– o

ffici

al IF

MSA

-NL

mag

azin

e on

glob

al h

ealth

– n

ot fo

r res

ale

– w

ww.

glob

alm

edic

ine.

nl

17

Febr

uary

201

5

6

12

16

To legalise organ trade in kidneys: A solution?

Globesity Integrating disease management models

Controlling parasitic infections Meeting global challenges?

GlobalMedicine

Editorial

In this ever-changing world, we have an ever-changing group of enthusiastic people in our Global Medicine team. This team proudly presents to you the 17th edition of Global Medicine, full of articles written by people from all over the world; people who care. Although it sometimes seems as if all seven billion humans, trotting along on this planet, are focussed solely on their own lives, I think it is our moral duty to look after one another, whether that be your

neighbour, or the individuals on the other side of the ocean. This being said, ethical questions often arise in situations like organ trade, cultural differences and maternal health issues. Who benefits from these circumstances and to what extent is suffering to be allowed to reach a certain goal? These articles explain the objectives from all parties, and help us to put our own lives into perspective. Together we can make this world a liveable and more beautiful place.

Yours sincerely, Sanne Jongma, Editor-in-chief

In this GM...

GM

17GMNews4

Column: Mbasu10

Organ trade

Globesity

18

The open acces movement16

Studying medicine in... Sudan

Tropical intership in Tanzania23 Polio and the road to eradication

20

6

1012

16 Controlling parasitic infections20

2426

30

GM

New

s

NEED FOR UNBANKED, DIRECT BLOOD TRANSFUSIONS IN INDIA’S RURAL AND TRIBAL AREAS The majority of India’s licensed blood banks are located in urban areas. The need for unbanked, direct blood transfu-sion is urgent in rural and tribal areas. Due to poverty, pa-tients in these rural areas are rarely able to access the urban area’s blood banks, even in cases of emergency. Despite this fact, the use of direct blood transfusions on patients has been illegal in India since 1999. Many surgeons and health activists have called on the government to legal-ize this practice due to the intense need. The process of unbanked blood transfusion usually includes screening blood of donors for type and infections and then transfus-ing directly into the patient. They claim that the precau-tions of licensed blood banks could also be applied to this form of transfusion. According to several Indian NGO’s, made up of surgeons and blood banks, a legalization of di-rect transfusion would prevent the deaths of many people in impoverished areas. MU

GLOBAL CHILD DEATHS REDUCED BY HALF SINCE 1990A recent report, published by several organizations (UNICEF, WHO, World Bank Group, and UN-DE-SA Population Division) concluded that 6.6 million children died globally, before the age of five, in 2012. This equates to 18,000 children per day. That may seem astonishingly high. However, the same report also indicated that this is approximately half of the under-fives who died in 1990, with a total of 12 million. Malnutrition is currently linked to half of the deaths occurring in this age-group . Important direct causes of death include pneumonia, prematurity, birth asphyxia, diarrhoea and malaria. Interestingly, five countries contribute about half of the deaths in this age group: China, Democratic Republic of Congo, India, Nigeria, and Pakistan. The overall reduction in mortality seems promising, even though it still remains insufficient to reach Millenium Development Goal 4, which aims to reduce the under-five mortality rate by two-thirds between 1990 and 2015. DK

children died globally before the age of five (2012)

6.6 million50% of global under-5 mortality

is caused by malnutrition (2012)

WHO’S HAND-HYGIENE STRATEGY PROVEN TO BE FEASIBLE A recent study in The Lancet Infectious Diseases revealed that the WHO’s hand-hygiene strategy is both feasible and sustainable in a variety of settings across the globe. The WHO’s strategy for hand-hygiene was implemented and assessed in 43 hospitals in Costa Rica, Italy, Mali, Pakistan and Saudi Arabia. Health-care worker’s knowl-edge of hand-hygiene increased significantly after implementation of the strategy. Hand-hygiene compliance also increased from 51% to 67%. Interestingly, the findings demonstrated a greater effect in low- and middle-income countries, than in high-income countries. Health-care associated infections, such as MRSA, are a major threat worldwide, and the lack of compliance to hand-hygiene is considered to be an important factor. Currently, in developed countries, at least seven of every hundred hospitalized patients acquire a health-care associated infection. In developing countries that number rises to ten in every hundred patients. Further promotion of health hygiene could potentially decrease this number. SCJ

References  UN: Global child deaths down by almost half since 1990. WHO, UNI-

CEF, World Bank Group, UN-DESA Population Division joint news re-

lease.

 Bhaumik S. Unbanked direct blood transfusions should be legal, say In-

dian surgeons. BMJ.

 Mallewa M, Vallely P, Faragher B, et al. Viral CNS infections in children

from a malaria-endemic area of Malawi: a prospective cohort study. Lancet

Global Health, Sept 2013;1(3): e153 - e160.

 Global implementation of WHO’s multimodal strategy for improvement

of hand hygiene: a quasi-experimental study. The Lancet Infectious Diseas-

es, early online publication. Benedetta Allegranzi, Angèle Gayet-Ageron,

Nizam Damani, Loséni Bengaly, Mary-Louise McLaws, Maria-Luisa

Moro, Ziad Memish, Orlando Urroz, Hervé Richet, Julie Storr.

VIRAL CNS INFECTIONS AND CEREBRAL MALAR-IA: POSSIBLE SYNERGETIC EFFECT ON DISEASE BURDENAn important reason for child hospital admissions in sub-Saharan Africa is the presentation of central nervous system (CNS) diseases. Defining symptoms include fever and reduced consciousness. Ce-rebral malaria is one of the most important causes. It is diagnosed when the patient has both a Plasmodium falciparum infection and also suffers from coma not attributable to another cause. However, a recent observational study demonstrated that viruses may also be an important cause of CNS infection in these patients. A prospective cohort study in Malawi included 513 children who were admitted on suspicion of a non-bacterial CNS infection. Of these, 163 (32%) were found to have P falciparum parasitaemia. In-terestingly, in 133 patients (26%) at least one virus was detected in the CNS. Twelve different viruses were found in total, adenovirus being the most common. Children with both a P falciparum para-sitaemia and a viral infection of the CNS had greater chances of ex-periencing seizures, compared to those with parasitaemia or viral in-fection alone. Mortality was also higher among children with a viral CNS infection. The authors concluded that viral CNS infections are an important cause of hospital admission and death. They hypoth-esized that an interaction between viral infections and parasitaemia may increase disease severity. MU

GMNewschildren died globally before the age of five (2012)

1 out of 3Indian inhabitants live in urban areas

To legalise organ trade in kidneys:

Elske van den Burg

IntroductionAs shown in the case above, there are many difficulties con-cerning organ donation and organ trade. The long waiting lists area major problem. These exist all over the world. In the USA, in 2012, there were more than 114.000 patients waiting for an organ. In the Netherlands, there were more than 1.300 people on the waiting list at the end of 2011. In the region where organ donation is organised by Eurotrans-plant, which consists of Austria, the Benelux, Croatia, Ger-many, Hungary and Slovenia, 15 499 persons were waiting for an organ at the end of 2011. Iran is one of the few exceptions: it is the only country in the world where kidney transplantation is assisted by a governmental reward. Iran’s controlled living unrelated donor (LURD) program for renal transplantation has resulted in an elimination of the renal transplant waiting list in 1999. This shows that selling kidneys could be an effective way to reduce the waiting lists.

The questions rises, however, whether this is also ethically acceptable. Organ trafficking is defined by the United Na-tions in the following way: “Organ trafficking entails the recruitment, transport, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of

the abuse of power, of a position of vulnerability, of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation by the removal of organs, tissues or cells for transplantation.” One of the keywords in this definition, is that organ trafficking is regarded as exploitation.

