Hotness of Body

Kenya is hot, the average temperature is about 85 degrees though the population seems to be used to warmer than that. On a 72 degree day we had mom’s bringing their kids in with many layers; winter hat and winter coat, sweater and 1st layer of pants followed by a long sleeve shirt and occasionally a second pair of pants, followed by thermal underwear and undergarments. It felt like an SNL sketch just trying to get close enough for lung sounds. What shouldn’t have surprised me was that the medicine fundamentals were the same. Get the history, do the exam and treat the illness with the most appropriate medication available. Physiology isn’t different around the world. There were some language differences, such as “hotness of body” or what I interpreted as subjective fevers.

How medicine is practiced however is different based on the resources available. Often investigations are unavailable, prohibitively expensive, unreliable or would simply take too long that the patient would have already experienced complications from whatever illness. Nearly 90% of patients seen in our hospital were given antibiotics similar to how we treat newborns in our ED while waiting for results just in case there is a bacterial infection brewing.

The other difference is that the history is often obscure or challenging. Yes, there is a language barrier but even in the same language it is a challenge. Its unreasonable to ask a mother of 5 who has to worry about feeding, providing for, cleaning and raising her children with no running water, intermittent electricity in a 2 room house made of tin sheets whether its day 4 or 5 of illness. With barriers to history, testing, follow up and limited physical exams from ferocious toddlers; often the safest thing to do is just treat the most likely life threatening illness.

We spent our last week at a community hospital where we helped a Medical officer who was trained in OBGYN run a pediatrics clinic. At home, I wouldn’t have prescribed anything for 90% of the patients though nearly every mom went home with some kind of prescription such as appetite stimulants for what seemed like picky eaters or antibiotics for kids who were afebrile but mom reports “hottness of body” after removing the seven layers of winter gear. Unfortunately that OBGYN officer was the only one available and did the best she could with the 50 patients she had to get through that morning. Treating the possible life threatening illness is the safest thing she could offer these struggling patients.

Of course the ultimate goal is to have enough staff and resources to conduct appropriate diagnostic testing and treat only those who need treatment but the experienced folks we met with seem to have done a good job with what they have.

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(Global) Adolescent Medicine

As far as countries go, Kenya is relatively young. Founded in 1963, Kenya is just 4 years older than Heart transplants. As a young country it received the aid of multiple foreign parties that helped it off the ground. In the last 15 years the country has had tremendous growth; a new constitution, new economic governance and elections; the second of which were just completed in August 2022. In this time Kenya has had an average GDP or economic growth rate of 4.8%. Poverty has been steadily declining, life expectancy, access to education, electricity and clean water have all rose. It seems that Kenya is now hitting its growth spurt and starting adolescence. The gross national income per person has now reached $2010 in 2021 categorizing it as a “Low-Middle” income country with over 50 other peer countries.

Like all adolescents there are some serious challenges, influence from peer countries, and increased autonomy. As a middle income country many of the international third parties have started to withdraw support to focus on other low income countries. For example the Global Fund and UNFPA have reduced family planning donations and funding. The US President’s Emergency Plan for Aids Relief’s ended its funding in 2019. Importantly, GAVI, the global alliance for vaccines and immunization which has provided nearly half a billion dollars worth of funds and vaccination supplies will be ending its contract in 2027. Over the next few years Kenya will have to start funding these programs independently. Individual healthcare workers seem nervous about access to supplies that are already scarce. With insufficient funding the vaccination rates can fall, family planning will be in limbo and the HIV epidemic can worsen. This pivotal, necessary, transition to healthcare maturity will be just as awkward and challenging as can be expected in adolescence but also exciting to see as Kenya flourishes and proves that these programs help facilitate countries independence.

The Great Brain Drain

Globalization has has brought numerous advantages to low income countries. On one hand, benefits include new markets to access and sell goods, an expansion in global education, greater political discourse, as well as a decrease in travel and migration costs. Low income countries such as those in South America and Africa have benefitted from investments from middle income and high income countries, contributing to a better quality of life for many of their inhabitants. On the other hand, globalization has also had many harmful effects such as excess resource usage, pollution, and as the name of this article suggests, loss of highly skilled workers from low-middle income countries to their high income counterparts.

