Khartoum mk. III: Mycetoma, a neglected tropical disease, the ideal app & the wrong shoes

Khartoum, 7^th July 2017. Its July 2017, and I’m back in Khartoum for a third time. The mission: to write a mycetoma app in 10 days. It was hotter last time, and less wet, the rainy season is just arriving. I brought the wrong shoes, but Khartoum seems to like all this water. Little reservoirs are expanding from every crack in the road and green things are sprouting at the Mycetoma Research Centre (MRC).

Growth: I’ve returned to the MRC to create the materials for an app. A lot has changed since my last visit in April 2016. The profile of this neglected tropical disease has soared following its addition to the WHO’s official list in May 2016. Research, funding and advocacy partnerships are budding around the world. The MRC itself is growing, with a new pharmacy, building underway for an ultrasound and biopsy suite and blossoming lab facilities; a larger staff with increased hardware can now perform all the tests required in-house. The first randomised controlled trial ever done in mycetoma has begun, led jointly with the Drugs for Neglected Diseases Initiative.

So have such fertile, tropical conditions yielded fruits for the care of mycetoma patients worldwide? No, not yet. Progress in Sudan and developments elsewhere are exciting, but they are unlikely to benefit patients in other parts of the world for several years.

So how does an app help?

Awareness of mycetoma remains low. A body of literature and practice has evolved over 50-60 years, but most of this knowledge and experience is trapped within pay-per-view academic journals or inside the minds of just a few expert physicians. Clinical practice and standards of care vary widely across the globe, and it is patients who lose out.

An app is the ideal solution – we’re hoping. It can distil a diffuse, inaccessible corpus of work into a streamlined, dynamic, free resource available at any time.

Aims: It will aim to provide some education on disease epidemiology, pathogenesis and so on. Then the more ground-breaking aspects, developed specially for the app, are the new guidelines on diagnostic tests and treatment recommendations. There are two clinical forms of mycetoma, bacterial (actinomycetoma) and fungal (eumycetoma). These are caused by over 50 different organisms, varying by geographical region. Despite this diversity, it is entirely possible to have a standard approach to diagnosis, identifying the disease process, causative pathogen and extent of disease. Although the evidence for different therapies has its limitations, the underlying principles of treatment, monitoring and cure are the same, and it is worthwhile highlighting those measures which currently have the best evidence-base. After developing the materials in English, we hope to work on Arabic and Spanish translations.

Overall, the app’s aims are to provide education on mycetoma for health-workers, to support clinical decision-making at all levels (e.g. primary, secondary, tertiary care). We hope it can be the vehicle to kick-start some immediate improvements in mycetoma patient care worldwide.

The Sudanese Medical Exodus

Someone in Khartoum said to me that Sudan has no middle class. Was he right? Is Sudan a socialist idyll, where contentment, fraternity and rational distribution flourish under a red-hot sun?

Well no, Sudan is in fact real country, not some rosy proletarian fantasy. My friend went on to declare that Sudanese society consists of just two classes; there are the elites, sitting up high on top of their mountain, and then ‘everyone else’ living down beneath their feet. Now I don’t think that either of us believed literally in this two-class hypothesis. But whether there are really two or twenty-two social strata in Sudan is not so important for the purposes of this post. Rather it is the feeling which prompted my friend, a doctor, to make his comment. It is this same feeling, of disaffection and disempowerment, which drives one of Sudan’s continuing tragedies, the exodus of health-workers. This blog explores this topic firstly through some facts and figures, to get an idea of the scale of things, and then secondly through considering what social status means across different societies and what some of the ‘push and pull’ factors there are for doctors in Sudan.

1 – In Facts and Figures: Education & Emigration

It wouldn’t be an exaggeration to say that almost every medical student or doctor to whom I spoke on my elective expressed a wish to leave Sudan and to work or study abroad. Most people knew someone who had already left and gone to the UK, US, Europe or to one of the states on the Arabian Peninsula such as Kuwait, UAE or Saudi Arabia. Indeed the issue is so widely acknowledged that one of the Sudanese newspapers even carried an editorial on the topic whilst I was there (Sudan Vision 26^th September 2012).

So what is the real scale of this? (Here follows five short paragraphs involving one or two statistics which aim to clarify the scale of the ‘exodus’.)

In a study published in 2005, Mullan lists an ‘emigration factor’ for Sudan of 11.1, i.e. 11.1% of doctors who qualified at home now work abroad in either the UK, US, Canada or Australia (Mullan, NEJM 2005). This proportion is likely to be much higher in reality. Mullan does not consider migration eastwards across the Red Sea, or indeed to Ireland where there are reportedly 600 Sudanese doctors registered with the Irish Medical Council (Ali et al 2012). However, using this estimate of 11.1% yields a minimum figure of 1250 practicing doctors who have left Sudan (anyone who wants to see my working is welcome!). Add to this figure those doctors working on the Arabian Peninsula, in Ireland and those within Sudan who have left the profession before retirement-age for whatever reason and you’re looking at a high number of doctors lost to the Sudanese medical system.

Statistics from 2008 show that Sudan had a total workforce of 10,000 doctors serving a population of 35 million people, which yields a workforce density of 0.28 physicians per 1000 population (which is fairly low) (WHO Global Atlas of Health Workforce). For comparison, the UK has a total of around 160,000 doctors serving a population of 62 million, yielding a workforce density of 2.6 physicians per 1000 population (OECD 2011; Global Atlas of Health Workforce2010).

To increase Sudan’s ‘physician density’ (taking into account an annual population growth rate of 2%), Sudan would need to have a net increase of at least 200 doctors per year (i.e. a positive balance between the number of newly-graduated doctors entering the system and those emigrating or retiring out of it) (UN Data).

This might sound fairly easy and indeed there are grounds for optimism from a statistical point of view. There are reportedly 2-3000 medical graduates each year from around 30 Sudanese medical schools, following two decades of rapid growth in the medical education sector (Fadlalla et al 2012; Ali 2009).

However, there are no available data on the rate of medical migration i.e. how many doctors leave each year, so it is impossible to predict the speed with which physician density in Sudan may increase.

Furthermore an increased number of medical graduates doesn’t automatically equate to more doctors. The percentage of government resources spent on health has decreased between 1995-2010, whilst total government resources are diminished following the separation of South Sudan (WHO Global Health Expenditure Atlas). Indeed I met graduates who had waited for up to a year for a House Officer position. So whilst more graduates might help to fill Sudan’s hospitals, they can also lead to a greater pool of young professionals looking for work, and considering emigration.