A good solution for reducing the waiting lists?

“Organ trafficking accounts for 5-10% of all the kidney transplants in the world”

A 60-year-old male from the United States has been on a waiting list for a kidney transplantation for almost two and a half years. Through unofficial routes, he learns that he can buy a new kidney in India. In the meantime, in India, there is a family with great financial debts. The husband pressures his wife to sell a kidney. He argues that he takes care of the weekly income of their household and, therefore, cannot be missed. The wife donates her kidney even though she was not adequately informed about the potential health consequences. She has terrible postoperative pains and starts having bad dreams. Meanwhile, back in the US, the receiver of the kidney sees his nephrologist, who urges him to test for transmittable diseases such as hepatitis, tuberculosis and HIV immediately.

Currently, organ trafficking accounts for 5-10% of all the kidney transplants in the world, as estimated by the World Health Organization. Commerce in kidney transplanta-tion occurs in many parts of the world, especially in India, China, Pakistan, South Africa, the Middle East and South America. The ethical issue concerning organ trade is that poor people are forced to sell a kidney: they sell an organ when they see no other way out of poverty. That is why many people do not consider kidney sales as an expression of individual autonomy, but as acts of desperation by im-poverished individuals. On the other hand, there are people who justify kidney sales as a practice to save the lives of pa-tients with no other treatment option, and at the same time to help a donor overcome poverty. There are a few aspects that have to be taken into account, when contemplating whether the legalisation of regulated organ trade is a good

option to reduce the waiting list for kidney transplanta-tions. Firstly, the health consequences of donating a kidney should be taken into consideration. Secondly, it is impor-tant to know what the economic consequences of selling a kidney are for the donor.

Health consequences There are many different types of health consequences that play a role in the lives of organ vendors. After selling a kid-ney, there can be complications. A survey in India showed that the subjective health status of people declined after selling a kidney. Furthermore, 50% complained of persis-tent pain at the nephrectomy site, and 33% complained of back pain. This survey reported that 79% of the par-ticipants would not recommend selling a kidney to other people, and they would not have sold their kidney had they

7

Global M

edicine 17 – Feb 2015

understood these consequences. In an article written for the World Kidney Forum it is stated that the health status de-teriorates after a paid kidney donation. High prevalences of depression and psychosomatic reactions have been re-ported among donors, which often leads to social isolation. Iran’s regulated system for unrelated organ donation leads to the same problems as in an unregulated system: in both cases, the donor is ‘forced’ to sell a kidney due to debts and poverty. The situation is different in the case of living related donations. Altruistic kidney donations generally do not lead to change or a deterioration of psychosocial health.

Not only the donor, but also the recipient may experi-ence negative health consequences after donation. This is especially the case when the transplantation occurs in a ‘back-street’ clinic. These clinics often do not even have clean sanitation, let alone good hygiene regulations, which increases the danger of developing complications after the transplantation. Furthermore, transmission of infectious diseases from the donor to the recipient may occur. Diseas-es like HIV and hepatitis are transmittable diseases. These diseases are normally transmitted through blood contact, but can also be caused by the transplantation of a kidney. This effect has been observed in different countries, includ-ing India, Iran, Pakistan, the Philippines and Malaysia. A recipient usually does not know where his new kidney is coming from. This issue could be solved by legalising and regulating organ trafficking. Where regulation is possible, testing potential donors beforehand can then be demanded.

An important problem regarding uncontrolled commer-cial renal transplants is that there is an incomplete medical follow-up for the donor and the recipient. This results in high incidences of complications. This problem could be

addressed by regulation, because the sale of kidneys would move from the black market to a regulated market. Un-fortunately, Iran shows that a regulated market does not automatically improve the follow-up. Even though it has a regulated system, the follow-up and health care after dona-tion are still inadequate. A study by Zargooshi showed that 79% of the vendors had no follow-up visit after the removal of stitches. This is because donors are often unable to pay the consultation fees. Also in Iran, it seems that many ven-dors are not well informed about the consequences of sell-ing a kidney, and of the precautions they should take. This resulted for many people in isolation, because they did not dare to return to their original work or they did not dare to practice sports any longer2. Isolation is also a major reason for deterioration in health status, as it causes depression and other psychosocial problems.

Economic consequencesBesides health risks, there are also negative economic conse-quences for kidney donors. Often, these consequences arise from the negative health consequences brought on by sell-ing an organ. Most donors sell their kidney to pay off finan-cial debts. However, research has shown that, after selling a kidney, the economic status of the majority of donors dete-riorates. Several reasons have been proposed. Firstly, agreed

prices are often not received. Furthermore, many people remain physically weak and become unable to work such long hours as they did before nephrectomy. Often they have to switch jobs or they cannot work at all. Donors are rarely adequately informed about the fact that they might be un-

“Most donors sell their kidney to pay off financial debts”

able to work for, at least, a while. In a regulated market, the up-front information could be improved. The question remains if this would change the situation.

ConclusionIn conclusion, organ trade in kidneys should not be legal-ised. The main reasons for selling organs are extreme poverty and accumulated debts. The regulation of organ donation could improve the awareness among organ vendors about potential negative consequences of donation. In addition, it could lead to a better follow-up of patients. Unfortu-nately, there are too many negative health and economic

consequences for the organ vendor that are difficult to over-come, even when regulating organ trade. Therefore organ trade in kidneys should not be legalised. It is, however, still a global problem that deserves our urgent attention, in or-der to come up with solutions to prevent this illegal trade in the first place.

About the authorElske van den Burg is a fourth year medical student at Maastricht University. She has followed the Honours Pro-gramme International health and this article was part of her thesis.

9

Global M

edicine 17 – Feb 2015

ColumnMbasuNathalie Bale

“Have you heard about the curse?”, my cousin asked me. “The curse? What curse do you mean?” She opened You-Tube and showed me a video of this mysterious curse.

All over Kinshasa, the capital of the Democratic Republic of Congo, people seemed to have been cursed. “They throw something at you and within several hours to days, your flesh starts rotting off your bones,” my cousin said. There were people with different presentations. Skin lesions that, to me, looked like simple inflammations, bloody infected limbs and some people even had skin tumours on dif-ferent parts of their bodies. ‘Mbasu’ they called it. Which means… well I don’t know what it means in dialect, but it sounded like a serious curse to me nonetheless!

My cousin and I kept watching the video with both interest and horror. But, unlike my cousin, I tried not to think of it as a curse. Instead, I tried to imagine how it had gotten to this point. ‘They throw it at you,’ but what is it exactly? There were people with different presentations of it. I noticed the great amount of children that had deforming mass-es on their faces. As a medical student with at that time a minor in paediatric oncology, I started thinking about the possibilities. My tunnel vision was in full mode that day and my brain screamed ‘Burkitt lymphoma!’ It grows rapidly and therefore seems to come out of nowhere. The endemic variant is also known as the African variant and it often presents on the face. But the problem with my theory was that you couldn’t throw it at another person. Moreover, cancer isn’t contagious. What else could it be? It must involve some kind of human contact; another person has to throw Mbasu at you, after all. That, and considering the poor hygiene conditions in some parts of my capital, I figured a microorganism must be involved. Quite disap-pointing: no curse to scare people with. On the other hand,

I didn’t recognise the disease. I’m not a perfect student, but I would have remembered a disease with such a broad and sometimes horrible presentation. Because I wasn’t able to solve it , I ended up thinking that perhaps it really was caused by a curse after all. What is it with some of us and superstition? Being a reli-gious student in higher education is sometimes seen as negative. And even I, being as religious as I am, uninten-tionally don’t have a high opinion of superstitious people who, for instance, believe in bad luck caused by crossing paths with black cats, or breaking mirrors. But then again, when this curse presented itself to me, I started to believe in it. And this was even just after watching an amateur video on YouTube. I wasn’t even onsite to see what was re-ally going on with my own two eyes. If I was, I’m sure that by the end of the day, I would have been running around town as well, screaming about how they throw the curse at people.

