Archive for March, 2014

Blood Crisis In Egypt

March 13, 2014

charts 1 n 2 (2)

According to the National Blood Transfusion Services (NBTS), which is the main entity following the standards and procedures of the World Health Organization (WHO) and mainly relying on voluntary non-remunerated blood donation, someone in Egypt needs blood every 5 minutes. Approximately 1% of the population is currently blood donors, the minimum needed to meet the basic needs of the country. Out of this 1%, only 35% are non-remunerated voluntary blood donors. The other 65% are family replacement & obligated donors, which means the blood donated carry a higher risk of diseases such as Hepatitis B & C.

The blood crisis in Egypt had worsened especially after the 2011 revolution. According to the ministry of health, the need for blood increased from 1.1 million unit in 201o to 1.4 million unit in 2011. One kidney patient had told IRIN news that she had to buy a blood bag for U.S $120; a process she had to do before each kidney dialysis.

Moreover, there is a high risk of unsafe blood in Egypt due to family replacements or obliged donors which represent a high-risk target group. As a result, many blood recipients are contaminated with Hepatitis B or C Virus and other transfusion diseases.

The most recent statistics found on blood donations in Egypt were for years
2006 and 2005. Chart 1 and 2 show that the total amount of donated blood has
decreased in Cairo -represented by the NBTC- by around 4 percent. Moreover (NBTC) receives an average of just 60 donors per day.

There is an urgent need to push MOHP to consider the blood problem is “a health priority”; NBTC should assure that no blood trading is talking place especially in rural areas where supervision is low. Most importantly, NBTC should consider all NGO’s working on blood donations as partners and collaborate with them to ease their task.

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Got Worms? The High Cost of Neglecting Parasitic Infections in Ecuador

March 11, 2014

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If asked which parasitic disease were responsible for the greatest burden of morbidity, the majority of us would likely respond with HIV or perhaps malaria. In actuality, the biggest cause of Disability-Adjusted Life Years (DALYs) are due to what health expert Dr. Peter Hotez refers to as “the unholy trinity”: RoundwormWhipworm, and Hookworm. Collectively, these worms are known as “Soil-Transmitted Helminths” or STHs. Current data show that up to 35% of people in the Amazon region are chronically infected by STHs (up to 75% in some villages!), many of them children. STH infection can be especially pernicious in the young, due the detrimental effects of parasitic burden – chiefly anemia – which result in reduced cognitive and physical function and compromised academic performance. Moreover, these infections trend highly with impoverished and underprivileged populations.

Fortunately, there exist clear and cost-effective interventions for STH infections. Mass Drug Administration (MDA) with anti-helminthic medications remains the gold standard, is cheap to implement, and has a proven track record of effectiveness in numerous countries. In order to complete a successful intervention in Ecuador, it will be necessary to engage stakeholders at all levels of involvement. Organizations like the Bill and Melinda Gates Foundation and the Sabin Institute can provide required funding and strategic planning, with branches devoted entirely to neglected tropical diseases. PAHO can also help with active implementation of deworming efforts, but interventions will require cooperation from indigenous nations (CONFENIAE) and Ecuador’s Ministry of Health. By strategically combining the resources and aims of these key stakeholders, a successful deworming campaign could finally end the vicious cycle of helminth infection that disproportionately affects the impoverished young and perpetuates their socioeconomic handicap.

"The Unholy Trinity"

Details about the infection with STH.

By Paola Santacruz, Justin Price

POWER TO THE PEOPLE! Getting misoprostol to CHW – Saving Lives

March 10, 2014

Yesterday the world celebrated the 103rd International Women’s Day, and yesterday 800 women died from complications of pregnancy and childbirth, a loss that occurs every single day of the year. Almost 350,000 women die every year due to complications of pregnancy and childbirth. According to the World Health Organization, 99% of those deaths occur in the developing world, with sub-Saharan Africa bearing a disproportionate part of the burden. And while maternal mortality has declined almost 47% since 1990, the number is still much, much too high.