2 – The Faces and Feelings: Status and entitlements

Photo of London by Jason Hawkes

So much for the facts and figures, what about people and their motivations? One of the doctors I worked with was a fairly typical example, bright, competent and independent – a pretty good doctor to have in your health system. And she wanted to leave. Her brothers worked in the UK, cousins in the US, an uncle in Kuwait and several friends were now in Saudi Arabia. We discussed her own options outside Sudan; the US medical licensing exams (STEP 1, 2 & 3) are hard and require an extended period of intense studying (on top of making a living). The visa requirements for entry to the UK have tightened over the last few years, and include rigorous English language-, and a different set of medical-, exams. It’s easier to get a visa and a license to practice in another Arabic country, but career progression is slower, as employment contracts for junior doctors often include a commitment to an extended period of work at a junior level.  So wherever a prospective émigré chooses, they must jump, spin and study their way through a whole series of hoops, hurdles and exams without a guarantee of success (e.g. gaining a visa or a job) at the end. So why go through it?

This is where we come back to my friend’s feelings about social relations. On the one hand, students and doctors wanted me to share in their strong affection for their people, country and it’s potential. On the other, they felt strongly that staying in Sudan themselves meant accepting for some years a life of limited opportunity and social stasis.

Without getting too theoretical, there are many ways to analyse a person’s societal status. In simple terms, you might consider the size of their bank balance, house or car. At the more sophisticated end is Amartya Sen’s Entitlement theory which was developed in the context of famine. Here, an individual’s status is effectively defined by their ‘entitlements’ which include all the means they can access, whether legal, financial, moral or whatever-else, to use in getting what they want (Sen 1981). Simplifying and applying this beyond a famine setting to society in general, a person’s status might be defined by all the means and opportunities they have to improve their professional or domestic situation – their chances of gaining a better quality of life.

Graduating from medical school in Sudan does not mean the same things as it does in the UK. In Britain, I don’t think it would be too controversial to say that medical qualification signifies an individual’s accession to a comfortable middle-class status. UK medicine (whatever doctors might grumble), is a well-rewarded profession. It carries a decent salary, robust degrees of domestic comfort and job security, and opportunities for career advancement. It also generally means admission to one of the medical unions, such as the British Medical Association (BMA) or the Medical Defence Union (MDU) which act to protect doctors’ interests. So for UK doctors, entitlements (as defined above) come in all shapes and sizes; financial resources, career mobility (i.e. you can progress up the career ladder) and legal support.

And isn’t this the way it should be? On the one hand, quite apart from the fact that doctors are all delightful people, they actually provide a very valuable service to their community. Shouldn’t they be afforded the advantages proportionate to this social worth? On the other hand, aren’t doctors merely performing their job like another other honest citizen and so should be paid on the same scale? Does a doctor working nine-to-five in an air-conditioned clinic have a harder job than the man who works day and night washing cars? It would be an abuse of doctors’ position to demand more money, no? In fact this second stance is perhaps not too far away from where things are in Sudan.

A hard-working car-washer can reportedly earn more in a month than a junior doctor (around US$500 or ~SDG£95/day). After their first year as a House Officer, Sudanese doctors must then take a pay cut and work without a contract as a ‘General Practitioner’. Career progression to the post of registrar depends on studying hard, saving-up the entrance fee for a further set of exams (e.g. the UK MRCP or MRCS exams) and doing enough shifts to stay afloat. Whilst Sudan does have its own “Medical Specialisation Board”, openings for postgraduate training are acknowledged to be limited and poorly funded. So it’s quite possible to get stuck at this level for several years (although once at the Consultant level remuneration can increase exponentially as opportunities for private sector work arise).

Since they may be unable to get a foot on the property ladder at this stage, doctors often live in hospital accommodation – which may be subsidised or even free – unless they can live with family. Whilst this might be a cheap, convenient and communal option, it is not (to put it one way) exorbitantly luxurious. Neither are the parking nightmares lived by UK healthcare staff a feature in Sudan, since relatively few doctors have cars.

As for legal rights, medical organisations do not function as trade unions and so do not engage in any political action. In 2010-11 doctors’ strikes were organised independently over unpaid salaries, working conditions and accommodation. These were met bluntly with threats, arrests and imprisonment, with no subsequent action taken by the government to address doctors’ grievances (McDoom 2010; Sudan Radio Service 17 March 2010; Sudan Tribune, 18^th March 2010, 3^rd June 2010, 17^th May 2011). The government response to this was perhaps tempered by remembrance of the 1985 revolution overthrowing Sudanese President Jafaar Al-Nimieri, which involved professional unions of doctors, lawyers, bankers and academics.

So overall, many of the entitlements that define UK doctors’ status are rather different in Sudan – whether this is in terms of a salary, a house, a car, job security, professional training and promotional opportunities or legal protection. So are doctors so different from car-washers in Sudan?

Perhaps the defining status symbol is a travel visa. Ultimately, medical knowledge and skills provide greater weight to a visa application than a bucket and sponge. Whilst migration may be difficult for Sudanese doctors, it remains possible. And the significance of a visa application is that it is the first step in reaching out towards the opportunities that exist in other countries.

Solutions (?) & Conclusions

The Sudanese Minister for Health, Dr Bahar Idris Abu Garda, is understandably keen to retain doctors within the health system. International solutions have been proposed including tightening immigration restrictions in countries such as the UK, ethical recruitment policies (i.e. not advertising NHS or BUPA vacancies in Africa) and paying compensation for training costs and labour value to the government of an immigrant. Such ‘solutions’ are likely to be little more than fripperous baubles, glittering briefly for those who glance at this issue, but lacking any impact on the root problems.

Surely the only real solution (and the hardest to achieve), is to begin lowering the mountain, to create opportunity, increase social and professional mobility and to close the gap between the elites and ‘everyone-else’. In other words, it would be better to try and make people want to stay, rather than just preventing them from leaving.

Maybe this starts with greater and more structured investment in the health system. There have been significant achievements already; undergraduate medical education has grown rapidly over two decades. Now postgraduate training and employment capacity need the same level of attention.

Quite how this is to be achieved is difficult to conceive, given Sudan’s reduced national income (since the secession of South Sudan), its high defence spending and the burden of international debt. But the green shoots of regeneration are present in the new cohorts of medical graduates and doctors coming through, with their desire to improve their country. The best response is not to decrease opportunities to leave, but rather to increase opportunities for those who stay.