When I used to think about global health, I always thought about how I would go back to my country and improve the health system there in a blink of an eye. Mbasu made me realise I was forgetting one important thing: the people and their culture. My own culture in this case. You should never underestimate the role that culture plays in develop-ing countries. It might be Mbasu, it might be a village chief wanting privileges. The fact is, we all have different beliefs and customs. Bringing change starts with understanding what you are changing.

Which brings me back to my curse. In the end, I found out it was a neglected disease caused by a member of the my-cobacterium family, M. ulcerans. The same family that is responsible for leprosy and tuberculosis. The official name of the infection is Buruli ulcer, but I think I prefer Mbasu.

Buruli UlcerMycobacterium ulcerans disease, known as Buruli

Ulcer, is a painless, necrotizing disease of the skin,

subcutaneous tissue and bone. Left untreated it

leads to severe handicaps, loss of livelihoods, and

social stigmata. The disease is endemic in more

than 30 countries, but is most frequently found in

the tropical wetlands of West Africa. Worldwide it

is the third most common mycobacterial infection

after tuberculosis and leprosy. The mode of

transmission and much of the pathology of Buruli

Ulcer remains unknown.

Further reading:

“Buruli ulcer, a neglected disease”, Menno Smit,

Global Medicine 8.

Nathalie Bale is a fourth year medi-cal student at the Erasmus Medical Center, Rotterdam, The Netherlands.

Global M

edicine 17 – Feb 2015

11

Globesity

Helena J. Chapman

IntroductionThe global epidemic of obesity, or “globesity”, impacts health outcomes in all communities and attacks physical, psychological and social health, as well as health-related quality of life. The traditional use of the body-mass index (BMI) defines overweight as a BMI between 25 and 29.9 kg/m2 and obese as a BMI of 30 kg/m2 or greater, or obesity grade 1 between 30 and 34.9 kg/m2, obesity grade 2 be-tween 35 and 39.9 kg/m2, and obesity grade 3 as 40 kg/m2

or greater. In 2008, the global population was estimated to have a total of 1.4 billion overweight adults, about a quarter of the global population. This includes 500 million adults who are classified as obese. These numbers cause great con-cern for the economic and health burdens related to direct and indirect health effects of weight gain.

Approaching the negative effects of obesitySeveral approaches can be used to alter the negative effects of obesity. First, there are disease management strategies. In general, these strategies tend to focus on the ‘medical model’, which evaluates an individual’s physical health and risk factors to determine a specific drug or intervention as a treatment plan to reduce disease morbidity, mortal-ity, or associated complications. An alternative approach is the ‘population health model’, which targets the health of

communities and the multi-factorial health determinants that aim for long-term weight reduction through the de-velopment of lifelong healthy behaviours. Combining these models and focusing on the reduction of risk factors of these health determinants may produce effective interven-tions and optimal population health outcomes.In 1997, it was estimated that 40 adults per 1 000 had diabetes mellitus type 2, compared to 59 adults per 1 000 in 2008. Interestingly, in that same period, coronary heart disease mortality decreased from 203 adults per 100 000 in 1999, to 135 adults per 100 000 in 2008. This was mainly attributed to compliance to new clinical therapeutics. Since obesity increases an individual’s risk factors for diabetes, hypertension and cardiovascular disease, treatment requires major lifestyle modifications through diet, exercise, be-havioural, pharmacological, or surgical interventions. No silver bullet will eliminate excess body weight in several weeks, without a combined effort of calorie reduction and increased energy expenditure, in spite of what commercial weight loss programmes try to sell.

Example: United States’ Healthy People 2010The Healthy People initiative was developed by the United States’ Department of Health and Human Services in 1979 to identify key health priorities and goals for the US popu-

Integrating medical and population health models for optimal chronic disease management

lation for Healthy People 1990. Through these initiatives that collect data for later comparison to ten-year target out-comes, the effectiveness of health promotional campaigns may be examined, and new goals can be established. As one of the major health priorities and indicators of poor health in the US population, obesity was identified to maintain a goal of less than 15% prevalence for Healthy People 2010. Statistics from the National Health and Nutrition Examination Survey (NHANES) of the previous two decades on US obesity preva-lence in adults (>20 years) showcased increasing trends, above the target prevalence, resulting from increased dietary intake of high-fat, high-carbohydrate meals and sedentary lifestyles (i.e. television, computer use). In conclusion, 78 million US adults represented 35.7% of the obese population in the US, and thus, the respective obesity goal of less than 15% prevalence of Healthy People 2010 was not achieved.

Medical Model versus Population Health ModelThe medical model utilizes the concept of disease patho-physiology to develop an appropriate clinical or surgical treatment plan for obesity in order to decrease morbidity and mortality. Physicians using this approach usually utilize anthropometric measures for classification, and then mea-sure cholesterol and glycaemia levels to evaluate overall risk, and other underlying conditions. They provide treatment interventions for weight reduction and subsequent co-mor-bidities. The US Food and Drug Administration (FDA) approved orlistat and sibutramine as weight loss drugs, al-though marketing in Europe was suspended for the latter. Another option is weight loss surgery, but invasive bariatric surgery is not only expensive, it may also result in lifelong complications. Therefore, these programmes should only be

13

Global M

edicine 17 – Dec 2013

13

Global M

edicine 17– Feb 2015

patients with high BMI’s, and multiple co-morbidities, af-ter other non-invasive programmes have failed. The follow-ing example highlights a frequently used approach when the medical model is used to treat obesity.

Señora Gómez is a 48-year-old Dominican female who visits your office as a follow-up visit for a routine health examina-tion. She is the mother of three children and works as a sec-retary. She has never smoked and frequently jokes about her “large” appetite. She has a two-year history of hypertension treated with Lisinopril 10 mg per day. During physical exami-nation, she has a blood pressure of 120/80 mmHg, a height of 1.58 m, a weight of 80 kg, and a BMI of 32. Her waist circumference is 98 cm. Fasting lab results are as follows: Total Cholesterol 190mg/dL (N < 200 mg/dL), LDL 100 mg/dL (N < 130 mg/dL), HDL 50 mg/dL (N > 50mg/dL), Triglycerides 140 mg/dL (N < 150 mg/dL), Glucose 200 mg/dL (N 70-100 mg/dL), and HbA1c 8% (N < 5.7%). Her physician proposed the following treatment plan: Orlistat 120 mg three times per day at main meals (for weight reduction), Lisinopril 10 mg per day (for hypertension) and Metformin 850 mg per day (for diabetes mellitus type 2). In addition, her physician proposed a consultation with a nutritionist.

The population health or public health model, on the oth-er hand, focuses on health promotion and understanding factors that may impede compliance for dietary changes, motivation or willingness to develop healthy lifestyles. The individual’s and community’s readiness to identify psy-chological, social and cultural barriers to develop positive health behaviours are essential components in health pro-motion campaigns for dietary modifications (smaller meal portions, low-calorie foods) and daily exercise. Once com-munity members understand the impact of obesity on their

health-related quality of life, co-morbidities and increased mortality risk, health care providers can also identify bio-psychosocial or cultural barriers in order to develop effec-tive interventions that can be utilized to target this popula-tion. The following section is an example of the use of the population health model.

