Prevention saves lives – Meningitis in a resource constrained setting -by Dr. Teddy Totimeh – A physician in Accra, Ghana

Four students have died. One after the other over a ten day period. And the diagnosis is only certain now, after they died. In a country with 5000 doctors, multiple teaching hospitals, a Ministry of Health, and a Health Service, this is not acceptable. Especially if the country has had 60 years to build a system. It is not right. If there was a war going on, it would be excusable. If there was famine, civil unrest, natural disaster… maybe, this would be easy to ignore. Not in this Ghana. Not at this time.

On the other hand, considering that there are 2 newly built, multimillion dollar, appropriately commissioned centers of excellence in the same city waiting for medical staff to start working in them months after completion; and that there are 3 hundred physicians newly trained, who have been sitting at home for six months unemployed. There are municipal hospitals in regional capitals run almost completely by physician assistants… it is not surprising, that 4 students will die, in rapid succession, and we have no idea why.

And in 2017, we are able to yield our intellects to rumors of spiritual deaths, and panicked desertions of schools, distributing potentially infected patients, unscreened, into the wider society without prophylaxis. In 2017, we still have no way of anticipating the meningitis season, and vaccinating the vulnerable populations in the endemic areas, and educating them so that if students in crowded dormitories in these areas present at the hospital with fever and chills, there is someone there prepared to make the diagnosis and administer treatment.

And we have a media, with reporters, repeating the theories debunked decades ago, about heat causing meningitis. We have communication departments in the Ministry of Health, Ghana Health Service, Ghana Education Service and there is not a single public service announcement on meningitis. And four students have died already! We have a media blitz on galamsey (illegal gold mining) and our impending water deprivation, and not a single poster on meningitis in the meningitis season, so that whoever first saw those four could have resisted the urge to dismiss the students as malaria infected. It was BBC which broadcasted the tens of deaths in nearby Nigeria, just weeks ago. It was BBC which informed listeners about a new strain, that had become more virulent in this epidemic. We have media that monitor the global news. We have strategists who follow the infectious disease trends. And not even the multiple deaths in the country next door, could alert us.

Four students have died of a preventable disease. And no one will resign, no one will take responsibility, not the headmaster, not the nurses at the sick bay, not the physicians who missed the diagnosis, not the governmental agencies who did not inform. No one will step up and say why this should not happen in a civilized country, and why it should not happen again because something can be done about it.

Four students have died. And this week the students have come back to the school in their numbers for academic reasons… some exam coming up. And someone in leadership at the school is on radio, and acting surprised that the students actually turned up. And I have not heard anything about the screening that is supposed to have started as the students started turning up, or the vaccines that are being arranged to be transported to the locality, or the strain of bacteria that has been isolated, and if it is the same as killed scores in nearby Nigeria.

And 4 students have died already.

 

Posting from Teddy Totimeh a colleague working in Accra, Ghana

My brother’s keeper – Healthcare in Trump’s America

my-brothers-keeper

I recently heard a story from a colleague about a patient that he admitted who refused admission for a potentially fatal illness because he was afraid he will be arrested and deported.  This incident happened during the Obama presidency that happened to have deported close to 3 million immigrants during the 8 years in office.  ICE (Immigration and Citizenship Enforcement) reports suggest that the exact number deported in the Obama era was 2,749,706; an average of 343,713 immigrants per year.  The Department of Homeland Security however still restricts enforcement from so called sensitive locations such as schools, places of worship, hospitals, and public demonstrations and rallies to allow undocumented immigrants easy access to those sites and services.  The problem that we face today with immigration policy is not the policy itself but the publicity associated with the enforcements.  As a physician I am focused on addressing the healthcare needs of all my patients irrespective of their immigration status. Unfortunately most undocumented migrants do not know and cannot be expected to trust us if they begin to feel that the whole nation is out to get them.ice-removals-edit-2

It is clear that the publicity related to the enforcement of our current administrations immigration policy can be harmful and may have unintended consequences on the health of our immigrants.  The current public nature of this policies is not all the fault of the Trump administration though.  The public nature of current enforcement is a relic of the election era utterances and pronouncement which continues to this day. A recent Pew Research survey suggest that numbers of undocumented immigrants in the United States has stabilized and as at 2014 a large majority (66%) of these immigrant are long term immigrants who have been in the United States for 10 years or more[i].  These are people with very strong social and economic ties to the United States and removing them from this country could have a significant economic impact on this country.  The health needs of these undocumented migrants unfortunately are the responsibility of the US government.  This may sound like a damning statement to some individuals but if you consider healthcare in its totality with the inclusion of communicable diseases we realize that creating an environment that makes our visitors as I would call them from now on unwanted can have a significant impact on the health of all Americans.

Our current leadership may have come into power with strong support from some evangelical Christian groups. Franklin Graham the son of Billy Graham in his speech at the inauguration of President Trump is reported to have said that Trump won the election by the hand of God[ii]. There is no way that anyone can challenge that because Franklin Graham most probably is basing his pronouncement on a personal message that he received from God.  I however have a very public message from the Bible Matthew 25 vrs 34 – 40 34 “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. 35 For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, 36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’ 37 “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink? 38 When did we see you a stranger and invite you in, or needing clothes and clothe you? 39 When did we see you sick or in prison and go to visit you?’ 40 “The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’(The Bible New International Version).

bible-2

This is what the bible says; unfortunately the man chosen by the hand of God if I should believe Franklin Graham is singing a totally different tune.  I guess I can only blame God for all the fear and hatred that we see and hear about nowadays.

