People with Mental Illness. Psychiatric Rehabilitation Journal 2008; 31(3): pp. 186-193.

13. Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, Iacopino V, Heisler M. The Impact of Universal Access to Antiretroviral Therapy on HIV Stigma in Botswana. American Journal of Public Health, 2008; 98(10): pp. 1865-71.