Joshua Schulman-Marcus reports on the anthropological and psychological impact of chronic diseases in developing countries. 

A Personal Reflection

Over the past year, I have written several articles for the Lancet Student on the growing prevalence of chronic noncommunicable diseases (CNDs) in developing countries.  Major studies have indicated that diseases and risk factors such as hypertension, diabetes, tobacco use, and asthma are increasing in low- and middle-income countries in all regions of the world (1,2).  Recognizing these trends, the World Health Organization (WHO) has recently begun to address this new global health priority (3,4).  Researchers and advocates have pointed out that more investment in prevention, screening, and treatment will be needed to avert the resulting unnecessary disability and mortality (5,6).  These reports indicate that CNDs will be a major item on the global health agenda for the duration of our careers.

Most of the research, including the recent series published by The Lancet (7), has been predicated on epidemiology, economic impact, health systems, and potential interventions.  Less has been said about the non-technical implications of a transition to chronic disease in the developing world.  This is unfortunate as “health” extends far beyond the biomedical realm; it is intertwined with sociological structures and culture.  A shift from acute infections and traumas to chronic, often asymptomatic ailments, thus presents a paradigm shift in the notion of what it means to be a healthy person.  This is a serious adjustment that deserves careful consideration.  For how can we expect people to take medicines or alter lifestyles if they don’t believe that they are ill?

I personally saw the anthropological and cultural challenges of the epidemiologic transition when I worked with the Ethiopian Israeli community in 2005.  Arriving in urban Israel from rural Ethiopia in the 1980s, the immigrants had a conception of health that largely revolved around the acute infections and malnutrition endemic to poor countries. Within ten years, though, the prevalence of Type 2 diabetes rose from 0.5% to 17% in some cities.  Similarly, asthma, blood cholesterol levels, blood pressure, and red meat consumption soared.

The Ethiopian immigrants had no word in their common language for diabetes.  I spoke with a man with longstanding diabetes who had never heard of the pancreas.  He didn’t believe he was sick.  As the deleterious elevation of blood glucose is often asymptomatic early in the disease course, it was exceedingly difficult to convince patients to adhere to therapy.  Even worse, the language used to explain diabetes can be very confusing, as the notion of “high sugar” led some patients to believe that sugary foods were the cause of the condition.  Miscommunication between the Israeli primary care providers and the Ethiopian patients, compounded by poverty and power disparities, led to distrust and very poor quality of care.  And this was in a country with a well-financed health system designed to address chronic noncommunicable diseases.

Indeed, the entire notion of chronic disease resulted in confusion and frustration for some Ethiopian immigrants.  “Why can’t the doctor cure me?  Why doesn’t he give me a shot?” asked one.  “He must just be a bad doctor, or maybe he doesn’t treat me because I am Ethiopian.”  I heard similar confusion about the concept of lifelong drug therapy.  One mother, for example, refused to give her son an asthma inhaler, lest he become “addicted” to it like tobacco.  Another, however, wanted constant steroids to treat his mild asthma, because “they make me feel good.”

My discussions with the Ethiopian immigrants and Israeli health workers also hinted at the complexity of advocating lifestyle changes to prevent chronic disease.  Lifestyle is the product of thousands of choices, many of which are heavily influenced by economics, sociocultural norms, and status.  People in developing countries may aspire to eat Western foods high in saturated fats and may choose to smoke American cigarettes to indicate their wealth.  Being overweight or obese, even having some diabetes, may be lauded as a sign of success.  These attitudes can be deeply ingrained, and modifying them will require interventions informed by a nuanced understanding of local culture and health beliefs.  If chronic diseases are not presented in terms that make them believable, most people will be hesitant to significantly alter their lifestyles in order to “prevent” an abstraction.

Over the past few years, attention has been increasingly paid to the coming epidemic of chronic noncommunicable diseases in the developing world.  These diseases can lead to devastating consequences, both physically and economically.  It has thus been recognized that many disciplines will need to be rallied in order to adapt health systems for chronic care, re-train workers, ensure access to medicines, and design cities amenable to physical activity (2-7).  Yet the barriers to the effective prevention and care of these diseases cannot be lowered through the technical expertise of biomedicine or policy alone.  Rather, my experiences have taught me that it will require a more holistic understanding of how individuals adapt to a revolution in the conception of health, illness, and healing.  To do so, I think we first will need to learn how to be better and more patient listeners.

Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York, USA

jschumar@gmail.com

(1) Lopez AD, Mathers CD, Ezzati M et al. Global and regional burden of risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367:1747-57

(2) Jamison D, Breman J, Measham A, Alleyne G, Claeson M, Evans DB et al. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press and the World Bank, 2006.

(3) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002

(4) Preventing chronic diseases: a vital investment.  Geneva: WHO, 2005

(5) Leeder S, Raymond S, Greenberg H, Liu H, and Esson K. A Race against Time: The Challenge of Cardiovascular Disease in Developing Countries. New York: Trustees of Columbia University, 2004.

(6) Yach D, Hawkes C, Gould CL, Hofman K.  The global burden of chronic diseases: overcoming impediments to prevention and control.  JAMA 2004; 291:2616-2622.

(7) Horton R. Chronic disease: the case for urgent global action. Lancet 2007; 370:1881-82.

Kush Patel reports on the violence that occurred in Kenya following the elections earlier this year.

For many years, Kenya has been considered as a refuge for people fleeing their own country because of domestic turmoil. However, on 29th December 2007, shouts emanated from an angry throng that had gathered on the streets. Marching determinedly towards them was a battalion of riot police. Within seconds, the rioters hurled stones at the police, who counterattacked using bullets and tear gas. In other parts of the country, youths clutching machetes and sticks launched themselves upon opposing tribes. Events such as these set the scene for a blood bath that has resulted in thousands of people injured, dead or homeless. Several camps for internally displaced people (IDP) were set up all over the country. Governmental and non-governmental organisations (NGOs) such as Merlin, Medecins sans frontiers (MSF), the Red Cross, AMREF and others, deployed teams to provide humanitarian aid.

Post-election violence in Kenya results in displacement 

photo source: savethechildren.org/au

Trauma victims requiring medical attention overwhelmed the medical facilities. When particularly violent clashes broke out, trucks full of injured or dead people arrived at hospitals, which in-turn became so over-crowded that patients were being treated on the corridors. A system of triage was implemented at many institutions, thus helping to treat the most severe patients first. (2,3) Patients were being rushed in with broken bones, stab injuries, blunt trauma and burns. Doctors reported certain cases where patients had sustained machete wounds that resulted in near-amputations. (3) Flying surgical teams were put on high alert, responding to violence in inaccessible regions. (4) In the worst hit areas, temporary first-aid posts were setup that quickly stabilized victims, while waiting for transport to hospitals. Any person who was critical and needed specialist care was air-lifted to the closest hospital. (3) Many of the victims were (and some still are) mentally traumatized from witnessing the violence or having lost loved ones. These people were given psychosocial support by medical personnel. (2,3)

Cases of sexual violence increased dramatically. These incidents took place both within IDP camps and outside. This will probably result in increased incidence rates of sexually-transmitted diseases, including HIV infection. Counselling and screening for sexually-transmitted infections have commenced in certain areas. (4)

Many people have been displaced and gathered at temporary IDP camps. At these camps severe public health consequences can manifest amongst the IDPs.. Four main reasons behind this are that the population is displaced, food becomes scarce, health care diminishes and living conditions worsen. Studies have shown that mortality rates are usually highest immediately after the migration. (1) Apart from the acute emergencies, an increasingly large number of IDPs need to be accommodated. At each IDP camp, tents were pitched, food and water was provided, sanitation and lavatory facilities were set up and medical camps were established. (2-6) Other essential equipment such as bed nets, (6) cooking apparatus, (3) and clothing, (2,4) was provided to the IDPs. Most IDPs had left their homes without anything. For many, important documentation was lost. Therefore, the task of registering the IDPs and getting new identification cards for them was set into motion. In order to keep the IDPs busy and lessen their emotional stress, some were given responsibilities in the camps such as cleaning. (2) Some NGOs have setup tracing agencies that help reunite lost family members.(4) Planes and helicopters had to be employed to deliver medical and other essential supplies to ill-equipped areas.(3)

