Primecuts – This Week In The Journals

January 31, 2011

By Matt Johnson, MD

Faculty Peer Reviewed

 After surveying the bevy of medical literature this week, a common theme that emerged was that of the many disparities in the world of global health.

 In the New York Times, there was an article about the impact of “lady health workers,” as they are called in Pakistan, on maternal and newborn health [1]. This was based on a study published in The Lancet which evaluated the effectiveness of a community-based initiative focusing on primary care and preventive medicine [2]. In 1994 the government of Pakistan unveiled the National Program for Family Planning and Primary Health Care, informally known as the lady health workers (LHW) program. The goal was to take young woman from the local community with some formal education and train them to provide primary care to their surrounding neighborhood. Each LHW takes care of about 1000-1500 people, and deals with issues such as antenatal care, contraception and immunizations. The study was a cluster randomized trial evaluating about 50,000 households over two years, and showed that the LHW intervention group had lower neonatal mortality (4.3% vs. 4.9%) and still birth rates (3.9% vs. 4.9%) than the control group in this rural region of Pakistan. Much like in the US, manpower is sorely lacking and the need for midlevel practitioners is steadily growing in the world of primary care.

 Another piece from The Lancet last week lamented the decision of many members of the scientific publishing community to disallow access to their cache of online medical journals [3]. The WHO’s Health InterNetwork Access to Research Initiative (HINARI) was created in 2002, and its goal was to provide low income countries with free access to our world’s scientific journals. Bangladesh, in addition to other countries such as Nigeria and Kenya, was just recently notified that it was no longer going to enjoy that privilege. Many of the major publishing companies involved in HINARI, including Elsevier, Lippincott Williams & Wilkins and Springer (which all together includes almost 2500 journals) have begun to withdraw their journals from the program. The reasons are unclear, but critics assume the decision is financially motivated. However, the big commercial publishers were providing this service to countries that were never a major source of revenue, so this endeavor was providing access at virtually no cost. There has been an outcry from the global health community to reinstate this mission of sharing knowledge with the poorest of nations, and it will be up to the publishers to answer the call.

 This week, the BMJ shed light on the roadblocks facing one of the United Nation’s loftiest millennium goals of reducing child mortality by two-thirds by the year 2015 [4]. A core component of this bold endeavor involves vaccinations against the most common afflictions of children worldwide – diarrhea and pneumonia. Some countries have made great strides in vaccinating their children with pneumococcal and rotavirus vaccines, along with the other basic childhood immunizations. However, many other countries still have a long way to go and face dire financial decisions about how to afford these expensive vaccines. Creative economic schemes will need to be devised if the UN realistically plans on putting a dent in the soaring rates of childhood mortality across the globe.

 Our neighbors in Haiti are still dealing with the fallout of the first cholera outbreak in over a century on their island. The MMWR report from December 2010 in the most recent issue if JAMA documents a total of 91,770 cases of cholera involving 43,243 hospitalizations and 2,071 deaths since the outbreak began in October 2010 [5]. More recent estimates place the number of cholera cases at 170,000 with over 3,500 deaths [6]. The high fatality rate is attributed to the hybrid strain of Vibrio cholerae which includes the classic toxin and the El Tor types – the classic toxin strain is thought to be more potent, while the El Tor strain persists longer in the environment. In addition, the baseline poor nutritional status and medical co-morbidities inherent in the population, poor access to clean drinking water and sanitation, as well as the overall havoc wreaked by the recent earthquake in January 2010 have made many Haitians very susceptible to this devastating outbreak. Seemingly simple yet frustratingly challenging interventions in a region with such a disabled infrastructure include more access to oral rehydration solutions, better hand-washing and food-handling techniques, clean water availability and improved sanitation practices. In the face of such a fleet and powerful epidemic, steady and consistent support from all who can help is essential to quell this growing debacle.

Back here in our own country, the Archives of Internal Medicine highlighted the inequalities faced by the non-English speaking members of our community [7]. A cross-sectional survey compared the pneumococcal and influenza immunization rates of Spanish and English speaking Hispanics with non-Hispanic whites. The study looked at seniors (age >65) from all parts of the country involved in the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. It found that there was a significant difference in rates of pneumococcal immunization among Spanish-speaking Hispanics (40%), English-speaking Hispanics (56%) and non-Hispanic whites (74%), in addition to a significant difference in rates of influenza immunization (64%, 68% and 76%, respectively) as well. Aside from the language barrier, other factors such as living in linguistically-isolated geographic regions and the type of Medicare plan were thought to be contributing factors to this disparity. Cultural competency has a long way to go, but improving immunization rates in this vulnerable population is an easy and attainable place to start.

 The common theme of all of the above articles deals with access…whether it is access to healthcare providers, medical journals, vaccines, oral rehydration solutions, or language services. Lack of access is not a new challenge, and it is also not a unique entity to only the poor countries of our world. As always, we should continue to use our available resources and skills to do whatever we can, as often as we can.

 Dr. Johnson is a 3rd year resident at NYU Langone Medical Center

Peer reviewed by Judith Brenner, MD, section editor, Clinical Correlations

Image courtesy of Wikimedia Commons.

 References:

 1. McNeil DG. Pakistan: Short training for women workers goes far in saving newborn’s lives. The New York Times (New York Ed.). 2011 Jan 24: Sect. Health. http://www.nytimes.com/2011/01/25/health/25global.html?_r=1

 2. Bhutta ZA et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. Lancet. 2011 Jan; 377 (9763): 403-412. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62274-X/fulltext

 3. Koehlmoos TP, Smith R. Big publishers cut access to journals in poor countries. Lancet. 2011 Jan; 377 (9762): 273-276.  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60067-6/fulltext

 4. Womersley K. Vaccination programme to protect children against pneumonia and diarrhea needs more funds. BMJ. 2011; 342: d534. http://www.bmj.com.ezproxy.med.nyu.edu/content/342/bmj.d534.full

 5. MMWR. Update: Outbreak of cholera – Haiti, 2010. JAMA. 2011; 305 (4): 349-351.  http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5948a4.htm 

 6. Pape JW, Fitzgerald DW, Johnson WD (GHESKIO, Weill Cornell Medical College, Port au Prince, Haiti. Conversation with: Warren D Johnson, Jr. (Center for Global Health, Weill Cornell Medical College, NY, NY) 2011 January 27.

 7. Haviland AM et al. Immunization disparities by Hispanic ethnicity and language preference. Arch Intern Med. 2011; 171 (2): 158-165.  http://archinte.ama-assn.org.ezproxy.med.nyu.edu/cgi/content/full /171/2/158

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