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References

Agwu, K. Llewelyn, M. (2009) Compensation for the brain drain from developing countries. The Lancet (373) 1665 – 1666

http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609609272.pdf

Ali, Z. (2009) The third international conference on medical education in Sudan: lessons about undergraduate medical education. Sudanese Journal of Public Health. 4 (4) 411-413

www.sjph.net.sd/files/vol4i4/SJPH-vol4i4-p411-413.pdf

Ali, Z., El-Higaya, E., Ibrahim, N., Elmusharaf, K., Shadad, A., Elshafei, M. Ahmed, M. (2012) Migration of Sudanese Doctors: Dynamics and Opportunities – Conference Report. Sudanese Medical Association UK and Ireland. 9th June 2012.

www.slideshare.net/SMAUKI/sma-uk-ireland-galway-conference-report-2012

Chen, L.C., Boufford, J.I. (2005) Fatal Flows — Doctors on the Move. New England Journal of Medicine. (353)1850-1852
www.nejm.org/doi/full/10.1056/NEJMe058188

Commission on the Social Determinants of Health (2010) Closing the gap in a generation: Health equity through action on the social determinants of health. WHO. WHO/IER/CSDH/08.1

http://whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf

Fadlalla, M., Jaffar, R., Abdalgadir, N. (2012) Strategic analysis of the surgical internship in Sudan. Sudan Journal of Medical Sciences. 7 (1) 35-40

www.ajol.info/index.php/sjms/article/view/78155

McDoom, O. (2010) Sudanese security forces beat doctors in protest march. Reuters.

http://uk.reuters.com/article/2010/06/03/idUKMCD332528._CH_.2420

Mohammed, G.K. (2007) Financing health care in Sudan: Is it a time for the abolishing of user charges?  Sudanese Journal of Public Health. 2 (1) 38-47

www.sjph.net.sd/files/vol2i1p38-47.pdf

Mullan, F. (2005) The Metrics of the Physician Brain Drain. New England Journal of Medicine.  (353) 1810-1818
www.nejm.org/doi/full/10.1056/NEJMsa050004#t=article

OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing

www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en;jsessionid=9tamks2ta7noa.delta

Sen, A. (1981) Poverty and Famines: An Essay on Entitlement and Deprivation (Oxford, Clarendon

Press)

Sudan Radio Service (17 March 2010) Doctors Strike in Northern Sudan.

www.sudanradio.org/doctors-strike-northern-sudan

Sudan Tribune (18 March 2010) Sudan’s Bashir threatens to fire doctors on strike over pay.

www.sudantribune.com/spip.php?article34458

Sudan Tribune (3 June 2010) Police in Sudan clash with doctors pushing for nationwide strike.

www.sudantribune.com/spip.php?article35276

Sudan Tribune (17^th May 2011) Sudanese doctors go on strike.

www.sudantribune.com/spip.php?article38935

Sudan Vision (26^th September 2012) The Brain Drain.

http://news.sudanvisiondaily.com/details.html?rsnpid=214526

UN Development Programme (2011) International Human Development Indicators. Sudan Country Profile. http://hdrstats.undp.org/en/countries/profiles/SDN.html

WHO (2006) Health System Profile: Sudan. Regional Health Systems Observatory – Eastern Mediterranean Regional Health System Observatory.

http://hinfo.humaninfo.ro/gsdl/healthtechdocs/en/m/abstract/Js17310e/

WHO. (2012) Global Health Expenditure Atlas. W 74

Available at www.who.int/nha/country/sdn/en/ – www.who.int/nha/atlasfinal.pdf

Websites

BUPA – www.bupa.co.uk/

General Medical Council (UK) – Postgraduate Education – www.gmc-uk.org/education/postgraduate.asp

Home Office – UK Border Agency – www.ukba.homeoffice.gov.uk/visas-immigration/

Sudan Medical Specialisation Board – www.smsb.gov.sd

United Nations Data. Sudan Country Profile – http://data.un.org/CountryProfile.aspx?crName=SUDAN

United States Medical Licensing Examination – www.usmle.org/

WHO. Global Atlas of Health Workforce.

http://apps.who.int/globalatlas/DataQuery/default.asp

WHO. Sudan Country Profile

www.who.int/countries/sdn/en/

World Bank. Data, By Country – Sudan.

http://data.worldbank.org/country/sudan

WHO. Global Health Expenditure – Table of key indicators, sources and methods by country and indicators

http://apps.who.int/nha/database/StandardReport.aspx?ID=REP_WEB_MINI_TEMPLATE_WEB_VERSION&COUNTRYKEY=84559

Tuberculosis and the Creative Spirit

Last Wednesday I visited Abu Anga Hospital in Omdurman, which is the only specialist centre for managing ‘Multi Drug-Resistant’ tuberculosis (MDR-TB) in Sudan.

I travelled by bus, which can get rather painfully hot when stuck in the morning traffic. But buses do give you a chance to see many examples of everyday Sudanese ingenuity at work. Today for instance, as I got to my seat, I stepped over a large hole in the floor resourcefully covered with wooden planks and several dozen nails, so that you could barely even see the road below anymore. Another little example – as the conductor started to collect fares, he ran out of pockets and hands and so started to put coins in his ears. Every inch of space on buses is used. An extra row of seats on hinges fold up and down to fill the aisle, so that passengers are packed in like sardines.

You can get on and off the bus at any point. To get the driver to pull over, you just click your fingers and make a “kssss kssss kssss” sound – as if he were a huge cat (maybe if I try to tickle him I can get a journey for free?). Indeed, for some reason that I haven’t yet discovered, many bus drivers seem to wear furry, leopard-print slippers. There are hundreds of these vehicles on Khartoum’s roads, bus-sized tins of sardines driven by huge furry cats.

Further inspired opportunism isn’t hard to find. Driving past one street corner in central Khartoum, you can see what is very clearly a hearse (i.e. a car with a large glass compartment for displaying a coffin on the way to a funeral). It now rests there on the pavement for evermore, and has been plastered bizarrely with blue and yellow advertisements, plus full colour photos, for a male baldness therapy. But my favourite example of this creative spirit, though unrelated to buses or roads, is the pot of strawberry jam in my room. The maverick designers have created a very colourful illustration on the label, which shows not a single strawberry, but does include figs, bananas, mangos, and (my new favourite fruit) carrots.

Whilst this kind of innovative approach to life can be very handy, when it comes to tackling tuberculosis then good intentions and creativity can create problems rather than solutions. 

The bit about Tuberculosis                                                                                             

Tuberculosis is common in Sudan, out of a population of 44 million people there are around 25 000 new cases every year and a total of about 82 000 cases at any one time (WHO 1). In the UK, for comparison, out of a population of 62 million people, there are just over 7 000 new cases a year, with a total of around 9 600 cases at any one time (WHO 2).