Physical: After Señora Gómez exits her ten-minute consult, she wonders, “Why do I need more medications when I feel so good?” The primary care nurse gives Señora Gómez brochures with pictorials describing obesity, cardiovascular disease and diabetes. Opening the brochure, the nurse explains where adi-pose tissue deposits, the impact on cardiac and metabolic func-tions and the mechanisms for each medication. Psychological: Señora Gómez confesses, “I want to lose ten ki-lograms, but I have been stressed about my daughter’s wed-ding planning”. As the nurse assesses her willingness to comply with recommendations for weight reduction, both agree to a six-week plan with daily (medication, reduced food intake and a 30-minute brisk walk during her lunch hour) and weekly (weight measurement) goals. Social/Cultural: Señora Gómez says, “My culture traditionally includes social activities with family and friends surrounded by ‘criollo’ food”. The nurse negotiates a plan to remain social and healthy through reduced consumption of these fried or high-carbohydrate foods and increased physical activity with her walking team of friends every evening around the local park. Philosopher Faust described these contrasting notions as follows: 1) the medical model portrays the ‘quick fix’ for measurable impact that may result in lifelong side effects, but fails to address other factors that impact an individ-ual’s health, and 2) the public health model describes the continuous process of health promotion which will have

a long-term impact on disease management. It focuses on how individuals perceive disease and barriers that prevent them from choosing healthy behaviours. Why not utilize both models to complement obesity management pro-grammes for patients for optimal outcomes? The following example describes this dual medical and pop-ulation health model integration for a major health cam-paign, “A Healthier Dominican Republic: Educating our Community”.

A total of 153 medical, psychology and dental students repre-senting the Universidad Iberoamericana (UNIBE), Univer-sidad Central del Este (UCE), Universidad Nacional Pedro Henríquez Ureña (UNPHU) and Universidad Tecnológica de Santiago (UTESA), collaborated with university libraries, cafeterias and fitness centres to offer a multi-disciplinary health intervention toward promoting healthy aging. Teams utilized five novel didactic strategies to highlight the impact of aging on biological, social and psychological health, including edu-cational materials, health seminars, departmental collabora-tions, community outreach and social media. Medical students utilized the medical model to evaluate health well-being and measured blood pressure, height-weight to calculate BMI and waist circumference to estimate cardiovascular disease risk for university students, staff and community members. Students integrated the population health model by educating over 15 300 attendees in six urban and 23 rural DR communities on risk factors for non-communicable diseases, awareness of the negative effects on health-related quality of life, strategies to de-velop healthy lifestyles for mental and physical health through improved diet, sufficient sleep, adequate hydration, smoking cessation, and dental hygiene to avoid caries and periodontal disease.

ConclusionsA healthy population can only result when individuals in a community select healthy lifestyles. Outcomes from a healthy population are decreased health care expenses, more productive work force and self-motivation for per-sonal efforts to develop healthy behaviours for a lifetime. Early health intervention programmes aim to educate citi-zens on how obesity affects organ systems and on strategies to establish a healthier diet and increasing exercise routines (i.e. dancing), which will increase energy expenditures to lose or maintain weight. Incorporating both the medical and population health models into the prevention of obe-sity and long-term chronic disease management may prove to be effective in building a lifetime of healthier individu-als in the global community by reducing “waistlines” and subsequent co-morbidities from cardiovascular disease and diabetes, and creating more effective non-invasive treat-ment interventions to ensure optimal population health and significantly reverse these obesity upward trends within the next decade.

About the authorHelena Chapman, MD, MPH, has recently graduated from the Iberoamerican University (UNIBE) School of Medicine in the Dominican Republic (DR). Currently, she is a doc-toral student in One Health at the University of Florida (USA). As founding member and first President of IFM-SA-Dominican Republic (ODEM), she currently serves as Supervising Council and advises DR medical students on local and national health initiatives with a preventive health focus that motivates community members to adopt healthy lifestyle behaviours.

15

Global M

edicine 17– Feb 2015

Controlling neglected zoonotic parasitic infections

Sonia Menon

Introduction The increase in both human migration and concomitant HIV infections are likely to cause important changes to the epidemiology of zoonotic parasitic infections. This article aims to explore the feasibility of strategies to prevent and control three neglected zoonotic parasitic infections. It emphasizes the urgency of the “One Health” philosophy, which is premised upon the inextricable connection be-tween human and animal health and the need to safeguard both.

Trypanosoma brucei rhodesiense Human African Trypanosomiasis (HAT), also known as sleeping sickness, is a vector-borne parasitic disease trans-mitted by the tsetse fly. There are two subspecies that infect humans. T.b rhodesiense occurs mainly in East Africa while T.b gambiense, arises mainly in West and Central Africa. Both infections are characterized by two similar stages. During an early stage, the preliminary haematolymphatic stage, trypanosomes are found circulating in the blood and lymph nodes, giving rise to hypergammaglobulinemia. The

second stage is characterized by symptoms of meningo-encephalitis. Development of the infection in Rhodesian sleeping sickness is similar to that in Gambian, with a few important exceptions. T.b gambiense is chronic and there is little lymphadenopathy. Also, invasion of the central ner-vous system takes place early in the course of the Rhodesian infection. Finally, T.b rhodesiense has an animal reservoir, in contrast to T.b gambiense, which is mostly confined to a human-fly-human cycle and controlled with detection and treatment of cases.

Control methods: The ability of the parasite to undergo antigenic variation dampens prospects of mounting an effective immune re-sponse as well as developing a trypanosome vaccine. This makes the discovery of alternative methods to control the disease necessary. These control methods have recently shifted from unsustainable, top-down, continent-wide spraying control campaigns, to local and individual con-trol measures that are more feasible. In Uganda, livestock has driven the epidemiology, with a cow being five times

Meeting a global challenge?

more likely to infect a tsetse fly than a human. This has had a profound impact on national level recommendations. It is now advocated that prophylactic trypanocidal drugs be administered to traded cattle on a regular basis to avoid the development of drug resistance, Unfortunately, until now, there has been a rather irregular use of prophylactic try-panocidal drugs, usually only in villages where cases occur and that have sufficient funds.

Insecticide regimen:The tsetse fly transmission cycle will be broken when the sleeping sickness parasites are eradicated in cattle, in areas affected by t.b rhodesiense. This consideration led to con-trolling tsetse with insecticide-treated cattle. Since tsetse flies feed mostly on the legs and on the largest animals in the herd, the application of pour-on insecticides or sprays restricted to the legs, known as the “restricted applica-tion method” enables farmers to save up to 80% to 90% of insecticides. However, an insecticide treatment regime requires continuous entomological and veterinary monitor-ing to assess insecticide resistance and the need for reappli-cation. This may not be feasible when the sole responsibility for treating livestock lies upon individual farmers, who are often ill-equipped for control, diagnosis and treatment to distinguish among common endemic diseases.

Diagnosis: Simple molecular tests are urgently needed for monitor-ing the effectiveness of the “restricted application method”. Molecular tools, like PCR targeting the Serum resistance gene (SRA gene), have greatly facilitated the unequivocal identification of T.b. rhodesiense trypanosomes. However, a recent systematic review on diagnosis in first-line health services of endemic countries found that the lack of labo-ratory infrastructure hinders the integration of PCR and

other and other available confirmation tests into the diag-nostic algorithm.

Zoonotic Visceral Leishmaniasis (ZVL)Another vector-borne parasite is the L infantum para-site, which is an obligate intra-macrophage protozoa. It is transmitted by phlebotomine sandflies causing ZVL in humans, and canine leishmaniosis (CanL), mainly in dogs. The emergence of cases of ZVL in new territories is usually preceded by an increase in the prevalence of CanL. A meta-analysis of dog studies confirms that infectiousness is higher in symptomatic cases. Infections in humans are generally subclinical. Most clinical cases occur among children and as opportunistic infections in HIV-infected patients. The endemicity of ZVL indicates that present control methods, consisting of human case detection and treatment, and direct and indirect CanL control methods to remove the source of infection, have been ineffective.