Among those who are migrating away from these countries, physicians are one of the largest groups. As low and middle income countries invest large amounts of resources in training their own citizens to train them such as in healthcare, many of these professionals have been leaving for high resource nations at greater rates. This often leads to staffing shortages and poor work conditions for those who remain. These countries continue to have the same burden of patients but are continuing to lose their highly skilled workers, creating a cycle of high investment but low return.

According to Botezat and Ramos, there has been a sharp rise in migration of physicians from countries in Africa, Asia, Eastern and Southeastern Europe in the past two decades. From their research, they found that many physicians leave their home country for those with better education and quality of life. Another interesting finding is that the GDP of the destination country is not correlated with an increase flow of physicians but the GDP of the home country is, this is speculated that physicians are better able to cover the costs of migration. Lower density of physicians in high income areas have been shown to be another strong correlator for migration, especially in countries with aging population with greater demand for health professionals. Higher pay has been shown to be a greater incentive for African countries. There also tends to be a preference to migrate to countries with their colonial roots due to a shared language.

According to the World Economic Forum, of those trained in Kenya, more than 50% of physicians are now practicing overseas. The physician to patient ratio is estimated to be 20 physicians for 100,000 in the population. The UN estimates financial losses between $29,000 to $59,000 to train each doctor when examining sub-Saharan African countries. Meanwhile, the UK has been estimated to have benefited to $2.7 billion and $846 million in the US from foreign trained physicians. A 2011 article by the Lancet cites that high income countries have sustained their physician – patient ratios by recruiting from low and middle income countries. Leaving more than half the countries in sub-Saharan Africa with ratios below the minimum standard of 1 per 5,000 set by the WHO. Due to these issues, the WHO announced a code of practice on international healthcare worker recruitment, which acts as a moral guide rather than laws to be enforced.

To reverse the brain drain will be difficult and will require many low and middle income countries to address the needs in their healthcare system. There needs to be a greater investment in healthcare infrastructure and general education in these countries however due to limited resources, these countries are already making difficult decisions with finances and may not be possible. The heads of the African Union pledged to allocate at least 15% of their GDP towards healthcare in 2001 but only six of those countries met the minimum threshold 12 years later. Alternative ideas include increasing the number of residency spots in low and middle income countries as those who complete theirs in countries like the UK and US rarely return to their home country. Other ideas suggested would be having physicians that are migrating pay back the costs of their medical school training back to their home countries, a “pay it back if you don’t come back” policy as coined by the World Economic Forum. In Trinidad, all doctors that train overseas are required to return home and practice for 5 years in exchange for government investment has been a successful strategy. Another possible idea would be recruit more students from rural areas as those who receive medical training are often from affluent backgrounds which may increase the likelihood of physicians staying to help where they are needed the most.

As the demand of physicians in high income countries, these governments need to reflect on their resource distribution namely in healthcare to address these global disparities rather than relying on foreign nationals to address the lack of physicians in rural areas in the US for instance. The includes increasing the number of residency spots, increasing compensation for those in primary care, recruiting students from rural areas, more government loan forgiveness programs in rural areas to incentivize physicians to work in rural areas. There are certainly many issues in healthcare that need to be addressed but the “brain drain” is one with a particularly large impact in global health and will continue for the unforeseeable future that requires action from countries throughout the entire socioeconomic spectrum.

Sources:

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-019-0536-0

https://www.weforum.org/agenda/2016/10/how-to-reverse-the-medical-brain-drain/

https://www.un.org/africarenewal/magazine/december-2016-march-2017/diagnosing-africa%E2%80%99s-medical-brain-drain

Introductions

According to the Merriam Webster dictionary, an introduction is :a part of the book or treatise preliminary to the main portion.” This definition literally applies to books, essays, and plays but I think it also aptly applies to the stories that we experience as we go through life. A strong introduction includes your greeting, explaining who you are and what you intend to accomplish as well as your goals such as one would expect from a Shakespearean play. From being in Kenya for the first time this week and meeting so many new people, cultures, and foods; I can tell you this chapter of my story has been full of introductions.

