Showing posts with label international child health. Show all posts
Showing posts with label international child health. Show all posts

Monday, November 17, 2014

The Challenges of Practicing Pediatrics in China

Pediatrics Assistant Editor Lydia Furman, MD, shares her perspective on a forthcoming article from our December issue. The full version of the article is available now to subscribers here, and on December 1, 2014, an extract will be freely available to all.


Chinese flag. Public domain photo via Wikimedia Commons
More than a decade ago, Shugerman and colleagues examined determinants of satisfaction among pediatricians in the US (Shugerman et al Pediatr 2001). They compared general and subspecialty pediatricians and internists and family practitioners, and found that “despite lower incomes, general pediatricians reported the highest levels of satisfaction and the least job stress of all physician groups…” and “[Pediatricians] were least likely to endorse symptoms of burnout or job stress.”

This finding likely makes good sense to many of us, and more recent work underscores this finding, with more than half of pediatricians describing themselves as “very satisfied” with their careers (Schmidt et al Health Care Manag 2014). These studies did not, and we would not expect them to, ask about personal safety and violence on the job; the focus of surveys is on burnout, job satisfaction, aspects of daily life such as patient volume and acuity, and hours worked. In general, we do not expect to fear for our physical safety while serving as pediatricians, with limited exception perhaps for those serving in uniquely high-risk environments.

Our good fortune is precisely our blind spot. The courageous Pediatrics article by Xu and colleagues (doi: 10.1542/peds.2014-1377) about the extraordinary and frightening circumstances of pediatricians in mainland China is a showstopper.

Perhaps there are knowledgeable colleagues among us who have friends or family in China who are aware that it may be physically dangerous to practice pediatrics in mainland China, but this shocking (and I believe the word is appropriate) underbelly to medical practice is not widely appreciated. Xu et al. describe instances of physical violence directed against pediatricians, with an increasing rate of medical violence unchecked by the courts or the government.

As fewer medical school graduates choose pediatrics or apply for pediatric jobs in mainland China, the wait time for patient care and the number of patients the remaining pediatricians see has risen dramatically, with each practicing doctor responsible for 80-100 visits per day (even up to 150 per day). Most US pediatricians cannot imagine this workload, and would rapidly change jobs or negotiate for better pay and better hours, citing not just personal exhaustion but patient safety as mandating a change.

Chinese pediatricians do not have ability to increase their pay, and unlike physicians in other specialties, do not have the option to perform procedures or prescribe medications that will supplement their incomes to a tolerable level. Per Xu et al., pediatricians are fleeing their jobs and the job market, with no resolution in sight and no solutions in the pipeline to prevent, improve or change working conditions.

What is our role as fellow pediatricians? What is our government’s role? Do we have any options? Shouldn’t children in every corner of the globe have the same access to health care as in the US? Shouldn’t our colleagues in every corner of the globe have the opportunity to practice medicine in a safe working environment? This brief piece raises issues many of us did not even know needed to be confronted.

Tuesday, September 30, 2014

The Role of Parenting & Home Stimulation in Overcoming Cognitive Deficits in Bangladesh

By: Lewis First, MD, MS; Editor-in-Chief 

Bangladeshi children. Photo by Mahmud Rassel via Flickr
Poverty certainly takes its toll on children's health given the association between poverty and cognitive deficit in infancy, but is it possible to improve this deficit with environmental and parental influence?

The answer is a resounding yes according to Hamadani et al. (doi: 10.1542/peds.2014-0694) who performed a longitudinal study of development in more than 2,800 infants in Bangladesh. They followed these infants for IQ changes over their first five years of life as impacted by such factors as parental education and home stimulation by parents. The results are impressive and stress the import of such factors in a way that can be generalizable to our own young patients born into poverty in this country.

To share even more lessons learned from this study, we invited Dr. Andrew Racine (doi: 10.1542/peds.2014-1375) to comment in an accompanying editorial that we are also early releasing this week.

Both the study and commentary are rich in take-aways that will be useful to you and the underserved families you care for.