Direct control:Direct control methods are aimed at infectious dogs. Al-though dog culling seems to have been effective in the re-duction of infections among humans in China, in Brazil, ZVL has increased steadily during the past 10–20 years despite the spraying of 200.000 houses and the killing of 20.000 seropositive dogs per year. Clinical treatment of symptomatic dogs is currently the method used to reduce the infectiousness in countries where culling is considered unethical or not logistically feasible. Although treatment of infected dogs reduces or eliminates clinical signs, it is not usually parasitological curative and treated dogs may still be capable of transmitting the parasite. These direct meth-ods partly rely on the immunofluorescence antibody tests, which are often used for mass screening of dogs.

17

Global M

edicine 17 – Feb 2015

However, sensitivity and specificity have been reported to be low, leading to many false-positive and false-negative re-sults, the first mainly caused by serological cross-reactivity with other pathogens. There is a need for more reliable di-agnostic tests.

Vaccine:In some areas of Brazil, vaccination of healthy dogs has been used as a preventive tool in combination with regular cull-ing of serologically positive dogs. Despite this promising tool, its use has been debated because healthy vaccinated dogs may present seroconversion, therefore being indistin-guishable from infectious dogs.

Indirect methods: In contrast, indirect methods consist of targeting vectors themselves. Similar to malaria control, which uses deltame-thrin impregnated mosquito nets, deltamethrin impregnat-ed dog collars are used for ZVL control. However, despite their potential use in control, the effectiveness of collars on domestic dogs, like direct control methods, will be restrict-ed in areas where wild canines or other mammals constitute a significant reservoir. The failure of dog culling to reduce human cases in Brazil can also indicate the existence of oth-er reservoirs. Both identification of the existence of other reservoirs, as well as accurate and early diagnosis of CanL are required to reduce ZVL. But unless field molecular tools are developed for ZVL, these few available control weapons may be in jeopardy.

ToxoplasmosisToxoplasmosis, one of the Center for Disease Control and Prevention’s five neglected parasitic diseases, is an impor-tant food-borne zoonotic disease caused by infection with

Toxoplasma gondii, an obligate intracellular parasite. Toxo-plasmosis has been found in nearly all warm-blooded ani-mals. The sexual cycle occurs only in cats, the definitive host. The majority of human infections with Toxoplasma are benign. When symptoms do occur, they are mild and mimic infectious mononucleosis, with chills, fever, head-ache, myalgia, lymphadenitis and extreme fatigue

Transmission: Infection can occur by ingestion of sporulated oocysts, following the handling of contaminated soil, cat litter, or through the consumption of contaminated water or meat. Transmission of tachyzoites to a human fetus can occur via the placenta following a primary maternal infection. Such an acute infection in pregnancy may lead to fetal infection and subsequent fetal loss, or birth of a manifestly or latently infected infant. Fetuses, newborns, and the immunologi-cally impaired are at risk for life- threatening toxoplasmosis. The seroprevalence of T gondii antibodies in the human population varies geographically, with prevalence rates ap-proaching 93% in Parisian women who consume under-cooked or raw meat and usually exceeding 50% in African countries. While, in industrialized countries, improved hand hygiene has resulted in undercooked meat becom-ing the most significant cause of T gondii infection, in re-source-poor settings, contact with oocyst-contaminated soil is the major means by which intermediate hosts, including humans are exposed.

Congenital transmission prevention: The major toxoplasmosis-induced public health issue in Europe is congenital toxoplasmosis. Congenital toxoplas-mosis may manifest as a mild or severe neonatal disease. Symptoms may include fetal death, stillbirths, or long-term

disabling ophthalmologic and neurologic sequelae, which can be present even when the congenital infection is asymp-tomatic. Prevention is through primary health education, by secondary serological prenatal or neonatal screening to identify and treat early gestational toxoplasmosis when still asymptomatic, and/or tertiary prevention by administering antimicrobial treatment of infected newborns, to prevent further clinical damage. France, a country with a high in-cidence of infection, has successfully instituted secondary prevention programs through universal maternal serum screening. The United Kingdom, which has a low incidence of T gondii, has no universal serologic screening program but a nation-wide health education for pregnant women.In Africa, where the infection rates are likely to be under-estimated, a cost effective national screening program is unlikely to be feasible. Pyrimethamine and sulfadiazine are currently recommended in the treatment of toxoplasmosis. These drugs act primarily against the tachyzoite form of T gondii, when visceral disease is clinically severe, following a positive fetal diagnosis. This treatment is often unavail-able and may, therefore, not justify a national screening program.

Opportunistic infectionThe significance of Toxoplasmiosis as an opportunistic in-fection has been recognized after the worldwide increase in immunosuppressed individuals. Central nervous system (CNS) toxoplasmosis is almost always caused by a reactiva-tion of CNS lesions, or by the hematogenous spread of a previously acquired infection. Symptoms may include con-fusion, ataxia, hemiparesis and retinochoroiditis. It occurs during advanced HIV infection when CD4+ counts are be-low 200 cells/µL. Without adequate prophylaxis or restora-tion of immune function, patients with CD4 counts below

100 cells/µL who are T gondii IgG-antibody positive have a 30% risk of eventually developing reactivation of disease.In industrialized countries, the incidence rate of Toxoplas-mosis as an opportunistic infection has decreased due to the availability of HAART treatment and primary anti-T gondii prophylaxis, trimethoprim-sulfamethoxazole, which is administered to all HIV-infected patients with CD4 counts of <100 cells/µL who are seropositive for Toxoplas-ma. However, in Africa, approximately 25 million people have an HIV infection, and co-infection with T. gondii fre-quently remains undetected and thus untreated. Given the public health impact of Toxoplasmiosis in Africa, Africans would benefit the most from the development of a vaccine.

Conclusion Controlling neglected, vector borne, zoonotic, parasitic dis-eases entails many challenges. Affordable and sensitive field molecular diagnostics are needed urgently. Unless a balance is struck between govern-ment and community involvement for control initiatives, zoonotic, vector-borne, disease control community-based programs may meet with limited success. Also, there is a dearth of contextualized, evidence-based control methods for controlling the spread of sporulated oocysts in resource-limited settings, which in turn may be hampered by the lack of baseline data. Neglected zoonotic parasitic disease control begs for a One Health approach, uniting human and veterinary medicine, an approach which is also inte-grated within national HIV prevention strategies.

About the authorSonia Menon is a PhD student at Ghent University.

Neglected zoonotic parasitic disease control begs for a One Health approach

19

Global M

edicine 17 – Feb 2015

Open Access: the Right to ResearchEske Ravensbergen

Introduction The problem illustrated above has been raising questions and has been a topic of debate for almost a decade now. That is why the Open Access movement was founded. The definition of Open Access includes the free availability of high quality, peer-reviewed scholarships on the public In-ternet with permission to use the text to its fullest possible extent. Simply put, Open Access advocates for ‘gratis’ (free to read) and ‘libre’ (free to use or adapt) research. Google Scholar as an example of a source where many Open Access articles can be found.

In the current mainstream publishing system, journal publishers obtain the academic articles of scientists and re-searchers for free in exchange for publication. The publish-ers coordinate several processes, such as the editing process and the process of peer reviewing the articles. Neverthe-less, with all the efforts they make taken into account, it remains a fact that the price organizations eventually pay for a subscription does not reflect the costs of publication the journals. Several large journal publishers have a profit margin of around 30%.