Clinics at both Soba Hospital and the Omdurman Hospital for Tropical Diseases have been full of patients with tuberculosis. The bug – mycobacterium tuberculosis (M. TB) – may infect many different parts of the body, and so patients can present to doctors with symptoms involving anything from the head, neck and spine, to the chest, abdomen and skin.

TB care is co-ordinated by the National TB Programme, based in Khartoum. Treatment for patients should be completely or partially subsidised, and there are very clear World Health Organisation (WHO) guidelines for the use of anti-tuberculous drugs.

(Any readers with a slightly shaky interest in TB management close your eyes now for a couple of paragraphs…)

Patients who fall into ‘Category One’ (i.e. patients newly presenting with tuberculosis) receive first-line treatment (two months of HRZE and then four months of HRE – see below for abbreviations).  If all goes well, patients can be completely cured and symptom-free after six months.

However problems arise when patients present with tuberculosis for a second time, after having started a course of treatment at some point in the past. There are generally three reasons for this:

1) Default – The patient did not complete the full course of medication (i.e. they stopped too early) – for example because they start feeling better, or cannot meet the costs of treatment, or supplies of drugs run out.

2) Relapse – the patient completed the treatment course and was cured, but has been re-infected.

3) Failure – the treatment failed to kill the TB bugs

In re-presenting patients with these backgrounds, the M. TB are more likely to have developed resistance to some of the first-line drugs. They then fall into one of two treatment pathways. Patients who (1) default or (2) have relapsed are deemed to be ‘Category 2’ and are prescribed an adapted regimen including streptomycin (see WHO 2010b).  

However if (3) first-line treatment has failed, then there is a strong possibility that the patient is infected with Multi Drug-Resistant Tuberculosis (defined as proven resistance to H+R). This can be investigated with Drug Susceptibility Testing (DST) of the TB bugs, though this is expensive and can be time-consuming. Where DST is not available (like in Sudan, where it is normally used only for research purposes), such patients are assumed to have MDR-TB, and begin treatment with second-line drugs (see note below for more detail on these).

This second line regimen is far more expensive, lasts for longer, and has more potential for causing serious side-effects in the patient. Financial help is available from a WHO subsidiary called the Green Light Committee (GLC), subject to some fairly stringent criteria to do with the use and monitoring of these second-line drugs. Considering the difficulties that many countries face in applying international standards even for first-line drugs, it can be a huge challenge to satisfy conditions for GLC funding. In such countries, the spectre of an MDR-TB epidemic is alarming.

In Sudan, data from 2009 shows that a quarter of previously-treated patients were confirmed as having MDR-TB, much higher than rates in neighbouring Ethiopia (12%) or Uganda (13%) (Eldin et al 2011).  This is where we come back to the beginning and the ‘creative spirit’.

(…and open your eyes again)

TB drugs are not like buses, you cannot get on and off when you want, you must stay on for the full ride (around 8 months for first line drugs). If part of the drug regimen is missing, it cannot just be tacked over and forgotten about. Each drug acts in a slightly different way, and if one of them is missing, then the M.TB may survive and develop resistance to the first line drugs.

Unlike my strawberry jam label, patients need to be very clearly informed about what they are about to consume. TB drugs can have a range of nasty side-effects. Doctors need to educate their patients, to steel them against coming difficulties, and advise them to continue taking their medications and report any side-effects.

But it’s difficult. Poverty and a lack of education are powerful stimulants to ‘creativity’. If you get some side effects, like hepatitis, or losing your colour vision, then without free and easy access to a doctor and some treatment it’s rather tempting to stop taking your TB pills – particularly if your cough has cleared up.

If they have run out of a particular TB drug at your local clinic or district hospital, or it is only available upon payment (as opposed to being free), then both patients and doctors may try to ‘adapt’ drug regimens to make the best of what they have. This has been a problem in Sudan, with patients being hurt by inadequate private sector regulation (Maalaoui 2008).

Conclusions

So what to conclude? I guess many of the things I’ve discussed here affect people all over the world, not just in Sudan – so maybe this should end with some kind of rallying call for global health. Tuberculosis is not like buses or strawberry jam, and health is not just about pills and doctors. It also involves access to healthcare, income levels, education, private sector behaviour, government regulation, international organisations, guidelines and financial programmes – and that’s all before you get down to the individual, creative level. So it’s not all that simple. It involves structures and processes which can appear very difficult to change, and presents some fairly testing challenges. But with a bit of creative thinking in the right places, surely its possible to get it right?

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Abbreviations:

First line drugs: H = Isoniazid; R = Rifampicin; Z = Pyrazinamide; E = Ethambutol; +/- S = Streptomycin

Second line drugs: These include a parenteral drugs such as amikamycin; fluoroquinolones, such as moxifloxacin and levofloxacin; oral bacteriostatic agents such as ethionamide or cycloserine; and ‘group 5’ drugs such as clofazamine and imipenem (see WHO 2011, especially p19, and WHO 2010b p84-7).

DST – Drug Susceptibility Testing

GLC – Green Light Committee

M.TB – Mycobacterium Tuberculosis

MDR-TB – Multi drug-resistant tuberculosis

WHO – World Health Organisation

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Documents:

Eldin et al (2011) Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs. BMC Infectious Diseases. 11: 219   – www.biomedcentral.com/1471-2334/11/219/

Maalaoui, N. (2008) Strengthening TB Drug Management in the Sudanese National TB Control Program: In-Depth Review of TB Drug Management – http://pdf.usaid.gov/pdf_docs/PDACO436.pdf

 

WHO (2011) Guidelines for the programmatic management of drug-resistant tuberculosis (2011 Update) – www.who.int/tb/challenges/mdr/programmatic_guidelines_for_mdrtb/en/index.html

 

WHO (2010a) The human face of tuberculosis in Sudan – www.emro.who.int/dsaf/dsa1077.pdf

 

WHO (2010b) Treatment of Tuberculosis: guidelines for national programmes. 4th edition

www.who.int/tb/publications/tb_treatmentguidelines/en/

 

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Webpages:

 

Green Light Committee (WHO subsidiary for tackling MDR-TB and XDR-TB) – www.who.int/tb/challenges/mdr/greenlightcommittee/en/

 

Sudan: Stop TB website – Eastern Mediterrean Regional Office – (Information about the National TB Programme).

www.emro.who.int/sdn/programmes/stop-tb-sudan.html

(WHO1) WHO Tuberculosis statistics for Sudan: https://extranet.who.int/sree/Reports?op=Replet&name=%2FWHO_HQ_Reports%2FG2%2FPROD%2FEXT%2FTBCountryProfile&ISO2=SD&outtype=html

(WHO2) WHO Tuberculosis statistics for Great Britain and Northern Ireland:https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/EXT/TBCountryProfile&ISO2=GB&outtype=html

Beans, Grains and Madura Foot: Tasty Food, Tasty Medicine

I’m eating quite alot of beans at the moment.