The most prevalent diseases amongst IDPs are diarrheal diseases, measles, acute respiratory infections, and malaria. Additionally, many people became malnourished because of the lack of food. This aggravates diseased states and worsens the patient’s prognosis.(1) At a single camp, 541 consultations were done mainly for respiratory tract infections.(3) Most of these patients were children and many had a poor prognosis. Factors that contribute to a high prevalence of respiratory tract infections are: over-crowding, poor ventilation, inadequate shelter, and prolonged exposure.(1)
The measles immunization was provided for children.(3) For those who survive the initial illness, it can lead to malnutrition and vitamin A deficiency. Previously, measles has accounted for high mortality rates amongst children in refugee camps. However, it is less of a threat now compared to before 1990.(1)

Diarrhoeal diseases are a common phenomenon in IDP camps. Factors that contribute to their high prevalence are unsanitary conditions and unsafe drinking water. Cholera and dysentery are the main problems. In some IDP camps, diarrhoeal epidemics had broken out. These were usually treated with oral rehydration salts. However, any serious cases of diarrhoea were referred to a hospital.(4)

Kenya has a high prevalence of tuberculosis (TB) (7) and AIDS. (8) A lot of IDPs with TB or AIDS fled their homes without anything, including their anti-tuberculosis or antiretroviral drugs.(2,3,6) Adding to this, the number of patients attending HIV/AIDS clinics reduced dramatically.(3) This can have serious consequences on their health, as non-compliance results in the development of drug-resistance. Patients also become susceptible to opportunistic infections and their risk of morbidity and mortality increases.(8) One report mentioned a woman trapped at home, unable to gain access to a new dose of anti-retrovirals. As a result, when she was found by relief workers, an infection had set in and she had to be admitted to hospital.(9) Another hurdle with respect to anti-retrovirals is that many HIV patients were not getting adequate nutrition. This resulted in patients unable to tolerate their medication, further increasing non-compliance.(9) Patients with tuberculosis, face a similar scenario where drug-resistance develops.(4,7) The problem with this is that patients then require second-line drugs that are more expensive than first-line drugs.(4) Long-term effects of this may result in increased infection rates within the population. These 2 diseases were a major concern for the NGOs, who constantly held testing clinics, offered counselling and provided medication.(6,2,3) Thankfully this volatile situation has calmed down allowing people to piece together their lives. Medical attention has also improved in most areas. (6)

A correspondent from Merlin gave the following account of a typical day at an IDP camp:
The day usually starts off early, with a meeting discussing the day’s agenda. A clinic is setup wherever space is available (a vacant room or under a tree). Patients are then prioritized according to their level of urgency. Immunizations, HIV testing and counselling and treatment for minor illnesses are provided to those who need them. For those who require referrals to health centres or hospitals, transportation is arranged. Other team members conduct health education sessions for patients while they wait for their consultation.

Kush Patel
Imperial College London
kush.p.patel04@imperial.ac.uk

References
(1) Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu.Rev.Public Health 1997;18:283-312.
(2) Kenya Red Cross operations update. http://www.kenyaredcross.org/highlights.php?newsid=61&subcat=1, 2008.
(3) Medecins sans frontiers. http://www.doctorswithoutborders.org/news/report.cfm?id=2470, 2008.
(4) International committee of the Red Cross. http://www.irinnews.org/Africa-Country.aspx?Country=KE, 2008.
(5) AMREF Kenya news and press releases. http://kenya.amref.org/index.asp?PageID=10, 2008.
(6) Merlin newsletters. http://www.merlin.org.uk/Where-we-work/Kenya.aspx, 2008.
(7) O’Boyle SJ, Power JJ, Ibrahim MY, Watson JP. Factors affecting patient compliance with anti-tuberculosis chemotherapy using the directly observed treatment, short-course strategy (DOTS). Int.J.Tuberc.Lung Dis. 2002 Apr;6(4):307-312.
(8) Frick PA, Gal P, Lane TW, Sewell PC. Antiretroviral medication compliance in patients with AIDS. AIDS Patient Care STDS 1998 Jun;12(6):463-470.
(9) BBC news on Kenya. http://news.bbc.co.uk/1/hi/in_depth/africa/2008/kenya/default.stm, 2008.

Amanda J. Redig, a student at the Feinberg School of Medicine in Chicago, has written an article on the challenges in biomedical research and the increased need - and opportunity - for translational knowledge sharing between physicians and scientists.