Video: Dying to Give Birth: One Woman’s Tale of Maternal Mortality
In Sierra Leone, photographer Lynsey Addario met 18-year-old Mamma Sessay, whose harrowing final hours of life show the perils of pregnancy in the developing world
http://content.time.com/time/video/player/0,32068,89844377001_1994479,00.html

The preceding video is disturbing and graphic as it illustrates the human face behind the numbers. Each maternal death cuts a story short; it changes a family forever, and leaves remaining family members vulnerable to poverty, illness and death.

photofamphotobabyhttp://www.unfpa.org/multimedia/slideshow_panama/slideshow_main.html

Over 80% of maternal deaths occur just before, during, or immediately after childbirth, with the leading cause of death being postpartum hemorrhage (PPH). A catastrophic obstetric emergency, PPH can lead to death in less than an hour if not properly managed. There are several effective means to manage this complication, including the medications oxytocin and ergonovine. These medications, while effective, are administered via injection and require refrigeration, both of which are barriers to use.

Recently, studies have proven the effectiveness of misoprostol in preventing and treating PPH. Misoprostol is a shelf stable, inexpensive oral medication that effectively prevents and/or treats PPH, with few serious side effects. It is my strong belief that misoprostol should be available to lay health workers, women and their families in low resource settings to prevent this devastating complication of childbirth. This strategy has been recommended by several major health organizations, including WHO and the International Federation of Gynecology and Obstetrics (FIGO), yet despite these endorsements, adoption of this policy has been slow.

VSIIn July 2012, a regional summit was held in Dar es Salaam, Tanzania, bringing together leading women’s health experts from 12 African countries. After a week of intense activities, the participants returned home, enthusiastic to reduce maternal mortality in their respective countries by supporting the use of misoprostol. It is now time to follow through on that promise.

A second conference is needed to renew enthusiasm for this life saving drug. In addition to leading physicians, this time national midwife organizations need to be included, as well as representatives of community health workers, and drug manufacturers. A strong collaboration needs to be forged between these entities; often seen as competitors, these disparate factions need to set differences aside and remember that each and every group is working towards the same goal. A united front of these key stakeholders cannot be ignored by policymakers. Please join me in calling for a renewed effort to place misoprostol where it can do the most good- at the bedside.

End of Life Care

March 10, 2014

Last year, Medicare paid 55 BILLION dollars to cover the expenses generated during the last two months of people’s lives! Studies estimate that this accounts for about 25% of the entire Medicare budget. At a time when budgets are being cut and necessary projects are being delayed due to insufficient funds, we as a society have to ask ourselves if spending this much money on end of life care is worth it and what are other alternatives?

One alternative which can decrease costs, and – more importantly – improve quality of life for dying people is palliative or hospice care. However, in order to take advantage of this care, it requires people to think about exactly how they want to die and what medical treatments they are willing to accept. Are they willing to be ventilated if they have trouble breathing, or do they want to be resuscitated if their heart stops?

While they are still relatively healthy, people with terminal disease should get an advance directive and appoint a power of attorney. Thinking about these issues prior to the finals days will not only prevent patients from having to endure procedures which they would not have wanted, but it will also save billions of dollars. The final days of a person’s life should be made as comfortable as possible, and not everybody wants to use the incredible advances of modern medicine just to squeeze out a few extra days.

Helmets for motorcycle riders in Florida

March 10, 2014
helmet

Motorcycle Helmet post-accident
Source: http://www.iridenewyork.com

I’ve lived in Florida most of my life. There have been countless times when I’ve been driving down a highway and been passed by a motorcyclist wearing only a ball cap for head protection. It’s scary to think what would happen if a car changing lanes clipped the motorcycle- for the canvas ball cap would be little match for the asphalt.

Many states have laws requiring helmets by all motorcycle riders, but Florida is not one of them. Florida’s universal helmet law was repealed in 2000. Now it is legal for riders over the age of 21 who have at least $10,000 worth of medical coverage insurance to ride without a helmet. According to the CDC, during the 2 years following this law change the motorcycle death rate in Florida increased by 21%. In addition, the hospital admissions for motorcycle riders with head injuries, brain injuries, and injuries to the skull increased by 82%.

Motorcycle helmet laws

Percentage of motorcyclist fatalities in which riders were not wearing helmets, by state — United States, 2008–2010
Source: CDC Morbidity and Mortality Weekly Report

Helmet use consistently has been shown to reduce motorcycle crash–related injuries and deaths, and the most effective strategy to increase helmet use is enactment of universal helmet laws. Reinstating a universal helmet law for motorcyclists in Florida will reduce health care costs, prevent serious injuries, and save lives.