Related Reading:

Saturday, May 31, 2014

A Five-Year Report from the Pediatric AIDS Corps

By: Lewis First, MD, MS

In 2005, the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) created a global health corps—the Pediatric AIDS Corps (PAC) to provide clinical and educational programs to bring better AIDS care to parts of the world where it was most needed.
Students in the Central African Republic learning about HIV/AIDS
Photo by Pierre Holtz for UNICEF via Flickr

Schutze et al. (doi: 10.1542/ peds.2013-2938) have compiled five years’ worth of evaluative descriptive data combined with surveys of PAC physicians to help us better understand the importance of this remarkable program and the magnitude of its accomplishments in such a short period of time.

One comes away from this special article appreciating the global health work of the PAC and wanting to know more about how to expand its work even more—perhaps at a national level, given the positive outcomes being obtained. Journey with the PAC team by reading this five-year report and learning more.

Related Reading:

Friday, May 30, 2014

Filtered Sunlight for Hyperbilirubinemia: Safe & Cost-Effective

Pediatrics Associate Editor William V. Raszka, MD, shares his expert perspective on a new article from our June issue. To learn more about Dr. Raszka and his work in pediatrics and pediatric infectious diseases, check out our Contributors page.

By: William V. Raszka, MD

Photo by Julia Falkner via Pixabay
Severe neonatal jaundice with progression to acute bilirubin encephalopathy and kernicterus is a worldwide problem. Here in the US, health care providers can select from a wide range of effective phototherapy options to treat infants with elevated bilirubin levels. In resource-poor settings, that is not often the case. The expense of the equipment, unreliable electrical power supply, inadequate maintenance programs, and limited number of testing and treatment choices all contribute to a lack of effective phototherapy options.

Slusher and colleagues in the June issue of Pediatrics (doi: 10.1542/peds.2013-3500) report a novel and cost effective way to treat neonatal hyperbilirubinemia. Infants in Lagos, Nigeria with elevated bilirubin levels were exposed to filtered sunlight five to six hours a day under an outdoor canopy. The canopy roof was made of one of two commercially available window-tinting films. The films prevent the transmission of most ultraviolet and infrared light while allowing the transmission of effective levels of therapeutic blue light. Up to six infants and their mothers could stay under each canopy. Investigators showed that during the midday hours, infants were exposed to the correct amount of irradiance and that treatment was effective on more than 92 percent of all treatment days. No infants required exchange transfusion. Some had transient elevated core body temperatures while a smaller number had decreased body temperature. No infants had to be dropped from the study because of adverse effects.

We talk about back-to-basics all the time, but this study demonstrates adherence to such a principle really can provide benefit. The observation that direct sunlight decreases serum bilirubin levels in neonates was originally published in 1958, and since that time we have focused our attention on developing equipment that artificially creates the optimal wavelengths necessary to photoisomerize bilirubin.

However, in many resource-poor areas appropriate equipment is either not available or functional. Exposing infants to direct sunlight increases the risk of sunburn, hyperthermia and other complications. Using a simple readily available film as a filter solves both problems. The film can be stretched over locally available materials at a cost of approximately $50 per canopy. Each canopy lasts approximately six months and this could be extended if they could be protected during storms. While $50 is still a sizable investment, the morbidity prevented is staggering. Though the canopy is most useful in sunny and warm environments, variations (e.g. tinting applied over plastic) might make the intervention useful in cooler climates. This novel, practical and effective method to treat hyperbilirubinemia is welcome news indeed.

Thursday, April 24, 2014

Healing and Rebuilding: A Visit to “The New Haiti”

Associate Editor Dr. Phyllis Dennery recently returned from a trip to Haiti. Here, she reflects on what it’s like to be both a physician and family member returning to a country still very much in the throes of a long, chaotic journey towards renewal.

Child bathing in the streets. Photo by Dr. Phyllis Dennery
It was meant to be a visit to Haiti to accompany my 82-year-old mother back to her home country after a 25-year absence.