An Indian fable tells the tale of several blind men asked to describe an elephant.  The man who reaches the tail declares the unknown animal to be like a rope; the man who brushes past the leg asserts that what is in front of him must be like a tree; while the final man bumps into the tusk and concludes that the unseen creature resembles a spear.  In the end, those of us who can see the elephant know that each individual assessment is both right and wrong: what is missing is the vision required to put all of the pieces together into a comprehensive whole.  What I want to know, as an MD/PhD trainee during arguably the most exciting time to be a student in the history of both medicine and biology, is whether the biomedical community is now confronting a similar challenge.  Recent advances offer a tantalizing glimpse of what our future could be, but has the quest to integrate an ever-widening information pool and spectrum of disciplines become an exercise in describing the elephant?

Without doubt the 20th century’s remarkable achievements in clinical therapies and scientific discovery provide a solid foundation for the enthusiasm with which we can move forward into the 21st.  Yet for every shining success story-the 85% survival rate for pediatric leukemias or the technical achievements behind transplant surgery-we must still confront the published survival curves for a disease like lung cancer.  And here, as with far too many other diseases, despite decades of effort and millions of dollars, not much has changed.  The complexity of understanding human health and disease means that we must continue what is often a painstaking process of piecing together insights that move from structural biology and model organisms to targeted therapies that do have efficacy in the clinic.  From Watson and Crick to chromosomal translocations and the development of imatinib, the connection between scientific advancement and new medical therapies is undeniable.  However, what I can’t help but wonder as I move through the process of dual training as a physician-scientist is if the current trajectory of our research efforts-the overlap between basic science and clinical medicine-is one that in the end will achieve the greatest results.  The progression from lab to clinic might be self-evident, but unless our framework for biomedical progress moves to truly integrate not only the expertise of multiple clinical specialties but also a full spectrum of scientific investigators, 21st century advancement in medicine cannot live up to its potential. 

The foundation of this challenge is clear: much of the time, physicians and scientists simply do not understand one another.  Both parties ask questions, but the good physician arrives at the same diagnosis as any other good physician while the good scientist sees what no one else has and arrives at a new conclusion.  Unfortunately, the stark differences in training and perspective that make laboratory investigators or clinicians successful within their respective fields can and do inhibit the success of potential collaborations that are not exclusively one discipline or the other.  Speaking to this challenge, much has been made in the literature of late about the directions of academic medicine, biomedical research, and the future of so-called translational research.  Editorials and analyses discuss the role of the physician-scientist or clinical investigator as a go-between (1,2) as well as concern about funding mechanisms and the increasing age at which investigators secure independent grants (3-5).  However, even as initiatives such as the National Institutes of Health roadmap or the recommendations of the Cooksey review are exploring ways to bridge science and medicine (6,7), there is also controversy over whether this is even a good idea let alone a feasible goal (8-10).  In the end, much of the discussion falls back to the fundamental differences between how basic scientists and clinicians ask questions-investigator-driven mechanistic grants on the one hand and large-scale correlative studies on the other.  Yet in order to build on the promise of the last century, our challenge is not merely to discuss the possibility of a new paradigm for biomedical research but rather to implement it.

First, we face the task of integrating physicians and scientists when the barriers between them are constructed with each year of the extensive training process.  In most cases, physicians must complete medical school, residency, and often some fellowship training before they have the time to become involved in meaningful laboratory research.  During this same training period, their early-career scientific colleagues have been just as immersed in the no-less rigorous and time-consuming program of focused graduate school and post-doctoral research.  By the time their paths overlap, the boundaries are set: physicians are physicians and bench scientists are bench scientists.  From the perspective of a post-doc who has spent the last ten years dissecting the most intricate of molecular details, the physician who waltzes into the lab not knowing how to pipet but expecting multiple first author publications in less than two years will never be a scientist.  On the other hand, for the senior resident who has thirty seconds to respond to a coding patient in the throes of cardiac arrest, the scientist planning to spend a career elaborating a pathway in fruit flies is out of touch with the real world.  Is it any wonder that each field can view the other with more than a healthy dose of skepticism and sometimes even outright resentment?