‘Ful’ is the most widely-eaten meal in Sudan. It is made from black beans, cooked until they are soft, and then eaten with cheese, salt, onions and bread. Fasulya is made from white beans, and is cooked in the pot with some meat on the bone for flavour. They, along with some saucy dishes of potatoes, courgettes and peppers form the basis of diet, supplemented by a rather delicious range of fruit juices and the odd half-chicken.

There are many restaurants around Khartoum, serving a range of Sudanese, regional (as in Egyptian, Lebanese etc) and Western food. However due to burgeoning US sanctions, no American companies (like MacDonalds) can set-up shop here.

Being so ‘ful’ of beans (ho ho ho) can be rather useful for long ward rounds. I’ve seen a number of very interesting clinical cases over the past couple of weeks. Briefly, I’ve seen patients with pellagra (vitamin B6 deficiency with the clinical triad of dementia, diarrhoea and dermatitis); with Guillain-Barre Syndrome where polio and mercury- and lead-poisoning from mining were real differentials; with severe, quinine-resistant falciparum malaria and acute renal failure; with a bad drug-reaction to anti-malarial quinine therapy; and with complicated portal hypertension, resulting in different patients from chronic hepatitis, schistosomiasis and alcoholism. At the clinical meetings, I’ve also heard two interesting case presentations, firstly of a patient diagnosed with Churg-Strauss Syndrome (in the textbook this is late onset asthma, eosinophilia, small vessel vasculitis and a range of other potential features), presenting with joint pain, purpuric rash, dyspnoea, peripheral neuropathy, loss of vision and fever. The second case was a patient brought in from Jezira State, south of Khartoum, with DIC (blood clotting inside the blood vessels) resulting from a cobra bite. All these  cases were of  patients on the general medical ward.

I also spent some time at a specialist institute, the Mycetoma Research Centre, at Soba University Hospital. Mycetoma  is also called Madura Foot, named by British physicians in the Indian city of Madurai, Tamil Nadu State. It is found across the world in the ‘Mycetoma Belt’, stretching around Brazil and Mexico, through Africa and Arabia to India and South-East Asia.

It is a progressive, granulomatous inflammatory disease caused by particular species of bacteria (actinomycetes) or fungi (eumycetes). It still most commonly affects patients’ feet and legs since the most common route of inoculation is via a thorn, carrying the bacteria or fungi, piercing the skin.

It presents as a clinical triad of a painless, subcutaneous (under the skin) mass, sinus formation and the discharge of yellow and red (actinomycetoma) or black (eumycetoma) grains. As it is painless, many patients present relatively late (i.e. several months or even years after inoculation). This can lead to devasting consequences, as the mycetoma may spread beneath the skin and destroy deeper structures such as bones. Following evidence-based management guidelines developed at the centre, patients have a set of diagnostic and staging investigations and may then undergo medical (taking medicines) and surgical (cutting bits out or off) therapy. Over months, patients can make a full recovery, although recurrence rates are high.

Both the Mycetoma Centre at Soba, and the Institute of Endemic Diseases at the University of Khartoum conduct  ground-breaking, cutting-edge research in their respective fields – fields which are comparatively neglected in other, richer countries with different burdens of disease. They are staffed by well qualified, highly motivated and internationally published and respected scientists and clinicians.

But a small footnote to this is the effect of the unilateral US sanctions, renewed annually by the US Senate, despite promises to repeal them after the signing of the peace agreement in 2005. These sanctions do not just prevent MacDonalds from doing business here, but also prevent a spectrum of American industries, including scientific, technological and manufacturing companies from engaging in Sudan. As is so often the case, the sanctions are hurting the wrong people. That’s not cool beans.

——-

Picture Credit: http://pmj.bmj.com/content/75/889/671.full – Akhtar, M., Latief, P. (1999) Actinomycetoma Pedis. Postgraduate Medical Journal (75) 671 

Fahal, A. (2006) Mycetoma: Clinical Monograph. Khartoum University Press. Sudan

Manson, K. (23 July 2012) US Sanctions take toll on Khartoum. Financial Times.

Institute of Endemic Diseases, University of Khartoum – http://www.iend.org/

Mycetoma Research Centre, Soba University Hospital – http://mycetoma.uofk.edu/

Storm clouds and CT scans (and some food puns to chew over)

My Friday evening this week was spent in a seminar room in a Khartoum hospital, sheltering from the thunder and lightening outside, and listening to a presentation on radiology and orthopaedics.

These first few roasting weeks have sometimes left me looking like a tender young lobster who has fallen into some strawberry ice cream (so yes indeed, exotic AND delicious). Even though I’ve now become a little more used to the heat and the glare, such a dramatic change in the weather was quite fun. Huge storm clouds blocked out the sun, lightening stretched from horizon to horizon, rumbling thunder drowned out the traffic. On the road towards the university, wind whipped up dust to fill the air (plus eyes, ears, nose and mouth), and just a few rain drops fell.

So instead of spending the evening being fried and battered (by lightening, wind and sand), we (the three other international elective students and me) sped off to a hospital to learn about bones on a radiological plate. The lecture was delivered (in English) by a Sudanese radiologist recently returned from working in Britain. It explored ways in which radiology can aid orthopaedic surgery, focusing on knee and back problems. I’m including the event in this blog just because it was interesting just how little seems to change between medical contexts. Indeed, in many ways the session was identical to every clinical meeting I have attended in the UK (although there were a few differences).   

The audience was arranged around a conference table, with the presentation projected onto the wall at the far end of the room, just as it might be in the UK. The senior professors and consultants, dressed in white jellabiyah (ankle length gown) and imma (turban) were sat around the table, with the juniors spread out behind on both sides.   The presentation itself (on powerpoint of course) was about an hour long, during which the row of turbans in front of me bobbed and shook at significant points (just as the front-row of heads do in the UK).

Afterwards came the questions. It seems that senior clinicians throughout the world develop their own tried and trusted habits, techniques and theories – their own ‘flavours’. ‘Question-time’ is a chance to share these favourite flavours, to give everyone a good long taste. And, just as in the UK, there is always some culinary disagreement, leading to more bobbing or shaking and a second round of tasting. The dessert, after all that, was two presentations from the pharmaceutical companies sponsoring the event.