Instead, it became a week of introspection where I asked myself what went wrong in
the island that used
to be referred to as
the “Pearl of the Antilles.” This beautiful country
with so many natural resources and pristine beaches had now become a post-apocalyptic shell of its former self.

Our first destination was Petit-Goâve. We spent 3 days at a friend’s home with no running water and sporadic, nearly absent and unpredictable electricity. I’m ashamed to admit that this felt like a major inconvenience to me, when this was a daily reality for even the middle-class residents of this small town. The challenge of transporting water for daily needs was unimaginable. I met Natasha, a 16 year old with a second grade education who worked in the day as a servant. She bore the scars of her mother’s wrath. My naïve assumption that I could help her learn her multiplication tables in a few days was quickly shattered.

Beach at Jacmel. Photo by Dr. Phyllis Dennery
At the next stop, Jacmel, my mother’s hometown, at least the power outages were predictable (from 2-4 pm), and we could take a real shower, but the population had exploded and her previously sleepy neighborhood had been overtaken by “bric-a-brac” stores and barber shops.  Her parent’s farm was littered with old trucks and was unkempt.  (Fortunately, the old gravesite was still there.) A once beautiful beach resort she had visited as a child was now a dirty rocky place with filthy shacks serving local food. Nothing was recognizable.

In Port-au-Prince, at least many of the blue tents that served as shelter after the earthquake were gone, but instead, a sprawling shantytown had been erected on the same mountain. It was impossible to tell where we my aunt’s Foundation Periodontique (dental clinic) once resided. The neighborhood seemed like one big anomaly—a big home could be next to a gas station, next to a barber shop, next to a church. Gone was any semblance of social order or zoning. The population had exploded and the squalor was visible everywhere.

In the new Haiti, sanitation is not a priority. Beaches are littered with bottles, wrappers and Styrofoam dishes, as are the streets. The lethal combination of lack of water, lack of sanitation and malnutrition clearly contributes to the ongoing cholera epidemic.

Physical therapist with sculpture. Photo by Dr. Phyllis Dennery.
She notes: This is special because the sculpture represents a child in
a wheelchair, which is rather unusual in Haitian Art and dates
from the earthquake when many people were maimed and became
amputees.  Before this, disabled people were mostly mocked.
Although I cry for my country, I do see glimmers of hope. The Bernard Mevs Hospital and GHESKIO Clinic that I visited two years ago, and again during this recent trip, had made significant inroads and were shining lights in the chaos. A rehabilitation center for amputees was staffed by a Haitian physical therapist. A sewing center (Project Stitch) allowed amputees to become independent earners. There were clean isolettes in the NICU and caring local nurses and doctors in the Spinal Cord Injury Unit. I commend my colleagues, the Bitar brothers and Dr. Vanessa Rouzier, and the many others who devote their lives to help their countrymen, women and children. I admire the ongoing efforts to promote sustainability in the health care system.

I will return soon to be a part of the solution, and I sincerely hope that my next visit will confirm there is a way forward for Haiti.

Thanks to all who still care.

Thursday, October 3, 2013

Tobacco Marketing and Its Effect on Children: More Than Just a National Concern!

We are certainly aware of the effects of tobacco advertising on children and teenagers in this country based on studies we and other journals have published on this topic. Yet, the United States is not the only country where this issue continues to be a problem. Internationally, tobacco marketing can affect young children and their attitudes and behaviors regarding smoking and as shown this week by Borzekowski and Cohen (doi: 10.1542/peds.2013-1150) in a study examining tobacco marketing to 5 and 6 year olds in six low- and middle-income countries. The children in the study were asked to match logos to products that included logos for cigarette brands in their countries. Suffice it to say, the greater the media exposure for a child, the more likely a young child could identify at least one cigarette brand logo. The authors share much more information about other factors that further enhance this recognition and call for better measures to restrict tobacco marketing internationally.

If your local school district is not working on curriculum to alert students to the influence of what current marketing can do to influence behavior (even years later), then this study should light up your desire to advocate for such a curriculum and other preventive measures to curtail as much tobacco marketing to minors as possible.