I was recently invited to speak to a global health class at
UW Tacoma about Ebola and my work in Sierra Leone. I decided to begin my talk
with an overview of tropical medicine.
I've been asked about tropical medicine several times,
usually after I tell someone that I have a master's degree in public health and
tropical medicine. I overheard one person speculate that tropical medicine was
fruit-flavored.
Maybe this is your idea of the tropics:
There are a number of different definitions of which parts
of the world are "tropical." The simplest definition is the area
between the Tropic of Cancer and the Tropic of Capricorn. This is the part of
the earth where the sun is directly overhead at least once during the year.
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| Zaire, 1988 |
There are different climates within the tropics. Before
going to Sierra Leone last year, the last time I had been in West Africa was in
the late 1980s. After spending time in the highlands and plateaus of East
Africa, I had forgotten how hot "tropical" Africa can be. I spent a
year working in the Ethiopian Highlands where, even though I was only a few
degrees from the equator, the weather was a lot like the Pacific Northwest in
spring and summer - it can get quite cold at night and it rains a lot.
Climate affects disease epidemiology and tropical diseases
are not evenly distributed throughout the tropics. Malaria, for example, is not
transmitted above an altitude of 2,000 meter. There are also arid regions in
the tropics where malaria is rarely found because there isn't enough water for
the mosquito vectors to breed.
Although the heaviest tropical disease burden is in the
tropics, they are not limited to that part of the world. Tropical medicine also
includes non-infectious diseases. The American Society of Tropical Medicine and
Hygiene (ASTMH) refers to tropical diseases as those that "disproportionately afflict the global poor."
Neglected tropical diseases (NTD) are infectious diseases that affect the poor in
developing countries and that have historically received little attention. NTDs
are caused by bacteria, fungi, parasites (protozoa and worms), and viruses.
As the name imples, the largest burden of NTDs is in the tropics:
Although malaria is not included in the list of NTDs, its
geographic distribution is characteristic of a tropical disease.
We also see higher burdens of child deaths in developing
countries.
I could spend a lot of time discussing NTDs and other infectious
tropical diseases. They were a large part the tropical medicine curriculum at Tulane, infectious diseases are the topics of most
of the scientific sessions and symposia at the American Society of Tropical Medicine and Hygiene (ASTMH) annual meetings, and I've
had a few of them.
Diseases associated with poverty include non-infectious
diseases like malnutrition, cancer, chronic diseases, and mental health issues.
My tropical medicine coursework also included envenomations and intoxications;
animals and plants that bite, sting, and poison people.
Around 80% of deaths due to non-communicable diseases occur
in developing countries including cardiovascular disease (e.g., heart disease and stroke), cancer, chronic respiratory diseases, and diabetes
(Koehlmoos et al., 2011).
Every week, millions of people in developing countries are moving from rural
areas into urban areas (urbanization).
Seventy percent of people living in urban areas in developing countries live in
slums where they may have no access to clean water, where there
is poor sanitation, housing is poor and overcrowded, and where they may live in
disaster-prone areas. As people move into cities, they frequently adopt high
calorie diets and sedentary lifestyles that put them at risk for chronic
diseases like diabetes and heart disease (Utzinger & Keiser, 2006).
Developing countries also have the highest burden of deaths
due to trauma. Ninety percent of deaths from motor vehicle accidents occur in
developing counties. Occupational injuries are also too common in developing
countries (Koehlmoos et al., 2011). When I worked in Tanzania last year I saw one young man who had both of his arms cut off at the
shoulders in a farming accident, another young man with C5 quadriplegia
from an occupational injury, and several work-related severe and sometimes
fatal head injuries.
I covered a number of other topics during my presentation,
many of which I've discussed here; influenza,
measles,
the demographic transition, and, of course, Ebola.
I ended my presentation, as I usually do when I speak to young people, by
asking them to consider a career in nursing. Since I was addressing a global
health class, I discussed the topic of a public health analysis that I wrote
while I was at Tulane:
Global migration of
nurses
There is a worsening global nursing shortage in both
industrialized and developing countries. The international demand for nurses is
driven by shortages in wealthy countries. Policymakers in wealthy countries
have failed to respond to the increasing demand for health services by
investing in recruitment from large pools of qualified applicants and retaining
nurses in the workforce. Large numbers of applicants are turned away from
nursing schools in the U.S., while the annual number of graduates from nursing
programs is insufficient to meet the current and projected workforce needs.
Industrialized countries have become reliant upon international nurse
recruitment, and an increasing number of nurses are leaving countries with low
nurse to population ratios and high disease burdens (Adams & Stilwell,
2004; Aiken, 2007; Bach, 2003; Bach, 2004; Buchan et al., 2003; Buchan &
Sochalski, 2004).