There were also some interesting observations about the way in which the Sudanese health system is fragmented. There are a large number of different hospitals in Khartoum alone, some public (state-subsidised), some private, some general and others specialising. This has many effects; it results for example in a large number of referrals between hospitals, with little continuity of care and no central patient data system. It also means that for disciplines such as radiology, where large and expensive equipment is involved, very few centres are large enough to afford such equipment, or will use it often enough to make it cost-effective.

I believe that health financing in Sudan is largely private, with patients at both private and public hospitals bearing most of the costs of their care. Health insurance companies and state health insurance also play a growing role. International organisations and mechanisms also support specific vertical programmes or local health facilities, such as the detection and treatment of tuberculosis or leishmaniasis. The balance between patients and profits is often a controversial one in health systems, and I suspect that a study of health financing in Sudan would make for some interesting reading (if anyone knows of any then please get in touch!).

So altogether, a stormy appetiser, some tasty morsels and plenty of food for thought!

Pete

‘Khartoum Burns’: What’s the score?

Photo: Ashraf Shazly/AFP/Getty Images

We had had plans for Friday 14th September. We (me and the four other international medical elective students, from Czech Republic, Norway and Poland) were going to spend the afternoon on Tutti Island, in the Nile, where you can sit in the leafy shade and drink tea.

But then at around 14:00 (Sudan time) we got a text from a Sudanese friend, “Don’t go anywhere alone today. Let me know if you’re going out”.

We had heard about the 14 minute Youtube video that had already sparked events in Libya and Egypt, and so assumed that perhaps today, the first day of the weekend, when everyone attends the mosque for Friday Prayers, there might be some kind of protest in Khartoum.

So we cancelled our plans, spent the afternoon out of sight in the Faculty of Medicine’s open-air cafe, and kept an eye on the news headlines. These did their utmost to out-do each other in the ‘shock-horror’ stakes. “Embassies burn in Khartoum”, “5,000 march on the US Embassy”, “Send for Lord Kitchener”, or whatever they were. Today (Sunday 16th and the first day of the working week here) there still seems to be significant confusion about the chronology of what happened, but from reading reports in the Khartoum and international press, and from speaking to different people here, it seems that this is what happened.

After Friday prayers, around 5,000 people (exactly and approximately) congregated outside the US Embassy. They arrived in buses, organised by ‘no-one-quite-knows-who’. The US embassy has been relocated in the last few years, so that it is no longer in central Khartoum, but about 20-30 mins drive outside it and well past the last houses on the outskirts (on the road to Soba Hospital where I am based). Hence the need for buses. The embassy itself is a long way back from the main road, and looks pretty formidable from a distance.

It was reported that ‘the mob’ gathered in ‘the square’ outside the embassy and started burning things. I drive past ‘the square’ every day at the moment on my way in and out of Khartoum. It would be more accurate to call it ‘a field’, as it has nothing in it except some dirt and some dust. It is lined on the main-road side by half-buried car tyres, presumably to discourage attempts at parking. Driving past this field on the morning after, I saw a boy poking some half-buried wires with a stick. So it would seem that these were the fuel for the fires of Friday afternoon.

It’s hard to say what exactly happened, as reports are rather thin and contradictory, but people here seem to agree that around 250 Sudanese security personnel were stationed there, that tear gas may have been used, and that three Sudanese men were killed in the course of the day.

So after some time at the US Embassy, this crowd got back on their buses, and shuttled into central Khartoum, where a number of other embassies reside. They alighted at the German Embassy – a move that neither the international media, nor our Sudanese friends could explain that afternoon. It seems that the Sudanese security services were also wrong-footed, as here the more reckless, violent elements enjoyed some success. They breached the compound walls, lowering the German flag and raising a black one in its place, smashing windows and starting a fire inside. Moving on to the UK embassy next door, a number of men again apparently scaled the wall, but did not enter the building itself (perhaps the security forces were present in greater numbers by this time?).

What seems clear is that these events were very different to those in Libya. In Khartoum, there was no well-armed, well-organised attempt to kill and destroy, or even apparently to send any kind of strong political message to the government (as some ‘conspiracy analysts’ have suggested was at the root of all of Friday’s protests across the region). It seems to have been more simply an expression of anger at the Youtube film – with the US selected as the focal point for discharging that anger.

It might indeed be argued that there is every right and reason for such emotion – given both the mucky, unhinged nature of the film, and the central, deeply-ingrained part that its subject plays here. The means for expressing such feeling however, is another point entirely.

And the reasons for targeting the German embassy? It was reported in a Khartoum paper that an offensive cartoon was published in a German newspaper in the past 2 weeks. Elsewhere, one international media group suggested it was because the German government had not banned a right-wing protest at which anti-Islamic banners were held. And the UK embassy? No-one really seems to know specifically, perhaps just because it was next door? Perhaps because everyone knows it’s an old devil?!

As I left the faculty cafe that evening, and walked to the bus-stop, past restaurants and street-stalls, parked cars and open lorry-cabs, everywhere the same radio station was blasting out some kind of feverish exhortation. What was it? Reaction to the demonstrations? Demands for more protests?

No, it was football commentary.

Al-Hilal, one of the two big Khartoumi clubs was hosting Interclube Luanda from Angola in the African continental Confederations Cup.  If they won, they would be just one victory away from the semi-finals. We had been hoping to go this match (I was even wearing my Al-Hilal shirt), but decided that perhaps today was not the best day to be part of a large excitable crowd.

Whilst walking past people on the street, and waiting at the bus stop, I must admit to feeling a little bit nervous after the furore earlier. But the only bared teeth were set in smiles, and the several shouts aimed at me were all directed in praise of my Al-Hilal shirt.

So what should I conclude after all of that?

Were the demonstrations in Khartoum trivial? No.

Were they exaggerated in the desire to create a story of arching Middle-Eastern chaos? Yes, I think so.

Photo: CAF Online

Khartoumi society (still less Sudanese or Islamic culture) is not some monolithic conformity; 5,000 people from a city of 10 million is not such a large proportion (1 in every 2000 actually), whilst I need to take my shoes and socks off to count the number of people from my small circle of acquaintance here who have quietly apologised to me for the offense of the violent excesses. Overall, passions may be strong here, but are they really so different to those you might find in London or Barcelona, Madrid, Munich or Milan? There are people who like to burn things everywhere, but the majority have rather healthier interests, like the beautiful game. My decision that morning to wear an Al-Hilal shirt may have been inadvertently fortunate, but I don’t for a second believe that it saved my life.