From the daily in and outs of life to the busy schedule we have as physicians, we all know the importance of a good introduction. It tells people who you are, your intentions, goals, and can set the stage for those relationships whether it is with patients, coworkers, or new friends. So far, this week, I have been extremely grateful to have the opportunity to meet a cast of wonderful humans. From learning a few words of Swahili, bonding over soccer, and to cooking traditional foods together, it all started with an introduction.

Working in Thika hospital has been an introduction in a different sense. The introduction of different cultures from the local areas did not seem particularly relevant to me at first. But as we saw patients their families, it became readily apparent that sometimes it was at the crux of their management. Parents from these cultures have certain child rearing practices that can be harmful to their children such as giving toxic herbs as cold remedies or not giving their children eggs for fear that they would not speak. This in retrospect is not so different as our own old wives tails back home. Education often times was the most important thing we could offer for these families. Introductions were also vitally important for setting the stage and guiding the conversation with the families (to tell someone that their traditional practices were harming their children could be taken poorly if not done with care). In was also introduced to new medical practices, given the prevalence of certain diseases, patients that clearly had simple febrile seizures to me were easily mistaken as infectious meningoencephalitis by those from the local area.

So far, the introductions I have come across have been humbling as they offer a piece of another person’s story and experiences. While I will never fully understand all of the nuances of the multitudes of cultures here in Kenya, a good introduction is always a great place to start.

Native Americans in the United States Military

When speaking to members of the MHA nation, they speak about veterans with the highest regard. Throughout the MHA nation, there are multiple tributes to tribal members who have served in the United States armed forces. Within the Elbowoods Memorial Health Center exists a church and prayer space with a wall dedicated to the past and present employees who have served. There are also historical placards scattered around the parks, museums, monuments, and bridges bearing the names of those who served. The pride for service members’ rings strong throughout the community. In North Dakota and across the country, Native Americans continue to commit to lives of service through enlisting in the United States military and do so at a rate 5 times more than the national average. What drives Native Americans to continue to sacrifice themselves for a force that was once their biggest rival?

Before Europeans ever set foot on the North American continent, the warrior tradition was a large part of Native American culture. In this tradition, men were warriors, protectors, and providers. These warriors were praised and respected among their tribe and feared by their enemies. They trained to be great warriors through skills passed down from generation to generation. They used many weapons like bows and arrows, hatchets, tomahawks, and clubs against rival tribes to defend their land and communities.

With the arrival of European settlers in North America, these warriors again fought to protect their land and way of life. One of the most well-known of these warriors was Crazy Horse. Crazy Horse, aided by Sitting Bull, is famous for his victory at the Battle of Little Bighorn in 1876 where he defeated Lieutenant Colonel George Armstrong Custer and his troops. Custer and his men were attempting to drive the Sioux and Cheyenne people off their land to gain access to the gold that lay in the Black Hills. The profound historical impact Crazy Horse had on his people was forever memorialized when in 1948 the Crazy Horse Monument began construction in the Black Hills and still is under construction to this day.

Not all battles fought by Native Americans were fought against the United States. Native Americans have fought side by side with the United States military for over 200 years, as far back as the Revolutionary War. During World War I, despite many Native Americans still lacking citizenship, more than 12,000 men volunteered. Then in World War II, the famous Navajo Code Talkers used their native language as a means to transmit sensitive information via radio communications so that messages could not be deciphered if intercepted. Even in the Vietnam War, where drafts were necessary to man the military due to the unpopular nature of the war, 90 percent of the 42,000 Native American people who served were volunteers.

I was lucky enough to experience a Pow Wow led by veterans at New Town High School the day prior to Veterans’ Day. I heard the beating of drums, the war whoops, and tongue rattles as well as saw the Victory dance. I could see with my own eyes elder members of the tribe teaching the high school students their traditions, actively trying to preserve their culture. The leader said “war whoop, don’t clap at the next basketball game as the war whoop is the Native way of clapping. Intimidate your rivals, like our ancestors used to.” After this celebration, the veterans spoke with pride about their military service and encouraged the students who did not plan on attending college to consider a career in the military. They spoke about the benefits of the military such as the ability to learn new skills, travel the world, and to challenge yourself. The veterans also emphasized that, whether a tribal member or not, if you were a graduate from New Town High School and a veteran, you would always be welcome in the community. They also stated that you would be recognized on the wall of veterans displayed in the high school.