Imagine: you are a medical student in a low-income country. Among few others you have the privilege of being able to attend university. At some point in your education, you are asked to do research on a certain topic or to write a literature report. You can start searching in Google or Wikipedia, but a database such as PubMed.org is much more convenient to use. Although PubMed is openly accessible, the journals it searches are usually not. What if your university does not have the budget to pay for access to these journals? In other words: how can you continue to learn, develop or even read about the latest breakthroughs in medicine, when a great share of the information you need is hidden behind pay walls?

Over the years, subscriptions to the academic (medical) journals have been getting more and more expensive, out-pacing inflation with over 200%. Examples of current an-nual institutional fees for medical journals are $5.006 for the Virology and $19.500 for the Brain Research. Only wealthy universities can afford access to full text articles of such journals. This can be illustrated by the fact that the University of Georgia has cancelled nearly 600 journal sub-scriptions in 2010 alone. So even for students, it is a ques-tion whether they can reach the information published in core (medical) journals, even though, as mentioned before, it is necessary for their education.

On the other hand, not only students, but also doctors who are not employed by large institutions and still want to treat their patients in line with the most recent evidence, as well as patients who want to know the latest news on their illnesses, can often not access these journals. All these individuals have good reasons to access medical journal in-formation, yet the current system in publishing often pro-hibits them from reaching it. It seems that the maximum potential of research published in high priced academic journals is by far not reached due to the limited population that can access it.

The odd thing is that many medical research efforts are funded by tax or tuition funds. This means that many in-dividuals that indirectly fund research do not have access to these studies. That also means that universities may pay for research performed within their own institutes, but do not have access to the published results. How unfair this is?

The solution The Open Access movement promotes several options to make research more publicly available. These are usually categorized into the ‘golden access’ and the ‘green access’ models. The golden open access model advocates making work publicly available. Journals with such a model are free-ly available for every individual. They are usually only dis-tributed electronically to decrease costs. Sometimes, these journals do require a processing fee. These charges are usu-ally not covered by the author; typically the researcher’s em-ployer or funder pays for these expenses. A journal is called a green open access journal when author self-archiving is allowed. This means that authors of a published study enter a copy of their article into an institutional or subject data-base. This self-archiving is allowed depending on the rules of the journal where the article was published in.

Currently, more than 5000 open access journals exist. These journals make millions of articles freely accessible and, to-gether, they cover about 20% of all published journals. Many other journals provide an option in-between the models mentioned above, which can be used as a system in the transition from the old model to the open access model. These journals still have the regular way of publishing as ba-sis, but if authors are willing to pay extra fees, the article can be published according to the golden open access model. These journals then are called hybrid open access journals.

The downsidesAs with every development, there are also a few downsides. One example is the prices researchers have to pay. Open

Global M

edicine 17 – Feb 2015

21

access is not the standard yet, which means not every insti-tute supports it and covers the expenses researchers make to publish their articles. Those are not the only expenses that may cause problems. Lower subscription costs may mean less income. The prices institutions and researchers pay may compensate some, but possibly not all. This means the pric-es of publishing a printed version of the journal may go up.

Open Access and Global MedicineHow does Global Medicine fit into this picture? Global Med-icine is a golden open access journal. The magazine is avail-able for free at Dutch and German medical universities, and the articles are published on the public Internet two weeks after the distribution of the hard copy magazine. Medically oriented articles, which are used for the content of many of Global Medicine’s journals, are either available because they are published in open access, or because writers have access to them through the universities they are associated with. ‘Global Medicine is an initiative of the International Federa-tion for Medical Students’ Associations -The Netherlands (IFMSA-NL). This federation is part of an organization called the “Right to Research Coalition (R2RC)” (see box). In this Coalition, 71 students’ organizations (representing

nearly 7 million students worldwide) have joined forces to tackle the issue of access together. The Coalition has two main goals: advocating for local and national policies on making research freely available in a timely manner, and educating the next generation of scholars and researchers in a way where open publishing becomes the new norm.

ConclusionIt can be concluded that open access certainly is a hot topic at the moment and is expanding it’s share on the journal market. There are still a few matters to be solved to make it fully applicable to our publishing industry, but the open access plan most definitely has a future and is here to stay.

About the authorEske Ravensbergen is a third year medical student at the university of Leiden.

Once a year, the organizations joined in the Right

to Research Coalition (R2RC) get together in the

Right to Research General Assembly to discuss

current problems and to brainstorm about new

projects and initiatives to promote Open Access.

Another important happening for the Coalition is

the international Open Access Week, which is, as its

name implies, an international meeting with focus on

worldwide Open Access.

Visit www.openaccessweek.org for up to date

information on initiatives taking place during this

week and how you can contribute to making Open

Access happen.

Polio and the road to eradication

Kimberley Anneveldt

PoliomyelitisPoliomyelitis is a highly infectious disease caused by the human enterovirus C group, one of the four human en-teroviruses with a single-stranded RNA genome. The three poliovirus serotypes are conveniently named types 1, 2 and 3 and all of them produce motor neuron disease. The trans-mission takes places by fecal-oral contamination but can also happen by pharyngeal spread. 95% of the poliovirus infections are asymptomatic. One in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralysed, 5% to 10% die when their breathing muscles get affected. After infection a major viremia occurs which causes the usual viral infection symptoms, but in some cas-es involvement of the central nervous system occurs, giving signs of meningitis or even more severe symptoms like the development of motor weakness. After invading the central nervous system the virus uncoats, viral replication occurs and the motor neuron dies leading to paralysis of muscle fibers supplied by this motor neuron. The gold standard for confirming the diagnosis is PCR amplification of poliovi-rus RNA from cerebrospinal fluid.There is no cure for poliomyelitis at this moment. Treat-ment includes pain relief, physical therapy and if necessary mechanical ventilation. The only antiviral therapy available

has shown mixed results. Because of this, prevention is the key to eradication for which an effective vaccine is available since 1956.

The Global Polio Eradication InitiativeRotary International took the initiative to eradicate polio worldwide in 1985. The World Health Assembly adopted a resolution in 1988 to support this initiative and both World Health Organisation and Rotary International have worked together with UNICEF and the US-based CDC in the Global Polio Eradication Initiative since. The basis of the GPEI has been immunization and surveillance of poliomyelitis.At the start of this initiative in 1988 polio was endemic in more than 125 countries and paralyzed at least 350 000 children each year. But since the start of the programme a fall of cases by 99% has been achieved. At this moment, at the end of 2014, only three endemic countries are left: Afghanistan, Nigeria and Pakistan. Reported cases in other countries are imported cases. Wildtype 2 has officially not been reported since 1999 and type 3 not since November 2012 and they could for this reason already be considered eradicated.Achieving eradication comes with high costs, especially in

The Global Polio Eradication Initiative

While in the Netherlands the last polio outbreak happened more than 20 years ago, several not western countries are still facing outbreaks. In 2014, 356 cases of Polio were reported globally, most of them (303) in Pakistan. The most recent case dates from January 3rd 2015, in Pakistan.

low-income countries. But the prevention of poliomyeli-tis through the GPEI has been shown to be highly cost-effective. Between the start in 1988 and 2035 net benefits of the GPEI have been estimated to up to 40-50 billion US dollars.

Recent outbreaksThe progress is tracked through surveillance of acute flac-cid paralysis cases and testing of linked stool specimens for polioviruses in selected areas. All thought the numbers of 2014 looked hopeful, only in 2013 different cases of out-breaks were reported in different areas of the world and most of them could be linked to conflicts which are still continuing. Because of the threat of increasing outbreaks, the WHO declared in May 2014 that the spread of po-lio had become a global public health emergency, posing a major threat to the global eradication effort. The reason of these (sometimes new) outbreaks had to do with interna-tional travel, but especially with limited resources of health systems and low poliovirus vaccination coverage because of military, politically and social conflict.