Unfortunately, the separation between these fields continues past the early stages of training. By the time a junior scientist is ready to start his own lab or a junior attending moves into her own niche as a professional, the responsibilities of career development at this crucial juncture take priority over exploring the complex challenges that will likely require input and ideas from both physicians and scientists to solve.  Molecular science is emphasized in the very beginning of medical school, but after that, the details take a back seat to the pathophysiology that is the territory of the physician.  This works for training clinicians, but what about clinician-investigators? In turn, Drs. Kaushansky and Shattil encourage aspiring physician-scientists everywhere as they editorialize about supporting the development of biomedical investigators in hematology-oncology, but this very same op-ed also highlights a hole in the cross-disciplinary mentoring of junior scientists (11).  If physicians who move into the scientific arena need support and mentoring to tackle multidisciplinary problems, then the same is true of their scientific peers seeking to apply scientific training to clinical problems.  Yet there seem to be few, if any, organized opportunities for scientists to be introduced to the clinical problems that their technical skills and hypothesis-driven training could help solve.  Even more problematic, although biomedical research buildings are often adjacent to academic hospitals in an attempt to promote translational research, it is much less common to see such collaboration with scientists several steps further away from medicine; engineering, applied math, and computer science have yet to become as closely integrated with biomedical research as molecular biology and genetics.  It is true that the more conventional partnership has led to some success stories-understanding the role of a single gene or pathway in disease has allowed the development of new therapeutic options.  However, as the aftermath of the Human Genome Project has made clear, the majority of chronic diseases-like cancer-that continue to cause great suffering around the world are too complex for the approach of inhibiting a single pathway or kinase to work.  Indeed, the molecular biology-based success of a targeted drug like imatinib remains to be replicated in the mathematically more complex signaling milieu of solid tumors.

While it is easy to take sides in the pull between medicine and science, morbidity and mortality statistics make it clear that we cannot afford to maintain the status quo: we need to fix the culture gap.  In order to translate our leaps and bounds of information acquisition into leaps and bounds that make a tangible difference in patients’ lives, we must broaden not only the scale of our vision but also the connections we are willing to forge to get there.  If communication-or lack thereof-amongst early-career trainees is a barrier to future success, then an added dimension to the training process might produce physicians and scientists with enough common vocabulary to minimize the height of the walls.  For example, Duke University’s medical training program-and now a joint medical school started in collaboration with the government of Singapore-includes a mandatory year of independent scholarship (12).  While the range of chosen research projects is broad, each graduating MD does so not only with firsthand experience of biomedical investigation but also with a new set of skills and language that can be a bridge to future collaborations outside of strictly clinical medicine.  Many academic institutions have recognized the need to better integrate medicine and the life sciences; key to these efforts will be not only involving medical appointees but also providing opportunities for scientists of all stripes to learn more about the clinical challenges-metastasis, antibiotic resistance, microimaging-that practitioners of medicine cannot solve on their own (13-15).  While excellence in a specific discipline should be the goal of graduate training, the gradual acquisition of blinders that prevent recognition of excellence in an outside specialty is not. 

What we are missing, it seems, is a greater focus on not only what our own skill set- whatever that might be-can bring to the table, but also what we stand to gain from the contributions of the others around us.  Although the initial steps of beginning an initiative that focuses on a problem, not a five-year grant project, can be daunting, the results of innovative collaboration are no less remarkable.  When the problem is that of infertility in young women who are cancer survivors, a reproductive biologist at Northwestern University chose to establish a partnership with an engineer to address the structural and biological challenge of ex vivo oocyte maturation.  The combined expertise of two divergent branches of science led to further expansion and a move towards the clinic.  Today, the Center for Families After Cancer encompasses the work of oncologists, surgeons, scientists, engineers, ethicists, and social scientists to move forward a new field that has been dubbed ‘oncofertility’ (16).  On their own, each member of this team held only part of the puzzle, but together their skills and uniquely valuable perspectives have combined to produce a vision that is both more extensive, more accurate, and ultimately more productive than anything they could have done on their own.  Within the time-span of a career, the members of this team will see a profound change-a giant step forward-in a clinical dilemma that until now had no solution.