Why do Native Americans choose to serve despite their tumultuous history with the United States? Based on accounts from Native Americans service members, they report being able to see the bigger picture with regard to wars involving the United States and realize that serving is how they are best able to protect their homes. Others state that careers in the military provide financial security. Many are proudly continuing a family tradition of military service. The most impactful explanation that I’ve heard is that by serving in the military, they are preserving the warrior tradition. To quote Jeffery Means, a member of the Oglala Lakota, “It’s about Native Americans reclaiming their identity, their sovereignty in a period where they’ve lost so much of it because of assimilation and colonization.”

Maybe We Shouldn’t Talk About It: Cultural Sensitivity After Trauma

The way we relate to the world around us is affected by our past experience, environmental situations and values. When the world affects us, especially in relation to trauma, each person is affected differently. All the more so, the way two cultures heal from trauma can be entirely different.

For example, broadly speaking, in the US there is a therapeutic norm to speak about past trauma. However, that may not be the case in other cultures.

The book “Crazy Like Us: The Globalization of the American Psyche,” by Ethan Watters, discusses the aftermath of the Tsunami that devastated large parts of Sri Lanka. In 2004, many US mental health workers flew to Sri Lanka – with excellent intentions – wanted to have the victims of the tsunami do psychoanalytic work, and talk about their trauma individually, however, that is not what was needed at that time according to the norms of the indigenous culture. This culture preferred not to talk about it, having been hardened by decades of civil war, and generally used other, more community-based methods to cope.

In the book, “The Body Keeps the Score,” by Bessel Van Der Kolk, FMRI studies show that PTSD affects Broca’s area of the brain, decreasing its activity. Therefore, the thought is that some people with PTSD would prefer not to talk about their trauma. The purpose of talking through trauma – such as through psychoanalysis is primarily useful in trauma that is hidden, for example if a child has trauma that is a secret and is afraid to inform anyone due to the potential consequences. For example, “dark secrets” that a child may have about a family member who abused the may be very important to talk about.

RSV Updates

In the beginning of November, Pfizer announced promising data from their study of a new RSV vaccine given to pregnant women to create transplacental antibodies that protect their newborn from RSV disease. The trial found the vaccine to be 80% effective in preventing severe RSV in the first 3 months of life, and decreased the risk of needing to see a doctor for RSV in half. With this exciting data, Pfizer submitted for FDA approval by the end of the year. GSK had been working on a similar vaccine, but paused trials in February due to safety concerns.

This development is exciting, but in the midst of a RSV surge, it leaves many wondering why we don’t already have an RSV vaccine. Currently, the only approved RSV prevention is palivizumab (Synagis), a monoclonal antibody which is only offered to high risk babies due to its high cost. It turns out, an RSV vaccine has been attempted in the past, but with major setbacks. In 1966, a new inactivated RSV vaccine was trialed in four US centers. Shockingly, the formalin-inactivated vaccine provided no protection against RSV, and participants who received the vaccine actually fared worse than the placebo group, with 16 times increase in hospitalizations and two deaths from RSV. Researchers are still not entirely sure why this happened, but there are several theories. One is that the formalin used to inactivate the virus altered the viral structure, leading the immune system to develop only weak antibodies to RSV. Another theory from animal studies in that the vaccine did not allow B cells to create antibodies with enough affinity to bind with the inactivated virus and neutralize it, leading to failed neutralization of active RSV when exposed. This is also allowed for the deposition of RSV antibody complexes in the lungs, leading to inflammation and proliferation of neutrophils, that worsened lung disease in these children.

However, vaccine science has come a long way since the 1960s. The new vaccine uses only the F protein of RSV, not the whole virus, and teaches the immune system to recognize and target that protein, similar to how the COVID-19 vaccines target the spike protein. Hopefully, in the near future the vaccine will be approved and become standard to administer to pregnant women, similar to the TDaP and flu vaccines, and transplacental antibody production can help protect even the youngest infants from the risks of RSV.

Burnout

Mayo Clinic defines burnout as “a state of physical or emotional exhaustion that also involves a sense of reduced accomplishment and loss of personal identity.” It affects people from different walks of life, and spans across various careers. For medical providers during a global pandemic, the concept has become all too familiar. Levels of burnout in physicians have increased greatly during the pandemic. Burnout levels in physicians before the pandemic had already been higher than one would hope, with 46 percent of physicians reporting at least one symptom of burnout in 2011. In the beginning of this year, this number increased to 63 percent. I found this statistic to be quite significant, yet not all that surprising.