—-

P.S. – From afternoon reports on Sunday 16th September

I’ve also seen reports in the international media that the Sudanese Foreign Ministry has refused to allow the US to deploy extra marines to protect its embassy – instead committing to use its own security forces. To my eyes, this story was put across with a negative, almost sinister spin, as if the buried question was “does the Sudanese government not want the US to be able to protect itself? Do they in fact want the US embassy to be imperiled?”

But isn’t it natural that a sovereign government should wish to trust its own security arrangements, and resent or refuse attempts to usurp its authority within its own capital city? Aren’t Sudanese forces likely to be more experienced and adept at handling Sudanese protesters than American marines? And couldn’t you argue that the government’s trust in its own forces was vindicated (at least as far as the US embassy goes)?

Heat Dreams

My room is its own little menagerie.
Above the bed, flocks of honking mosquitos flap about with their sharp bills and beady eyes. But they cannot find a way through my mosquito net to lay their golden eggs.

Below, cockroaches gambol merrily over the floor, stopping every now and then to pass the time of day. They whisper very quietly.

One afternoon we were even joined by an extremely handsome toad, about the size of a melon, with very fine mustachios and collars around his face. After we had processed three times around the room with gathering speed, he plopped gracefully into the little puddle which runs the length of one wall, and followed it out and under the door, which I closed behind him.

In the hallway outside, some kind of dragon-sized hornets have been making their mud-nests on the walls, and have stopped in for a drink and a snack in my room.

Across the road, there are goats who play ‘Here we go round the mulberry bush’ whenever I go past.

I think there should be some kind of story about what they all get up to, but I haven’t had that dream yet…

 

 

 

 

 

 

 

 

 

 

 All images from http://www.history.navy.mil/library/online/thisisann.htm

Leishmaniasis galore!

My placement at Soba Hospital hasn’t really settled into any kind of rhythm as yet. Its all a little bit haphazard. I’ve spent quite a number of hours just waiting around, wondering if I’m in the right place. In some ways thats reassuringly familiar – its a major educational dimension of just about every placement I’ve had in London too ! But its also rather familiarly frustrating.

So I’ve started taking a little more initiative, and have been creeping (walking) around the hospital, lurking (waiting) in the places where I know my team of doctors might be – the outpatients referral clinic, the male medical wards, procedure rooms and so on – and then jumping out (standing up) and asking if I can join them.

Through this subtle method, I’ve found out the times and specialties of the clinics each morning, and I’ve seen some very interesting patients.

For example I caught the last three patients in the chest clinic today. The first man had pulmonary TB (in the lungs), with bilateral pleural effusions (water in the lungs). The second was a young man with congestive cardiac failure (a bad heart), with a very clear textbook pansystolic murmur (his heartbeat sounded wrong).The final patient was a young lady in her 70s, who had disseminated TB, including pulmonary, lymphadenitis (Scrofula or TB in the lymph nodes of the neck), Pott’s Disease (TB in the spine) and a TB psoas abscess (an abscess in one of the muscles of the leg). All of this can (and would) be treated, although I’m not sure of the prognosis. (Photo of TB Lymphadenitis below taken with permission of patient)

On Mondays and Thursdays I go the Omdurman Hospital for Tropical Diseases, a 20 minute bus journey across the Nile from Khartoum.

Again, each morning starts gently with some stretching and yawning in the consultation room for an hour or so. But when the consultant arrives, its a fantastic learning experience. I think I probably saw more tropical medicine in my first clinic there, than most UK physicians get to see in their whole careers, and after each patient we discuss the case with the doctor.

From a 17 year old boy, with portal hypertension (high blood pressure in the liver’s blood vessels) from chronic schistosomiasis, through patients with TB, malaria, leprosy, suspected HIV, tertiary syphilis, others with schistosomiasis, to three patients with Cutaneous Leishmaniasis. This disease is endemic in parts of Sudan (as is Visceral Leishmaniasis). One of these patients has a typical history. He is a soldier in his 40s, in the Sudanese army, and has been stationed in the south of Sudan (in South Kordofan State). He has three circular, raised, painless lesions on his arm, the largest is around 5×6 cm, with a dry, ulcerated centre. These are caused by the body’s reaction to infection with a species of Leishmania parasite, which is transmitted via the bites of sandflies. If left untreated, they may resolve themselves, but (depending on the species) may also spread further, or cause Mucocutaneous Leishmaniasis (involving the linings of the nose and mouth) (which is worth avoiding). I think there is a multinationally-sponsored programme for Leishmaniasis in Sudan, and so he will be put into this and recieve for free the treatment of Sodium Stibogluconate (Pentostam). Whilst it may be good in the long run, it has to be administered via painful injections (the drug has local toxic effects) – so this man has some tough days ahead.

For me, tomorrow holds a gastroenterology clinc, so lets see what that throws up (sorry for the pun!).

Pete

Mix-ups and Marriages

Greetings from Khartoum!

Its Friday, the first day of the weekend here. And no,  I didn’t get married through some slight misunderstanding, but I have now completed my first working week (Sunday to Thursday) at Soba University Hospital, just outside Khartoum.

Its been great fun, but really all about finding my feet and getting my bearings. I’ve felt a little like a fish probably feels out of water – hooked by something I don’t quite understand, but realising that some pretty speedy evolution is going to be rather handy!

For example on my first proper day (after some introduction and orientation on the Sunday), I got to the front of my accommodation (I am staying in the doctors’ mess) to catch the shuttle bus to the hospital, which supposedly went at 08:00am. After waiting peacefully alone for a few minutes,  I went up to a man sitting in the shade of a tree nearby (the mess sits in a large scrub field a little way from Soba Hospital) to ask about the bus.

Me: Hi, is there a shuttle bus now?

Man: No bus.

Me: When is the next bus?

Man: Uh?

Me: (In faltering arabic) At what hour is the next bus that goes to the hospital of Soba?

Man: (In English) The next bus?

Me: Yes

Man: Not now.

Me: Oh (pause). At what time?

Man: Uh?

Me: (Arabic) At what time is the next bus?

Man: (English) This evening.

Me: Ah (pause). Okay, so I can walk?

Man: No.

Me: Oh (pause). But I think maybe I walked yesterday with one of the doctors?

Man: Not now, too hot.

Me: Ah (pause).

(We watch for a few seconds as some of the doctors from the mess stroll past on their walk in to the hospital)

Me: But I think really I should go in to the hospital, so maybe I should try to walk.

Man: Okay, I will walk with you.

From one perspective, I think this gives an idea of my first few days. Its taken just a little time to adjust to h0w things are – from routes into Soba Hospital and bus routes into Khartoum, to meal times, ways to stay hydrated, and how to shift my sleeping patterns to make the most of the cooler parts of the day (day time average is about 40 degrees C at the moment).