Future The strategy of the polio vaccine only works when high levels of vaccine coverage are maintained. However, fail-ure in implementing the planned strategy leads to ongo-ing transmission of the virus. Because of this the new Polio Eradication Endgame Strategic Plan 2013-2018 has been developed by the GPEI together with polio-affected coun-tries, WHO-partners and national and international advi-sory bodies and was presented at a Global Vaccine Summit in April 2013. Once polio is eradicated the world can cel-ebrate a new step made towards health equality and thou-sands of people won’t have to suffer from the horrible effects of the polio virus.

About the authorKimbery Anneveldt is a fourth year medical student at the University of Groningen. In the past she has been president of IFMSA-Groningen and Vice President of IFMSA-NL. References

  www.polioeradication.org

 www.endpolio.org

25

Global M

edicine 17 – Feb 2015

Memorable experiences in TanzaniaJeroen Berkhout

First impressionsI could not believe my eyes as we passed the crowded and very chaotic wards. Rows of patients on filthy mattresses only covered with a cloth looked at us with big questioning eyes, too shy (or weak) to ask for anything. The intern I was replacing spoke Swahili quite well and chatted with the pa-tients casually. Incomprehensive and insecure, I stood next to her, smiling at the questioning eyes, occasionally manag-ing to squeeze out a greeting in their language. I promised myself to learn Swahili as quick as possible.

Experiences on the wards The first half of my internship I spent on the internal medi-cine ward. I really had my ups and downs during my in-ternship. The last day on the ward was especially difficult and demanding. This day, not only were there the usual malaria, tuberculosis and HIV patients, but a collection of heavy complex medical cases and emergencies. It felt as if they all had been waiting for this day to come. While I ran from one infectious patient to the other, hastily prescribing antibiotics, I was taken aback by the extreme size of some livers I palpated. Unfortunately, I had no one to discuss the particulars with. At some point, the staff nurse came to me and told me that ‘the condition of one of the patients had changed’. That

often meant trouble, so I immediately went along with her. It was a new patient, just brought in, unconscious and gasp-ing. According to the swiftly written note in the file, this was an HIV-positive patient with severe anaemia. A bag of blood was already dangling by his side and my guts told me this was not going to end well. Two minutes later the gasp-ing had stopped, as had his pulse. Because of the conditions of this very sick man and his HIV positive status, I decided not to resuscitate him, took a minute to give my condo-lences to the family and ran off to the next patient. Fortu-nately, at the end of the day, Marie José, a truly dedicated Dutch nun and tropical doctor who has lived in Tanzania for thirty years, stopped by and I could talk to her about my experiences and discuss any complicated cases on the ward. Exhausted, I stumbled home, glad that this was my last day on the internal ward.

Children’s DepartmentMy first days on the paediatric ward began quietly because of heavy rainfall. This means that patients as well as doctors arrive late. My first patient was Dotto, a 14 month old girl. I looked into her status and saw that she had malaria and only weighed a meagre three kilograms. ‘How can a mother walk around with such a poor thing for so long?’, I won-dered. As I examined her carefully, afraid that she would fall apart out of pure misery, the Dutch student nurse next

The Sengerema Mission Hospital in Tanzania, my destination for three months last year. As part of my medical studies at the Academic Medical Centre (AMC) in Amsterdam, I went to Tanzania for a ‘tropical internship’.

to me asked: “Where is Kulwa?”. In Tanzania, twins are al-ways named Kulwa and Dotto. If a third child follows it will be called ‘numba tatu’ (literally: number three). The nurse thought: ‘Where there is a Dotto, there should be a Kulwa’, and so there was. Two minutes later he was brought in. Though he was almost twice his sister’s size, his weight was still severely below average. As I looked up the mal-nourishment management protocol, another intern came to me, saying that we had to take a blood sugar of a third child in a precarious condition. Thirty seconds later, the twins’ mother fell to her knees and began to scream. One of the twins had died in front of our eyes. As I tried to comfort her, it all became too much for me, I had to walk outside, into the fresh air, to let my own tears flow.Fortunately, it was not always this dramatic. Later that very day for example, I went to the intensive care to check up on a patient with severe pneumonia. The previous day he had been so short of breath that I wondered whether he would survive. When I saw his empty bed I feared the worst, but the nurse told me that he was playing outside without oxy-gen!

FrustrationsEven though I tried not to compare the situation in the hos-pital to my western standards, it was sometimes extremely difficult not to get very annoyed. These were my top five frustrations:1. The behaviour of some nurses. The hospital has ’student nurses’ and ’staff nurses’. Especially the first group had a tendency to lumber around in their pink suits, chewing gum with a dull look in their eyes. On my first day, when we arrived on the children’s intensive care unit, we found a sleeping nurse. When the other intern sarcastically said ‘goodnight’ the nurse looked up briefly and then continued her nap. I was informed about the work mentality of some nurses. Sometimes you have to wait days for your requested investigations, simply because they do not feel like doing it.

2. Communication problems. As a common example, a patient who can not go to the operating room because he or she has been eating, even though it has been extensively documented and communicated to nurse and patient that they should stay sober. 3. The handwriting of some staff. Is it Chinese or Eng-lish? Due to illegible handwriting, previously composed treatment plans could not be executed, ultrasounds could not be interpreted, and wrong medication was given. I thank heaven that, nowadays, more and more hospitals are equipped with computers.4. Disappearing patients. Too often I heard that a critically ill patient went home against medical advice, for example because the family could no longer wait or because they could not afford treatment. 5. Waiting for laboratory results. Too often you get back only half of what you requested, sometimes because the re-agent is out of stock, but more often without any apparent reason.

EvaluationOverall I had a good experience in Tanzania. Even though I think this hospital needs further education for all its em-ployees, in order to deliver motivated doctors, nurses and managers, I learned a lot from all my experiences as an in-tern. Besides my physical examination skills, I can now say I am a more independent medical student and future doctor.

About the authorJeroen Berkhout currently works at the emergency depart-ment of the Sint Antonius hospital in Utrecht.

27

Global M

edicine 17 – Feb 2015

A life changing career

Besides the well known medical professions, such as physician, medical specialist or researcher, there are many other interesting career options in global health care. Through these short interviews we would like to introduce different, fascinating, and sometimes unknown professions.

Let us introduceKees Rietveld studied medicine and international law in Leiden, the Netherlands. He focused his career on conflict situations and post-transition states. He has worked for MSF (Doctors Without Borders) for many years and in numerous countries, often under life threatening conditions. Dr. Rietveld is seen as an expert in the field of internal relationships in fragile countries and advises organizations such as Unicef, WHO and the European Commission on the rebuilding of healthcare systems in war-affected areas.

How would you describe your career path?I started working as a physician at MSF Holland in 1987. At first, I was based in Afghanistan, and later I worked in several countries such as Romania, Somalia and Liberia. After these deployments, I started working with many different organizations. Between 1991 and 2005, I was in Iraq on and off for the United Nations (United Nations High Commissioner on Refugees, UNHCR), the Coalition Provisional Administration, and the United States Vice Regal Administration of post war Iraq. I also represented the European Commission’s Humanitarian Office in Iraq and later on in Afghanistan, and represented the Euro-pean Commission in East-Timorafter the independence from Indonesia in 2000. In addition, I represented the World Health Organisation (WHO) during the civil war in Kosovo and consulted for them in several other conflict situations. I like to work wherever my help is needed!

What do you like best about your profession?The fact that for twenty-five years I have been living the world news! When I was in Romania, I witnessed the fall of the iron curtain. I was in Somalia during the beginning of the 90’s when the society collapsed after the ousting of Said Barre. I played a role in the transition to independence of Kosovo. I worked in Liberia, Yugoslavia, Afghanistan, and Iraq. I have witnessed almost everything!