Often times, medical providers are faced with seemingly endless administrative tasks and paperwork, which can increase frustration and decrease the amount of time a physician has for his or her personal life. This is all in addition to already taxing patient care duties; caring for sick patients in a high-stress environment takes a toll that is hard to measure. Some physicians have been shown to be at higher risk of burnout, including those practicing emergency medicine, family medicine and pediatrics.

Burnout has been linked to negative outcomes for physicians, such as increased rate of suicidal ideation and alcohol abuse, as well as for patients, with increased medical errors being linked to burnout. Burnout is not just an issue of individuals. It is an issue that has persisted over time, now affecting over half of physicians, and requires a system-based solution approach. The culture of medicine requires reform to make it more conducive to physician wellness and to reduce levels of burnout – now more than ever.

Acknowledging Trauma as Pediatricians

I recently read that almost 50 percent of American children have faced at least one potentially traumatic early childhood experience. These traumas can vary vastly, from violence or unintentional injuries, to refugee trauma, to parental substance abuse or separation from a caregiver. Research has shown that accumulated trauma has physiologic consequences on the body. Keeping this in mind, it is our responsibility as pediatricians to identify and respond to childhood trauma.

Providing trauma-informed care in our practice is one step in this process. Recognizing that a hospital admission can be significantly traumatic for our patients is extremely important. Pediatricians should make an effort to clearly communicate with patients about expectations and procedures, in an effort to reduce their trauma. We should offer them choices and allow them to be involved in their care when possible.

Addressing past trauma is another component of helping our patients. Since there is a range of traumatic experiences that children can experience, the symptoms can vary, which determines our response as providers. For example, if a patient experiences a single event or minor trauma, we might provide secondary prevention, anticipatory guidance, and close monitoring. For a patient who has experienced a major traumatic event or cumulative trauma, we may offer tertiary prevention and treatment, including referrals to community services or evidence-based mental health services. 

Overall, it is extremely important for pediatricians to be adequately trained in trauma-informed care, because our patients are at high risk for the long-term consequences of childhood trauma, which significantly impacts their overall health outcomes.

To read more about Trauma-Informed care, you can visit: https://publications.aap.org/pediatrics/article/148/2/e2021052580/179745/Trauma-Informed-Care?autologincheck=redirected?nfToken=00000000-0000-0000-0000-000000000000

TikTok Docs

In recent weeks, my “scrolling through TikTok” habit as a method of relaxing and destressing from work has somewhat backfired. Instead of my usual automatically curated content, which includes the same Meghan Trainor choreographed dance over and over, and parody videos made by doctors and nurses, TikTok has started showing me videos of sick babies, retracting on high flow as their parents sit anxiously by their side. As the so called “tripledemic” worsens, lay parents are sharing videos of their children, often with helpful messages to others about what to look out for as signs that a baby is struggling to breath and needs medical attention.

Desperate parents are also taking to Facebook parenting groups, asking which ER is best for kids and has the shortest wait time. As usual, they are also asking for medical advice and receiving a whole variety of ideas, only occasionally with a sprinkling of “ask your pediatrician.”

I’ve seen instances where good advice is given, and parents are urged to go the ER for a true indication, but also many instances of terrible, dangerous advice, as well as fear mongering that only adds to the burden of patients in the ED.
As more and more parents take to social media for advice rather than calling their doctor, there are also a growing number of pediatricians (and other specialties) joining social media to share evidence based, non-patient-specific advice. These doctors continue to be on the frontlines of fighting myths about COVID and vaccines and are now sharing important information about RSV and the flu. Taking the standpoint of “if you can’t beat them, join them” these hip doctors are out there making a difference and helping parents and babies alike. In addition to medical advice, many of them share public health statistics and write about current issues such as physician burnout and understaffing.

While TikTok, Instagram, and Twitter are often dismissed as frivolous social media, these sites also serve as powerful tools. Physicians and other healthcare workers are helping to change the narrative on social media as they bust myths, offer medical tips, and sometimes even dance.