Tag Archives: Primary Health Care vs Magic Bullets

Forgotten: Emergency Care in the Context of Public Health Care Frameworks

In the 1970s and 1980s, discussion around what and how health systems should be implemented sparked a heated debate. In 1978, the Alma-Ata declared that ‘Health for All’ should be the international goal of countries through Primary Health care. Unfortunately, the Alma-Ata failed, likely due to not specifying where how it was to be funded and the inability to hold countries to their commitment. After this, the concept of selective primary health care emerged, a way to package health services in a cost effective manner. Although both of these approaches aim to improve health, neither of them specifically mention emergency care, and where it belongs in the context of these frameworks and life.

Ziad Obermeyer conducted a study in low-and middle-income countries (LMICs) about the emergency care available. In “Rethinking emergency Care is key to ‘Health for All,’” he summarized his findings. He shed light on the fact that people in LMICs still get pneumonia, diarrhea, heart attacks and asthma. Something I think most people don’t realize is that studies consistently put emergency conditions at the top of list of causes of death and disability worldwide. The number 1 cause of death in LMIC is Ischaemic heart disease at 11.5% of deaths in LMIC, while HIV/AIDS was the 4th cause of death at 6.1% (Razzak & Arthur). Despite this, LMICs tend to have a lack of emergent care facilities, leading to an average of 10 times the caseloads of primary care doctors in the region. I believe that because of this, emergency health care should be a part of any country’s health system, even if it wasn’t in the plans of health care in the 1970s and 80s.

In the Alma-Ata Declaration, statement V says that all people should be at a level of health “that will permit them to lead a socially and economically productive life” by 2000. It then explained that the key to this target is primary health care. While I do agree that primary health care is necessary to track and prevent diseases and should be implemented around the globe, Obermeyer states that 10-15% of deaths in Nigeria occur in emergency care facilities. Most of these people are young and generally healthy, so they lose the most productive years of their lives. If primary health care and emergency health care both support preserving a productive, healthy life, then why didn’t Alma-Ata include emergent care?

Included in the principles of selective primary health care is the idea the main disease problems of poor countries can be solved through low-cost technical inventions, as Cueto explains. In this is the philosophy that “international agencies had to do their best with finite resources and short-lived political opportunities” (12). Though emergent health care was not originally discussed when it came to selective primary health care, I believe that these philosophies are very similar to what Obermeyer observed. In higher income countries, a small portion of the national medical expenditures helped emergency care providers focus on improving quality and training. As many providers in emergent care facilities in LMICs don’t have specific training, select LMICs have benefited from this training too.

The end of the Alma-Ata and the Cueto article on selective primary health care both focus on cost-effectiveness and the reallocation of resources. Investing in emergency care could relieve the burden of primary care doctors, allowing them to better serve their community. Emergency care could also alleviate some of the death and disability in LMICs, allowing for a more productive workforce, possibly boosting the country’s economy. Though the Obermeyer article doesn’t suggest a specific intervention, it does mention the opportunity for low cost, quality education of providers. This, along with a possible creation or renovation of an emergency care facility, could be perceived at a cost-effective strategy. As such, emergency health care would be a valuable addition to health care around the world, even if it’s philosophy is the only thing that might line up with other health care strategies.

  1. Should emergency care systems be thought of as separate of primary health care and selective health care, or are they already integrated into this framework? Are emergency care systems necessary if a strong public health care system is in place?
  2. Would implementing an emergency care facility in rural areas be feasible due to the lack of access to them and the number of providers that would be needed? How could communities be involved in the implementation of an emergency care facility or practices?
  3. Would you consider emergency care a magic bullet?
Alma-Ata Declaration. USSR. 6-12 Sepetember 1978.
Cueto, M. “The Origins of Primary Health Care and Selective Primary Health Care.” American Journal of Public Health, 2004. 94(11)1864-74.
Obermeyer, Ziad. “Rethinking Emergency Care Is a Key Part of ‘Health for All'” Brookings. N.p., 25 Aug. 2015. Web. 20 Oct. 2015.
Obermeyer, Ziad, Samer Abujaber, Maggie Makar, Samantha Stoll, Stephanie R. Kayden, Lee A. Wallis, and Teri A. Reynolds. “Emergency Care in 59 Low- and Middle-income Countries: A Systematic Review.” Bulletin of the World Health Organization Bull. World Health Organ. 93.8 (2015): n. pag. Web. 20 Oct. 2015.
Razzack, Junaid, and Arthur Kellermann. Emergency Medical Care in Developing Countries: Is It Worthwhile? (n.d.): n. pag. Web. 21 Oct. 2015.