I certainly do not have the ear of President Trump so I do not believe what I have to say on these issues matters at all. I am just a lowly doctor and teacher trying to ensure that my patients believe they have unfettered access to my services and the services that other healthcare providers provide. These people that we call illegal immigrants are our neighbors, friends, uncles, aunties, brothers, sisters and co-workers. They pick the grapes and tomatoes that we eat. They clean our yards and sometimes they actually help build some of the information systems gadgets that enables us go to cities and towns we have never visit yet freely navigate these places.

Today, in America we hear about our visitors getting shot just because they did not look or act American enough[iii]. In this environment nobody can feel safe because we can never guess what the stranger on the street thinks of us.  This is America a country of immigrants and nobody should be made to feel unsafe or unwanted just by virtue of how they look, talk or act. My message to everyone especially to some Trump supporters who believe the United States is for only whites is; “ Please remember we are all immigrants the only difference is a matter of time”   We all need to feel safe and secure in this land and some of the xenophobic rhetoric must be toned down to ensure the safety of all of us living in this country citizens and visitors.

Bibliography

[i] Pew Research Center; 5 facts about illegal immigration in the US; http://www.pewresearch.org/fact-tank/2016/11/03/5-facts-about-illegal-immigration-in-the-u-s/. accessed 3/1/2017

[ii] Religious News Service; Inauguration speaker Franklin Graham: God allowed Donald Trump to win; http://religionnews.com/2016/12/30/inauguration-speaker-franklin-graham-god-allowed-donald-trump-to-win/ accessed 3/1/2017

[iii] CNN; Deadly Kansas Shooting: a senseless crime and a friend lost; http://www.cnn.com/2017/02/27/us/india-kansas-olathe-bar-shooting-911-calls/ accessed 3/1/2017

The holistic physician

I recently read a book by Dr. Barbara Natterson-Horowitz a UCLA cardiologist who also happens to be a consultant for the Los Angeles Zoo. In her book ‘Zoobiquity’ Dr. Natterson-Horowitz demystified the story of HIV (Human Immunodeficiency Virus) transmission from monkeys in West and Central Africa to humans. Most doctors today including me have a very limited knowledge of zoonosis the science surrounding bugs that can be passed from animals to humans and can be totally unaware of the extent to which we share pathogens with our animal neighbors.

After reading about rabbit syphilis, Chlamydia in Koalas in Australia which almost threatened to totally wipe out these small cuddly creatures, and Trichomoniasis in T. rex, I could say nothing but agree that SIV (Simian Immunodeficiency Virus) from the chimpanzees to humans was not that fantastic a tale after all. Of course if Trichomonas has moved through the different species from as far back as the time of the dinosaurs to now infect both pigs and cats what stops SIV a close viral relative of HIV from expanding its real estate empire to include humans. We humans are after all are the most dominant specie on earth and as such we are a very attractive real estate acquisition for any bug.

Today HIV is a worldwide pandemic affecting almost every community in the world but it is believed that prior to its journey to the western world the virus had affected various communities in West and Central Africa for several decades. HIV-1 the commonest HIV subtype in the US and many western countries is believed to have entered the United States by way of Haiti. This is based on molecular genetics which shows close to 99% similarities between the gene sequences of viruses from Haitian patients compared to US patients. In the early days of the epidemic HIV had been known to be associated with the 4 Hs, Homosexuals, Hemophiliacs, Heroin Addicts, and Haitians. Unfortunately on account of the stigma associated with HIV, my Haitian colleagues did not look too pleased when I mentioned this on a recent visit to Haiti as a visiting faculty.

Today more than 30 yrs after I read the Newsweek headline on AIDS in 1986 which featured Rock Hudson’s declaration that he was gay and had AIDS the stigma still persists. In this era of good life sustaining treatment though, the terror and fear that made most people treat individuals known to be HIV positive like lepers has abated. The stigma still persists and in many cases makes efforts at prevention very difficult. This is a stigma that I can understand based on how society addresses sexuality.

Sexuality is humanities biggest double standard; whilst most of us are sexually active getting a sexually transmitted disease is considered a social taboo. Somewhere between our birth and early adulthood we somehow conveniently forgot that if sex really was so nasty we will be extinct as a race.

To adequately address this issue we should all start working hard on our skills in talking about sex clearly and effectively with our sexual partners and doctors. From my experience most doctors do not mind talking about sex with their patients but may still harbor some misconceptions that may sometimes make it difficult for them to start the conversation. More often than not doctors are trying to gauge patient’s comfort level instead of just realigning themselves and their patients and diving into the conversation. If a patient starts that conversation though most physicians are always happy to talk to their patients about this most important aspect of their lives. Conversations about sexuality and sexual issues if done well will open doors to preventing STDs (Sexually Transmitted Diseases) and HIV. Doctors can only know how best to treat a patient if they are aware of the sexual practices of their patients. Whilst most medical procedures are standardized there are modifications that are made to accommodate individual differences in patient characteristics and behaviors.

Currently even though there is a pill that can reduce risk of HIV infection rates by more than 90% in appropriate individuals most doctors fail to use or even think about this medication in appropriate patients. One important reason for this low utilization is because the sex conversation rarely ever happens to any meaningful extent. We cannot allow stigma and societal taboos around sexuality to get in the way of our health. If we think that HIV and other sexually transmitted diseases are dirty diseases then we are all dirty anyway. So let us get it out all in the open especially when it comes to our conversations with our doctors. “A word to the wise is enough”.