GMMix

Which achievements in your career are you most proud of?I don’t have the capacity to change the world, but sometimes it is possible to change the little things. As a result of my experi-ences, I know what works and what does not. By using my experience, I know how to improve complex situations, or at least make it function less bad!

If you were not inhibited by rules or finances, what kind of project would you set up?In most countries where I have worked, 9 out of 10 initiatives didn’t actually work out. The working powers are very large and the interests are often too well established. Due to this political atmosphere, there is only a small possibility of actually chang-ing anything. Even wisdom, at times, takes a second seat to political aspirations. Oftentimes, you are a minute cogwheel in a very large machine. Nowadays, it is harder to change things because there are many more players involved. Think about it, there are commercial interests, national states, military and paramilitary powers and politicians.

What message would you like to give to future doctors?That they shouldn’t work for money alone. That it is worthwhile, both as a doctor and as a human being, to go to a developing country or a conflict area to improve something in the local humanitarian situation. From a Western perspective, it may notbe appreciated as a great contribution to your resumé. However, it will enrich you as aperson and offer you other career oppor-tunities elsewhere just as challenging, and potentially more gratifying, on a personal level. I read Persian and Arabic poetry now in the original language and play not only a violin, but also a Persian Sitar on Ustad level. I know my way around the souqs of Baghdad and Kabul, but get lost in Amsterdam. In a way, it is a choice you make. It is not an easy life you choose, but it comes with many beautiful experiences.

How would you see the role of the physician in that picture?Well, there are many factors that contributed to my decision to continue working in what I got involved in. My decision basi-cally boiled down to the following: if I would faint or disappear during my clinical round of surgery in a hospital somewhere in the Western world, I would immediately be replaced. I wouldn’t be missed at all. But if the same thing would happen to me in my valley in Afghanistan, it would be a disaster! The fact that I was indispensable gave me great pleasure.

“ ”In most countries where I have worked, 9 out of 10 initiatives didn’t actually work out

GMMixSTUDYING MEDICINE IN…

Khartoum, SudanAshraf Fadul (26) studied medicine at the University of Khartoum and graduated in 2012.

How is university life in Sudan? In Sudan there are 28 medical schools. Eighteen of these are pub-lic or governmental universities. The others are private. The cur-riculum differs per university. While in some universities the study takes five years, most of the universities, including mine, apply a six year system. We spend around thirty hours per week on lectures, lab practice and clinical rounds. In Sudan, it is not possible for everyone to study medicine. Although there is not a real financial barrier, you need to get really high marks in secondary school de-pending on the university to which you apply. At the University of Khartoum, you have to score at least 92 percent, which is dif-ficult to achieve. Depending on a family’s economical status, the payment ranges from $100 to $1000 in governmental universities.

What do you think is the best part of medical education in Sudan? During our clinical rounds, we see and examine many interesting cases that you would not imagine can still exist in this century, ranging from tropical and endemic diseases to cancer and meta-bolic diseases. In addition, there are medical missions organised by students. During these missions, we travel to the remote rural areas in the country where we work under the supervision of graduated colleagues to examine patients and prescribe drugs for free. We also work in the laboratory and learn simple pharmaceutical knowl-edge.

If you could change one thing in the medical education in Sudan, what would that be? Unfortunately, the quality of the medical schools differs highly throughout the country. Most of the state universities lack teaching staff members and facilities. This generates doctors of a wide range in quality. Some even lack the basic knowledge and skills required for safe practice.

What is the biggest difference between studying medicine in Sudan and other countries? I think especially the way of teaching the clinical part and the re-search part is different. In Sudan, our clinical teaching starts when we reach the fourth grade. On a regular day, we go to the hospital from eleven AM to two PM and not even every day. We have to do rounds in large groups of twenty students. Therefore, only few students are able to take patients’ histories and examine them. The clinical internships are done after the graduation as ‘houseman-ships’. This is a paid training job. The types of research we do are so simple, and mostly involve Knowledge, Attitude and Practice (KAP) studies (non-experimental and non-interventional) due to our limited facilities. We don’t have the opportunity to do lab work or travel.

Describe your life in 2020.I hope to be a successful professor of surgery trained in either the United States or Europe, and a well-known professor of molecu-lar medicine – travelling around the world to speak at scientific conferences. But all of that comes after religion and my family’s success.

34 000 000inhabitants

♂ 61 yrs ♀ 65 yrs life expectancy

7.3 % of GDP for health

2.8doctors/10 000 people

/$

Colophon

Global Medicine is an official IFMSA-NL publication.

Editor in chief: Sanne JongmaSenior editor: Daniël KorevaarProject coördinator: Merve Ulubas, Lieke BakkerusEditors: Nina Achten, Stevie Jaarsveld, Lotte SchaafsmaArt Directors: Bich Bui, Esra Dede, Lung Jeung, Anne Marye de Jong, Freshte SijaniLogistics and Distribution: Simone CornelissePublic Relations: Esther van Althuis, Lung Jeung, Kimberly Anneveldt, Freshte SijaniWebmaster: Geert van der VeerProof-reader: Wail Alkhaldi, Victoria Aucoin, Johan van Breda, James Cavell, Jonathan SmartIFMSA-NL Liaison: Deniz WesselsContact coordinator@globalmedicine.nlInternet www.globalmedicine.nl

ISSN 1474-4345

Global Medicine is being distributed free of charge among the eight medical faculties in the Netherlands and interested faculties world wide. The printed edition has a circulation of 3000 copies and is published three times a year. The magazine is also available through our website www.globalmedicine.nl.

Except where otherwise noted, this work is licensed under the Attribution-Non-Commercial-Share Alike 3.0 Netherlands Creative Commons licence. In summary: You are free to copy, distribute, display, and perform the work and to make derivative works, under the following conditions: Attribution/Non-Commercial/ Share Alike. View the full license at www.globalmedicine.nl before (re)using any content.

Reference lists per article are available on our website.

Photos & illustrations p1/32 IAEA Imagebank, p2/30 Retlaw Snellac, p3/9 Hey Paul Studios, p3/13 Paul Watson, p3/20 Judy**, p3 Jeroen Berkhout, p4 spike 55151, p5 kokeshi, p7 Tareq Salahuddin, p10 WHO (Dr. A. Tiendrebéogo, Nigeria), p16 kibuya, p22 Eske Ravensbergen, p25 Honisoit

Global MedicineOfficial IFMSA-NL magazine on global health

€ 10 (student; I’m studying in

(minimum € 15) donation fee

Yes, I would like to subscribe to Global Medicine. Global Medicine is published 3 times a year. After 1 year we will send you a request for continuation of your subscription.

I hereby authorize IFMSA-NL once only to debit my bank account as I have indicated above.

Subscription type:€ 15 (non-students)

€

Bank account number

Adress

EmailName

Postal code City

Signature

Global Medicine will use the personal information on this form only to establish authorized payment and remittance. Personal data won't be shared with third parties.

Team vacancies Are you good with pencils, pennies or promotion? Are you interested in global health? Do you want to contribute to an international magazine? Well, Global Medicine is looking for you! Curious what the possibilities are? Just send an e-mail to coordinator@globalmedicine.nl and join one of our meetings.

PhotogalleryDo you have a relevant picture and want it to be featured in Global Medicine? Please send your contributions to editor@globalmedicine.nl

Subscribe now Subscribe to Global Medicine and receive this magazine at home. Go to our website www.globalmedicine.nl to subscribe or fill out the coupon below and send it to: IFMSA-NL, Fg-2.17a, Dr. Molewaterplein 50, 3015 GE Rotterdam, the Netherlands.

Global M

edicine