And if this and similar advancements are slowly developing in some areas of medicine, then why not in one area after another?  As an aspiring oncologist, the challenges are clear-from lung cancer to pancreatic cancer, the list of malignancies for which there are very few options is still far too long.  Yet with the combined expertise of talented scientists and clinicians the world over, are we closer than we think to moving past the pieces of the elephant?  The mainstay of lung cancer therapy is some combination of surgical resection, radiation, and chemotherapy, which in the end most often delay, not prevent, the inexorable progression of the tumor.  But what if that picture changed?  Imagine a world that still started with thoracic surgery and the metastasis of lung cancer but then moved to a physical chemist and nanoscale visualization techniques implemented by an engineer and then data-mined by a mathematician using a program designed by a computer scientist who then together present a kinetic model of invasion to a molecular biologist who uses an animal model to uncover a mechanism and then collaborates with a pharmacologist to design an inhibitor cocktail which is prescribed by a medical oncologist working in tandem with a thoracic surgeon.  And in the end, the patient goes home to live, not to die. 

These changes have already begun and I know they will continue-but as baby steps or giant strides? The extent to which we can revolutionize both scientific inquiry and medical treatment is directly proportional to our ability to see beyond the walls that can-but only if we let them-separate us from our colleagues.  We owe it to ourselves, to each other, and most of all to the patients who are our family and friends and sometimes even ourselves, to work towards a future that is worthy of what we have already gained and what we stand to lose if we let our moment at this historic juncture slip away.  The men in the elephant fable are blindfolded, but we don’t have to be. 

Acknowledgements: I am grateful for the thought-provoking discussion and insightful commentary provided by Alan Hauser, MD, PhD and HG Munshi, MD during the preparation of this manuscript.

(1)  Varki A, Rosenberg LE. Emerging opportunities and career paths for the young physician-scientist. Nat Med 2002;8:437-9.

(2)  Dickson D. UK plans to encourage physician scientists. Nat Med 2000;6:490.

(3)  Weinberg RA. A lost generation. Cell 2006;126:9-10.

(4)  Vastag B. Increasing R01 competition concerns researchers. J Natl Cancer Inst 2006;98:1436-8.

(5)  McNally N, Kerrison S, Pollock AM. Reforming clinical research and development in England. BMJ 2003;327:550-3.

(6)  Zerhouni EA. Clinical research at a crossroads: the NIH roadmap. J Investig Med 2006;54:171-3.

(7)  Black N. The Cooksey review of UK health research funding. BMJ 2006;333:1231-2.

(8)  Marks AR. Rescuing the NIH before it is too late. J Clin Invest 2006;116:844.

(9)  Marks AR. Rescuing the NIH: the response. J Clin Invest 2006;116:1460-1.

(10)  Crowley W, Courtney J, Jameson L et al. The Clinical Research Forum and the Association of American Physicians disagree with criticism of the NIH Roadmap. J Clin Invest 2006;116:2058-9.

(11)  Kaushansky K, Shattil SJ. Bloodlines: the importance of mentoring for the future of hematology. Blood 2007;109:1353-4.

(12)  O’Connor Grochowski C, Halperin EC, Buckley EG. A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum. Acad Med. 2007;82:375-82.

(13)  Humphrey JD, Coté GL, Walton JR, Meininger GA, Laine GA. A new paradigm for graduate research and training in the biomedical sciences and engineering. Adv Physiol Educ. 2005;29:98-102.

(14)  Tadmor B, Tidor B. Interdisciplinary research and education at the biology-engineering-computer science interface: a perspective. Drug Discov Today. 2005;10:1183-9.

 Dianna Louie and Shafik Dharamsi discuss the role of health workers as health advocates and use Dianna’s experiences in Uganda to illustrate their points

“We are the first generation in history that can end extreme poverty. 
That’s our good fortune, our challenge and our responsibility.” Jeffrey Sachs

Many students spend the summer between first and second year conducting medical research in order to improve their resume for entry into postgraduate medical training. Others shadow different specialists in an attempt to figure out what type of medicine they want to practice at the end of their four year program.