AFRICA: A VICTIM OF THE BATTLE BETWEEN PRIMARY HEALTH CARE AND MAGIC BULLETS

At the turn of the Twentieth Century, at a time when many of today’s nations, especially Africa, were colonized by the major powers of Western Europe, Paul Ehrlich, a German physician and scientist, discovered that a certain chemical compound, Arsphenamine, effectively combatted spirillum spirochaetes bacteria, the subspecies of which caused syphilis. The treatment of syphilis, using this compound, that targeted only the specific bacteria causing the syphilis, and had few if any negative side effects, was, in short, a miracle. Ehrlich reasoned that if other medications could be created that “selectively” targeted specific disease causing organisms, with few side effects, it would be a “magische Kugel”—magic bullet.

In 1908, Paul Ehrlich received the Nobel Prize in Physiology/Medicine, for his contributions to immunology. As a direct result of Ehrlich’s “magic bullet” theory, scientists and physicians around the world began their own research and experiments to discover more and more magic bullet cures.

Various and thoughtful people, from around the world, have posed an important philosophical and moral question, “Should First World countries intervene in the politics, medical practices, and social structures of Third World countries, in any manner whatsoever, even if it is to save their lives?” After much reflection, I believe the correct answer is yes, for the following reason: lives matter—all lives matter.

I would like to expand on the definition of a magic bullet, defined, “as selectively targeting a specific disease, with few or no side effects;” and create a “financial” magic bullet that selectively targets specific health needs, in a positive way, with as little collateral damage as possible. And, once again, the “financial” magic bullet will be played out in the villages of Africa.

Although Measles, in the United States and Europe, is now virtually a disease of the past, measles has been increasing dangerously in many countries in West Africa, hit hard by the recent outbreak of Ebola. A Time’s article titled, Why West Africa Might Soon Have 100,000 More Measles Cases, talks about how the Ebola epidemic has caused a disastrous overwhelming of the Primary Health Care system in West Africa, leading to increased mortality and morbidity rates, due to Measles. The author then goes on about the eradication campaign that was set up to vaccinate all the children who were born during the Ebola epidemic, before expanding to older children and adults, who are more susceptible to dying from Measles, in order to prevent an even greater Measles epidemic, in the future.

Who lives, and who dies? Who decides? Who funds the Primary Health Care facilities? In the end, the decisions are obviously made by the First World countries.

Packard, in his chapter, Malaria Dreams: Postwar Visions of Health and Development in the Third World, explains how there has been a long reach of colonial medicine and how medical colonialism and imperial conquest set the stage to practice science and medicine, abroad—mostly, in Africa.

Looking at the medical history of Africa, since the time of Ehrlich, there have been many serious outbreaks of deadly diseases, in Africa—some of them eradicated by magic bullet cures, some of them tackled and overcome by the hard work performed by Primary Health Care doctors and nurses who have employed both magic bullet cures to eliminate small pox, prevent cholera, mitigate diarrhea, treat malaria, and a host of other remedies to assuage suffering and prevent deaths.

Returning to the “financial” magic bullet, how do we know which is more effective and efficient: funding Primary Health Care systems; funding research in hopes of developing another magic bullet cure; or, funding both? And, what are the possible unintended consequences? Because there will be collateral damage, and the outcry of unwanted intervention and colonialism. For example, during the Ebola outbreak, which killed thousands, in West Africa, before the First World countries, decided it might be in their own best interest to develop a magic bullet vaccine to protect themselves—of course, the vaccine had to first undergo clinical trials in a lab setting, before being guaranteed safe for use. And, of course, there has to be a controlled study—those who receive the vaccine (and live) and those who receive placebos (and die).

As mentioned in Determining Global Health, by Farmer et al., medical history is essential to understand and predict the intended and unintended consequences of different global health interventions, and many attributes of medicine and public health are due to the unintended consequences of globalization.

 

Discussion Questions:

  1. To effectively treat diseases, does it make sense to go where the diseases exist? If there is resistance from the local population, what other methods could we use to eradicate these diseases?
  2. One or two hundred years from now, with all of the eradication campaigns and programs that are set up, do you think that most if not all diseases now existing in Africa will be eradicated? And why?

 

Course Readings:

Packard, Randall. “Malaria Dreams: Postwar Visions of Health and Development in the Third World.” Medical Anthropology . 17 (Sep 1997).: 279-296.

Paul Farmer, e. A. (2013). Reimagining Global Health An Introduction.

 

Outside Sources:

Kluger, Jeffrey. “Why West Africa Might Soon Have 100,000 More Measles Cases.” Time. Time, 12 Mar. 2015. Web. 17 Oct. 2015. <http://time.com/3742361/ebola-measles-alliance/>.

“Paul Ehrlich – Biographical”. Nobelprize.org. Nobel Media AB 2014. Web. 21 Oct 2015. <http://www.nobelprize.org/nobel_prizes/medicine/laureates/1908/ehrlich-bio.html>