Although the total number of nurses migrating to an
industrialized country may be relatively small in comparison to the recipient
country’s stock of nurses, the loss of highly skilled health workers from
developing countries with smaller stocks of nurses has severe implications for
health care services in the source country (Aiken, 2007; Brush & Sochalski;
Buchan et al., 2003). The benefits to source countries from nurse migration are
significant. The total annual value of remittances from laborers of all
categories working abroad exceeds the annual total global developmental
assistance (Marchal & Kegels, 2003; Stilwell et al., 2003). For several
decades, the Philippines has encouraged migration of nurses, who contribute
almost $8 billion per year to the Philippine economy in the form of remittances
(Brush & Sochalski, 2007). Nurses in the Philippines earn $75 to $200 per
month, but earn $3,000 to $4,000 per month working in the U.S. (Bach, 2003;
Brush & Sochalski). Thousands of Filipino physicians, who earn $300 to $800
per month, have retrained as nurses for export, and thousands more are enrolled
in nursing schools (Bach; Brush & Sochalski).
On the other hand, the workforce crisis in developing
countries limits the capacity and sustainability of health care systems to
address health issues (Kiringia et al., 2006; WHO, 2008). On average, countries
in sub-Saharan Africa have insufficient numbers of trained health care workers
required to provide basic services (Dovlo, 2007; Liese & Dussault, 2004).
There is also a tendency towards permanent migration of nurses, which
represents significant losses not only to the health care workforce, but also
loss of investment on health worker education (Bach, 2003; Buchan, Parkin,
Sochalski, 2003; Kiringia, Gbary, Muthuri, Nyoni, & Seddoh, 2006; Marchal
& Kegels, 2003).
The demand for nurses in industrialized countries, created
by the failure to train and retain nurses from their own population, has
profound effects on the health workforces in developing countries (Aiken, 2007;
Bach, 2003; Buchan et al., 2003; Marchal & Kegels, 2003; Pond & McPake,
2006).
My long term career goal is to return to Africa to teach
nurses.
My PowerPoint presentation
References
Adams, O. & Stillwell, B. (2004). Health professionals
and migration. Bulletin of the World
Health Organization, 82(8), 560.
Aiken, L. H. (2007). U.S. nurse labor market dynamics are
key to global nurse sufficiency. Health
Service Research, 42(3p2), 1299-1320.
Bach, S. (2003). International
migration of health workers: labour and social issues (Working Paper 209).
International Labour Office: Geneva.
Bach, S. (2004). Migratory patterns of physicians and
nurses: still the same story? Bulletin of the World Health Organization, 82(8),
624-625.
Brush, B. L. & Sochalski, J. (2007). International
nurse migration: lessons from the Philippines. Policy, Politics, & Nursing Practice, 8(1),37-46.
Buchan, J., Parkin, T., & Sochalski, J. (2003). International nurse mobility: trends and
policy implications (WHO/EIP/OSD/2003.3). World Health Organization:
Geneva.
Buchan, J. & Sochalski, J. (2004). The migration of
nurses: trends and policies. Bulletin of
the World Health Organization, 82(8), 587-594.
Dovlo, D. (2007). Migration of nurses from sub-Saharan
Africa: a review of issues and challenges. Health
Services Research, 42(3p2), 1373-1388.
Kiringia, J. M., Gbary, A. R., Muthuri, L. K., Nyoni, J.,
& Seddoh, A. (2006). The cost of health professionals’ brain drain in
Kenya. BMC Health Services Research,
6(89), doi:10.1186/1472-6963-6-89.
Koehlmoos, T. P., Anwar, D., & Cravioto, A. (2011).
Global health: chronic diseases and other emergent health issues in global health.
Infectious Disease Clinics of North
America, 25(3), doi:10.1016.j.idc.2011.05.008.
Liese, B. & Dussault, G. (2004). The state of the health workforce in sub-Saharan Africa: evidence of
crisis and analysis of contributing factors. Washington D.C.: World Bank.
Marchal, B. & Kegels, G. (2003). Health workforce
imbalances in times of globalization: brain drain or professional mobility. International Journal of Health Planning and
Management, 18(S1), S89-S101.
Pond, B. & McPake, B. (2006). The health migration
crisis: the role of four Organisation for Economic Cooperation and Development
countries. Lancet, 367, 1448-1455.
Stilwell, B., Diallo, K., Zurn, P., Dal Poz, M. R., Adams,
O., & Buchan, J. (2003). Developing evidence-based ethical policies on the
migration of health workers: conceptual practice. Human Resources for Health, 1(8), doi:10.1186/1478-4491-1-8.
Utzinger, J. & Keiser, J. (2006). Urbanization and
tropical health – then and now. Annals of
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