Professional Documents
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Tropical medicine
Professor Castelli 3 July 2014 Author Luigi Bonini Reviewer EBV
I am Francesco Castelli, doctor in the hospital of Brescia, I am the director of he WHO Collaborating Center for
TB/HIV co-infection, and the president of the Italian Society of Tropical Medicine.
I would like to start telling you a story, the story of Awa, a 38 y.o. lady who had 7 pregnancies and 5 living
children. She lives in Burkina Faso. Awa is illiterate, and she is also very poor, living in a rural area, and her job is
to work the soil. She has never seen a doctor nor a midwife. She also has chronic malaria, with a lot of helminthes
in her belly (which means that her Hb level is usually 9-10). She also lives in a very hot country, where there may
be 45C.
She gets pregnant again. While she is working in the countryside she sees blood coming out of her legs going
down to her feet. So she comes back to the village and she is advised to go to a doctor. So she goes to the nearest
health center, which is 3 Km far. Now the Hb level is very low, around 7. Anyway there is no doctor in the health
center, nor any midwife, so she has to go to the district hospital. She asks to be carried there, because she is very
tired, but there is no possibility. So Awa goes to the district hospital: when she arrives, there is a very young doctor
there. She is transfused one unit of blood (only one is available). She has to undergo surgery to deliver the baby,
but unfortunately Awa and her baby die. The doctor said that Awa died of antepartum hemorrhage due to placenta
previa. So did Awa died due to a tropical disease or due to a poverty related disease?
So, what is a tropical disease? We have many definitions:
The branch of medicine that deals with the diagnosis and treatment of diseases that are found most
often in tropical regions.
Science of diseases seen primarily in tropical or subtropical climates. It arose in the 19th century
when European colonial doctors encountered infectious diseases unknown in Europe.
Education
concerning
prevailing
health problems and the methods of
preventing and controlling them
Promotion of food supply and proper
nutrition
An adequate supply of safe water and
basic sanitation
Maternal and child health care
including FP
Immunization against major infectious
diseases
Prevention and control local endemic
diseases
Appropriate treatment of common diseases
Provision of essential drugs
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Japan
82 y.
Sierra Leone
34 y.
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TOTAL N. DEATHS (X
1000)
Equatorial
Guinea
191.5
4.9
Guinea
Bissau
169.6
9.8
Chad
168.2
84.4
Japan
2.9
3.1
Sweden
2.8
0.3
Iceland
2.6
In this map you can see the countries which will reach the goal.
Eritrea
NUMBER OF
MOTHER
DEATHS
1081.3
2107
MATERNAL
MORTALITY RATIO
COUNTRY
Liberia
906
1425
Burundi
894.2
2585
Ireland
4.1
Austria
Iceland
1.5
NDs are those for which there is an insufficient market or political status to drive adequate private sector or
public sector research and development (R&D).
The term ND should not be used for those diseases for which effective and safe drugs exist
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Availability
o
Transportation
Affordability
o
Acceptability
o
Traditional medicine
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Keep in mind the story of Awa while reading the previous points.
In Italy we have roughly 200,800 $ per person per year for health expenditure, and the vast majority of this
amount is paid by the public service, and a small fraction is private. In the country where Awa was living, Burkina
Faso, the health pro-capite expenditure is roughly 10-12 $ per person, and the majority of this amount of money is
private, which means that if you go to the hospital you have to pay.
Lets make a small example. In the Hpital National Yalgado, a public hospital in Ouagadougou, the city where
th
Awa was living, patients can stay in 5 categories (the first category being the most expensive), and the 5 category
means that you can enter the hospital and you can sleep on the ground, but not enter the rooms. For this category
you pay 15 cents, so it is very cheap. But patients have to pay 10 days before they go in, so it is already 1.50 ;
and if you want to see a doctor, you have to pay the equivalent of 3 , every time you see a doctor. And if the
doctor decides that you need ampicillin, or any kind of drug, then you need to pay it by yourself. At the end Awa, in
this public hospital, would have paid 30-40 , which she didnt have. So affordability is a problem.
The last point is acceptability, which means taking into consideration culture and tradition.
Now I will tell you another story, the story of Fatima: Fatima is an African woman, living in a town (so not in a
rural area like Awa), who has 2 children and is pregnant again. The fertility rate in Italy is 1.3, while in Sub-Saharan
Africa it is 7-8. Fatima, after seeing a public signal increasing the awareness of HIV, decides to take the test for
HIV, and she is positive. So she is scared, and she doesnt want to tell her husband. At the end anyway she tells
the husband that she is HIV infected. The result is that she is expulsed from the family and she goes to a place
where all the rejected women like
her stay, living of charity, together
with her children. In this situation
she doesnt have access to
physicians and health personnel.
She delivered the baby there, and
the baby had HIV, because she
couldnt be given antiretroviral
treatment. Then Fatima got sick
and died.
In many African countries many
women cannot decide on their
health, but it is their husband who
can decide, so decide also for their
children. This is an obstacle for
many health programs.
Africa:
h p://gamapserver.who.int/
gho/interac ve_charts/
health_workforce/
PhysiciansDensity_Total/
atlas.html
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In my hospital in Brescia we have roughly 1000 doctors, not considering the resident physicians.
To train a physician in an African
country, it costs 21,000 58,7000 $.
And if the doctor trains in the country of
Awa and then he/she lives, this money
is lost. Who is gaining for that?
Countries like UK, where it was
estimated that the net benefit for
importing health personnel was more
than 2 billions $/year.