What that 2 minute ‘conversation’ barely touches though is just how friendly, welcoming and helpful so many people have been to me in these first few days – particularly at Soba Hospital and in the doctors’ mess. I spend my day shifts with the house officers, who mostly speak excellent English. They have helped me to see patients, taking some histories and doing examinations, correcting my clinical technique and encouraging me to try and pick up the odd medical word in arabic (and if I ever remember any they could be useful as many patients don’t really speak English).

I have also been to a pre-wedding ‘henna’ party – at the kind invitation of the chief administator at Soba Hospital – which I think is essentially about the groom (or the bride) celebrating the end of their single days and forthcoming marriage. From 21:00 onwards, around 200 people were up dancing to the live music and songs. One of the female singers in particular had a fantastic voice, kind of the female equivalent of Tom Waits, only I think with an even bigger set of lungs.

I have to come into Khartoum to use the internet (which takes around 40 mins via 2 microbuses) – so it may be less easy to blog as often as I had hoped.

I will post again soon – particularly about the medicine I’ve seen, including my first day at Omdurman Hospital of Tropical Medicine – where I will be spending 2 days a week from now on.

Pete

‘Saving lives on holiday?’ or ‘What is a medical elective?’

The seven weeks in Khartoum will be my medical elective, part of my final year at medical school.  Such placements have been part of medical curricula in the UK since the 1970s. But what are they like?

Should an elective be a chance to have a bit of a holiday and save a few lives for fun? Or a courageous, single-handed slog against all odds for the good of mankind? I rather suspect (and hope) that it’ll turn out to be neither of these. So in that case, again, what exactly is an elective? And what’s the point of it?

If you were to ask me, I’d say that an elective is probably a little like a cross between a gap year and a regular medical placement: A short clinical attachment (i.e. 2 months based in a hospital) abroad or in the UK, which is normally self-selected and self-organised.

Like any of the modular placements which make up training for medical students (e.g. paediatrics or cardiology), an elective provides some important educational opportunities. Various authors have identified several of these medicinally-based benefits, including the improvement of knowledge, skills and confidence, the accumulation of resource- ‘awareness’, and the development of some insight into future career choices*. Overall, in this clinical vein, you could see an elective as a chance to enrich your academic soul through exposure to favourite medical specialties, different teaching or supervision, and new therapeutic experiences.

But like a gap year, it’s also supposed (I think) to be a bit fun! Depending on your destination, your elective is your ticket to leave behind the familiar scenes of the past five years and immerse yourself for a couple of months in a new place, culture, language, and health system. If you play your cards right, you can spend those weeks somewhere you’ve always wanted to visit – whether that’s for reasons of history, culture, family connections, or simply because it’s five minutes away from the world’s best beach! Put this way, wouldn’t it be good if most career paths included an elective period?!

But hang on a minute, is that all there is to it? Education + Enjoyment = Electives? If that was really the whole equation, couldn’t we just substitute in a couple of lectures, a few ward sessions and a holiday for the elective? Be a lot easier to organise wouldn’t it? There must be something more to it, and sticking with the E’s, I’m going to suggest the last component might be called ‘Edge’.

Shouldn’t an elective occasionally push you out of your comfort zone, turfing you out of the cosy certainties of medical school into the precipitous unknowns of the real world? Unlike medical school, where responsibility always lies with someone higher, electives students’ decision ‘to act, or not to act’ may actually mean something. This is where a hint of controversy touches the topic. How far should you as a student go? Where exactly is the edge here?

Whilst on elective, many factors may come into play to increase students’ autonomy. These might include a low staff to patient ratio, limited student supervision with unrealistic expectations of their performance, and a high value attached to clinical decisions (due for example to limited availability of lab tests or specialist opinion). Simultaneously, students may be more frequently exposed to situations and demands closer to the limits of their competence than ever before. Overall, it may occasionally appear as though they wield a new and giddy power over their patients.

Conceivably, an elective student’s decisions may concern whether to attempt a solo-appendicectomy (the answer is no!), which drug to use to treat cutaneous leishmaniasis, whether to act as lead assistant in an emergency caesarean section, or just simply whether to admit someone for observation. The difficulty is in knowing where the edge is, and which path to take in order to avoid pushing both your patient and yourself over it.

A major factor in these situations is presumably your attitude – how you see yourself and your role. I think it can be very difficult, with reasons both plausible and implausible stacking-up to justify you in pushing the boundaries. Isn’t your help better than no help? The chance of life better than the prospect of death? Isn’t it in fact a duty to bring painstakingly-acquired knowledge and skills to bear upon deprived patients and depleted medical systems?

However, whilst such propositions may be beguiling, aren’t they in fact little more than excuses for exercising this new-found power? Surely a more searching question to ask yourself is exactly what help your knowledge and skills would give to a patient’s chances of life?

I would guess that the best solution might begin with trying to keep any surging adrenaline at bay and then, placing your patient’s interests uppermost, quickly consider your capacities and limits. Remember that you’re a medical student! I’m not suggesting that students should never do anything new – they’d never get anywhere, let alone qualify – just that they should be doing things for the right reasons. The acid test is probably ‘if this patient was a member of your own family, would you make the same decision’?

Or is that all too simplistic and short-sighted? Should there in fact be different standards for different settings? If patients live under different realities and have different expectations of health care, then do Western standards just hold things back? Ultimately, I doubt that there’ll ever be a great deal of regulation or evaluation of all this. Different authors have commented on the scarcity of real data or studies of such situations. Until there is more, I guess it remains down to each individual student to evolve their own sense of professionalism, to decide where their own edge is.

After all of that, what will I be hoping to get out of my own elective? Perhaps a little of each of those three E’s! Some opportunities, lots of fun and some chances to learn more about medicine and where I fit into it. I would also like to get to know Khartoum and its people a little whilst I’m there. And why Khartoum in the first place? Well that’ll hopefully be for my next blog…

Will write again soon!

Pete

* If you’re interested then read Dowell, J., Merrylees, N. (2009) Electives: isn’t it time for a change? Medical Education. (43) 121-6

Also some interesting thoughts in the following letter, comment piece and article respectively.

–          Banerjee, A., Banatvala, N., Handa, A. (2011) Medical student electives: potential for global health? The Lancet (377) 555

–          Graham, N. (2010) Elective Ethics. Student BMJ (18) 65-67

–          Edwards, R., Piachaud, J., Rowson, M., Miranda, J. (2004) Understanding global health issues: are international medical electives the answer? Medical Education. (38) 688-90