Revoke CABS foreign aid suspension in Malawi

March 10, 2014

Approximately $150 million (USD) in direct foreign aid committed to Malawi has been suspended in reaction to the country’s ‘cashgate’ scandal, where in late 2013, government officials were caught looting public funds estimated to be worth $32 million (USD).

The locked aid comes from the Common Approach to Budget Support (CABS) in Malawi, whose members include the European Commission, the Norwegian Embassy of Malawi, the African Development Bank, and the United Kingdom’s Department of International Development (DFID).  CABS decided that dispensing funds into a dysfunctional financial management system would be irresponsible until it could be proven that the resources would be used for their intended purposes.  Additionally, whereas the majority of the deferred funds were to go to the Malawian government under general budget support, DFID also halted sector budget support contributions of approximately $28 million (USD).  Said one expert, “… DFID’s actions may have huge adverse impacts on the health and education sectors…”

IMG_6734

(Residents of Lilongwe gather and wait for maize from foreign donors. Source: Author)

To make matters worse, a March 11, 2014 meeting between CABS and the Malawian government regarding the possible release of aid was recently postponed.  And while the Malawian government took necessary austerity measures in response to CABS’ action, the truth remains that foreign aid represents 40% of the country’s national budget.  In fact, the last time DFID cut funding in 2011, it directly impacted the public health sector by leading to drug shortages and stock-outs, demoralized doctors, and major lapses in the medicinal supply chain.

Unquestionably, CABS (DFID included) should follow the lead of the International Monetary Fund (IMF), who had also been withholding aid but recently decided to release their funds totaling $20 million (USD).  In doing so, CABS might avoid negatively affecting innocent people (and a public health sector), who should not suffer as a result of their government’s recklessness.

Accessing the Need for More Primary Care Physicians in Minority Communities: A Health Policy Review

March 10, 2014

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There are not enough primary care physicians (PCP) in the United States to address the medical needs of its nation.  Such a shortage contributes to suboptimal health outcomes in communities with limited access to quality health care.  In the coming years, the implementation of the Affordable Care Act (ACA) will allow a greater number of Americans to seek and access medical services.

 However, the growing number of those accessing health care services reflects our aging population with its myriad of comorbidities, and thereby, makes it more apparent that the current number of available primary care physicians is not sufficient to address the health needs of those newly seeking medical attention, especially in underserved areas.

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As a result, the need for additional PCPs is more urgent.  So, what is the root cause of this shortfall?  Although the reasons are many, a major contributor to the shortage of PCPs is the slow expansion of available residency slots as evidenced by the modest increase from 96,000 to 113,000 residency seats over 30 years.  Moreover, in 1997, the United States Congress elected to keep the number of existing subsidized primary care residency positions constant and further limited the number of available PCPs, especially in underrepresented communities. Surprisingly, the only growth in residency slots has occurred in lucrative specialties that the current fee-for-service billing system rewards and not in primary care or pediatrics.

In order to address this gap, an increase in the number of PCP residency programs, as well as, changes in payment methods (expanding Medicaid payments for primary care services provided by certain primary care physicians, etc.) are recommended.  What’s more, increased funding for medical education is needed.  The increase in funding would enable medical schools to support a larger incoming class of students with an expressed interest in primary care.

The ACA has promised an expansion of PCP training programs by allocating $167 million towardThe Primary Care Residency Expansion program.  This is intended to increase the number of new residency slots in order to address the shortage of PCPs in the United States.  As part of the expansion program, in order to increase the number of new graduates applying for PCP residency programs, the medical school curriculum needs to increase the exposure of medical students to family practice during their clinical rotations.