I decided to do something different. (more…)

 In the second installment of his experiences, Paul Park tells us more about the situation in the Ugandan refugee camps 

The clinic tent

An elementary school in the bordertown of Busia, Uganda housed the 2,000 refugees with each packed classroom inevitably creating a ripe environment for disease.  In addition, the threat of violence was still present due to the proximity to the border and the similar tribal demographics in comparison to that of western Kenya. The Red Cross refugee site was located just 1.5 km from the local public clinic.  Thus, without any medical infrastructure, Red Cross personnel were sending all refugees with health needs to the clinic.  As you could imagine, the Red Cross staff was pleased to learn of my medical background and immediately gave me all clinical and public health responsibilities.  I gave health education presentations (sanitation, personal and community hygiene, etc.) and continued to make referrals, in which I would write a brief history and physical to assist the overwhelmed clinic.  Additionally, I initiated a patient record system.  As a medical student, it is easier to feel competent when the safety net of your attending is always in place, and this scenario was no different.  However, that was all about to change. (more…)

Medical student, Paul Park, was in Kenya when the violence started. In the first installment of his experiences, he explores some of the ethical considerations of his evacuationTension ripped across an entire nation on the 29^th of December, 2007, just two days after the Kenyan presidential election, when the election results were surprisingly announced to be “too close to call.”  In Eldoret, Kenya, the majority, being of Kalenjin ethnicity, were ready for a new beginning with the expected victory of their presidential candidate, the challenger Raila Odinga of the Orange Democratic Movement (ODM) party.  News of riots breaking out in other cities of western Kenya began trickling in as Eldoret citizens anxiously continued to wait.  As the day progressed, accusations against Mwai Kibaki, incumbent candidate for the Party of National Unity (PNU), of election fraud gained credibility as his popular vote deficit of 900,000 was reduced to 100,000 out of 8 million votes, while Odinga’s numbers remained virtually unchanged.  That afternoon, I received a text message from the manager of my housing compound: DO NOT GO INTO TOWN, RIOTS. (more…)

 Mukhtar Ahmed shares an uncomfortable experience

My elective and adventure in Africa began in London. I remember the feeling of excitement and nervousness tying my stomach into a knot; all the new sights, sounds and smells that I was going to experience! For me this was what made medicine so appealing to me. It would be my key to the world. With it I was going to experience life. (more…)

Misty Richards, Marc Freiman, Stephanie Van Dyke, and Neil Gray discuss the ethos behind the setting up of the Engeye Health Clinic in Ddegeya Village, Uganda

Religion, wealth, and power are among the principal causes of human conflict.  Religious, nationalistic, and ethnic ideologies are frequently exploited to facilitate the dehumanization of another people, allowing violence to become an acceptable option.  Frequently, migration is both a contributor to, and a result of, such conflicts.  The influx of a new people into a region often leads to conflict over land, resources, and political power, particularly when accompanied by significant cultural, religious, and/or ethnic differences.  Conversely, prolonged or significant conflict frequently creates a strong impetus for migration, as people abandon their homes in search of a security.  Hence, conflict and migration are linked in a vicious cycle. (more…)

According to Guus Bol, this situation  is a problem induced by a failing mental health system

A homeless man on the beach in San Francisco

Just arrived in San Francisco and I already ripped my sneakers. Still a bit drowsy from my jetlag I wander out of the hostel to find a shoe store so that I can replace my beloved but tormented shoes. I’m walking down Mission Street when a homeless person asks me if I can spare a buck, I give him a dollar and walk on. A little further a guy in the same outfit asks me the same question, and as I am a guest in this city I should be friendly, I give him a dollar as well. Next, one peculiar guy requests nuclear weapons instead of money. This scene is repeated until I reach the shoe shop where I find some nice sneakers to replace the old ones, although I now have no money left to buy them. (more…)

 Love it or loathe it, it looks like facebook is here to say. Elizabeth Leyland discusses how this latest social network phenomenon could affect medical practice

Raging across the globe with alarming speed, the spread of Facebook shows no signs of stopping. It has been doubling its users every six months and now has more than 55 million worldwide. (1) Perhaps worryingly, even medical students are susceptible to its highly contagious charms. Having signed up as a half-hearted sceptic eighteen months ago, I now find myself craving a daily Facebook fix. Should there be a role for Facebook in the life of a medical student? Don’t we poke innocent victims quite enough when practising examinations, without subjecting people to unlimited Facebook poking? I launched an investigation to determine whether social networking is predominantly positive or destructive. I began my research by checking my Facebook page. (more…)