References:

AACM;https://www.aamc.org/advocacy/washhigh/highlights2012/282566/cmsproposesmedicaidpaymentincreasetoprimarycaredoctorsforcys201.html

Forbes; http://www.forbes.com/sites/peterubel/2013/02/18/solving-the-primary-care-physician-shortage-by-turning-pcps-into-anesthesiologists/

New York Times; http://www.nytimes.com/2013/12/15/business/solving-the-shortage-in-primary-care-doctors.html?_r=0)

Postpartum Depression in Saudi Women: Culture and Biology Collide

March 10, 2014

Postpartum depression (PPD) is one of most common complications of childbirth. Currently, the prevalence rate of PPD is between 10–15% of mothers who recently delivered. Many women experience some emotional disturbances in the month after giving birth, often typified by crying, anxiety, and irritability. The “baby blues,” a normal, temporary period after childbirth, usually resolving a few weeks after delivery; however emotional disturbance may predict the development of chronic mood disorders that can have a lasting negative impact on the mother and her family.

Its high profile in the United States often overshadows its presence in nations outside the western hemisphere. In fact, compared to its prevalence of 10-20% in developed industrial countries, it is estimated that developing nations hold a prevalence of 20-40%.

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Figure: From Postpartum Depression and Miriam Carey

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Figure: From Postpartum Depression: Information for Rehabilitation Counselors

Saudi Arabia is one of the largest countries in the Middle East in size and population. Its recent economic growth and development has led to improvements in medical care and technology. However, psychological services are still in short supply for most of the population, most of all, pregnant women.

As an OB/GYN resident in Saudi Arabia, I found that most of my patients do not know about PPD and the vast majority of the time, do not seek help, even when having experienced similar problems in previous pregnancies. In addition, those mothers can be very young in age, with low educational levels, simply accepting the status quo. Conversely, a recent study showed that women who work and have children in Saudi Arabia have marginally increased prevalence of PPD. Researchers interpreted these results as stemming from the pressures of financial need: while Saudi Arabia’s economic development is growing fast, social systems to support low income families are non-existent.

The Saudi health system must improve their health policy and increase awareness of the risk and complications of PPD. Given the wide reach that primary health care services have in Saudi Arabia, general physicians must be involved in identifying the risk factors and early signs of PPD to prevent its complications. In addition, OB/GYN physicians must be familiar with PPD and at the very least, know the required methods available to detect PPD during standard postpartum visits. More specifically, physicians have to be familiar with Edinburgh Postnatal Depression Scale, the standard, validated scale used to measure a woman’s postnatal mood that has also been translated into Arabic.

Women whose PPD is identified are often shuffled around different specialists in the prospect of acquiring treatment. Unfortunately most Saudi primary care physicians did not have adequate training in identifying this condition, let alone the basics of its treatment. Moreover, OB/GYN staff usually refer any patients they believe to have any sort of psychiatric disorder to psychiatrists. Large hospitals usually have psychiatrists as well as a psychiatric ward, but hospitals like this are few throughout Saudi Arabia. However, knowledge of the postpartum needs of women is improving as recently, the new Health minister, D.Alrabeaah recommended that the government establish two large and well equipped hospitals to serve the community, especially poor and medically underserved communities.

PPD is also affected by a woman’s home life. Postpartum support from husbands is low in Saudi Arabia and it represents one of the major obstacles to improving a woman’s postnatal state. Husbands must be educated about the needs of their wives and provide support. Moreover, the child’s gender can often contribute to a mother’s PPD. When a mother delivers a baby girl, they tend to receive less care and support from mothers, sisters, and family. Saudi culture prefers boys for their potential to add to family wealth and productivity. These cultural expectations and beliefs must be fundamentally changed if mothers are to feel supported and worthy of their family’s care. To do this, people should be educated, starting with young children and women, who often serve to perpetuate these beliefs of unequal gender worth.

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Figure: From Ica’s Tales of Mommyhood

From my experience as a Saudi citizen and physician, the only real support new mothers can receive after delivery is from immediate family, especially their own mothers, who usually take their daughter and the new baby to stay with them for 1-2 months. While families can increase a woman’s risk of experiencing PPD, this much needed support serves to help a woman acclimate to her role as a mother to a new child.

Kuwait, a neighboring country, shares the same beliefs and cultural values and generally experiences similar issues with PPD. In recent years, the government of Kuwait took many steps forward in improving the mental health of its citizens, particularly those afflicted with PPD, and I hope the Saudi government uses these changes as an example to make strides in its own mental health system for women.

In conclusion, it is imperative that we improve access to PPD screening by increasing training for primary care physicians and OB/GYNs and on a more long term level, change cultural attitudes that decrease a husband’s involvement in the postpartum period and places greater value on one sex over the other.

Should we recommend a mandatory HPV vaccination program?

March 9, 2014

According to CDC, approximately 12,000 women get cervical cancer in the United States each year. Most cervical cancers are caused by the Human Papillomavirus (HPV), which is a sexually-transmitted disease. One of the best ways to prevent HPV is to get the vaccine, Gardasil®, which works against many common strains of HPV. This vaccine is recommended for girls ages 11 to 12. The goal is to get girls vaccinated before they are sexually active.

Although highly effective in preventing HPV among girls, HPV vaccine has very low coverage in the United States. Only 33.9% of American girls reported to the CDC in 2010 that they had been vaccinated against HPV. For the distribution of state rates of vaccination, there is a dramatic difference, from only 19% in Idaho to 60% in South Dakota.

The State of Arizona is now considering a vaccine policy requiring mandatory vaccination of adolescent girls for the HPV vaccine. However, this policy alternative has been criticized by some parents and groups. Parents opposed to the HPV vaccination believe that this would encourage earlier sexual activities. Some groups, such as Family Research Council, Focus on the Family, and Concerned Women for America, are also opposed to the mandatory vaccination program. These groups believe that parents should have the right to decide whether to get their children vaccinated or not.

Despite of all these oppositions, I still recommend a mandatory vaccination program. The risk of early sexual activities can be reduced by education. The vaccination program itself won’t make a big difference. Also, some parents are misinformed on the vaccination and refuse to get their children vaccinated. Since the safety of HPV vaccine has been proved, why should we say no to HPV vaccines?

Helmet use for motorcycle drivers and passengers in rural Thailand

March 9, 2014

The problem has been thoroughly researched and recognized by the government for years now… tens of thousands of head injuries or deaths of motorcycle drivers and passengers in Thailand, many of which were preventable by helmets.

Scooter

Although helmet use has been mandated for motorcycle drivers and passengers since 1994 and 2007, respectively, rates of helmet use are still strikingly low in rural areas, hovering around one third for adults and only 1% for children in the Chiang Mai North Region, according to the Thai Accident Research Center which specializes in investigating auto accidents. A survey of approximately 4,000 motorcyclists in Thailand revealed that 15% were not even aware of the helmet law for motorcycle passengers. The relative risk for fatality by accident is as high as 4.5 times greater than for those who wear helmets in the Surat Thani South Region.

To combat low use of helmets, organizations have collaborated with the Thai Ministry of Interior to educate communities regarding the importance of helmet use, such as AIP Foundation which launched the Thailand Helmet Vaccine Initiative. However, with less than half of Thai motorcyclists wearing helmets, the need for a stronger collaboration between government, public organizations, private sector, and communities is urgent.

Many people and organizations can benefit from getting the public to adopt helmets when traveling by motorbike. Efforts in raising public awareness of the importance of helmet use need to be further strengthened, especially in hard-to-reach areas, in conjunction with tougher enforcement by the Royal Thai Police.

Web Links and Resources:
Thai Accident Research Center: http://www.tarc.or.th/
Isara Foundation: http://www.isara.org/community/pages/thailand-helmet-campaign
Asia Injury Prevention Foundation: http://asiainjury.org/our-reach/thailand/
Safe Driver Education Company Limited: http://www.thaisafedriver.com/default.html
Federation Internationale de l’Automobile (FIA Foundation) organizations: http://www.fiafoundation.org
Space Crown Helmets: http://www.spacecrownhelmet.com/company.php

More articles covering the Thai helmet problem and efforts to solve it:

Charity motorcycle ride from Thailand to Cambodia to supply helmets:  http://www.phnompenhpost.com/lifestyle/bikers-ride-thailand-cambodia-good-cause

NY Times expose on Thai road safety:   http://www.nytimes.com/2014/03/01/world/asia/crash-that-kills-schoolgirls-highlights-thai-road-dangers.html?_r=0

Thai Vespa distributor hosts charity gala to unveil new model and give helmets:  http://asiainjury.org/news/vespiario-thailand-organizes-la-dolce-vita-charity-gala-dinner-in-to-unveil-the-new-vespa-946-and-benefit-helmets-for-kids-in-thailand/