Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs

Welcome back! The first GEMS LP  journal club of the season took place on October 4th, 2021. During each meeting, we discuss a journal article, a global health clinical topic, and a book chapter from one of two books: An Introduction to Global Health Delivery by Joia Mukherjee or Reimagining Global Health: An Introduction by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico.

The goal of journal club is to expose our mentees to fundamental global health concepts and their applications in the real world. Having a diverse cohort of participants allows for lively and engaging discussion based on each participants’ life experiences. Below is a summary of each section presented at journal club. Be sure to join us at our next meeting, taking place November 8th, 2021.

Many of the global health disparities that exist today are a result of centuries of exploitation of developing countries that can trace its roots to the slave trade. As slavery ended in the 19th century, the extraction of people was replaced with the extraction of resources as European nations divided up Africa amongst themselves. By the 20th century, centuries of exploitation had robbed newly independent countries of the resources needed to provide healthcare for their citizens. Newly liberated countries came to rely on Western monetary institutions for loans, which often came with strings attached. Loans from the World Bank and the International Monetary Fund limited the amount of public expenditures on vital healthcare infrastructure, medication, and personnel. Healthcare in developing countries was further undermined by the neoliberal policies promoted by Western countries beginning in the 1980s. Developing countries were compelled to fund healthcare through above-cost user fees, which reinforced unequal access to care and widened healthcare inequality. The neoliberal approach also championed the concept of sustainability, which focused on low-cost preventative care instead of treatment. By the 1990s, this approach had led to widening healthcare inequity between the developed and developing worlds.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Discussion Questions:

·Reflect on prior medical service trips you may have gone on or may be offered by your university. In what ways do these trips reflect the legacy of colonialism? How can we “de-colonize” global health in medical education? 

·Should all medical interventions in lower-income and developing countries be “sustainable”? 

Medical tourism is a modern practice in healthcare that is exacerbating global health inequity. For centuries, people of higher socioeconomic classes commonly visited higher developed countries to receive care for their medical ailments. Their journeys are much more expensive than an ordinary citizen could afford but with the advent of air travel and a rapid development of the middle class with a larger share of disposable income, many more people are travelling for medical services today than ever before. The propagation of medical tourism is exacerbating the divide in quality of care in developing countries. As private hospitals primarily attract international patients, they attract more doctors with higher salaries and benefits paid for by medical tourists’ bills. This develops a positive feedback loop that continues to neglect the care of the poorest patients who need the most advanced care and rely on public hospital systems that are already overburdened. Rather than focusing on bettering the care of public hospitals and working for the native populations, private hospital systems and governments encouraging medical systems are further dividing the health gap between socioeconomic classes and contributing to health inequity.

Discussion Questions:

What are some ethical issues developed by private healthcare systems motivated by financial incentives?

• How can medical professionals in our country educate patients about the risks of medical tourism?

 

Global health disparity is apparent in the care of pregnant individuals, with 94% of all maternal deaths occurring in low and lower-middle-income countries. A leading cause of maternal and perinatal mortality in these regions is hypertensive disorders of pregnancy, especially pre-eclampsia and its spectrum of diseases. Crucial to the screening and diagnosis of these disorders are regular antenatal care and assessment of risk factors, such as advanced maternal age, obesity, diabetes, and existing hypertension. For pre-eclampsia and eclampsia, the WHO has released evidence-supported recommendations for both preventative measures, such as calcium supplementation in areas with low intake, and treatment, such as using magnesium sulfate over other anticonvulsants. In low resource settings, some of the barriers that hinder the care of pregnant individuals with hypertensive disorders are a shortage of specialty-trained healthcare workers, inadequate transportation to healthcare facilities, limited antenatal care, and traditional cultural practices. While much work still needs to be done in tackling many of these challenges, especially in improving basic obstetric emergency treatment at primary community settings, innovative strategies such as task-shifting to train community health workers (CLIP initiative) in providing regular antenatal care and community cost-sharing schemes to eliminate financial barriers to obstetric care in Mali have been shown to have positive outcomes.

Discussion Questions:

· What other non-health related barriers may contribute to maternal mortality?

· What roles can emergency services/emergency medicine physicians play in improving the outcome of obstetric emergencies?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings, the next of which is taking place November 8th, 2021.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Brian Elmore, MS4

Brian Elmore, MS4

Medical University of South Carolina

Jai Shahani, MS2

Jai Shahani, MS2

Rutgers New Jersey Medical School

Luxi Qiao, MS4

Luxi Qiao, MS4

Washington University School of Medicine

Sources:

  • Mukherjee, Joia. “Chapter 1: The Roots of Global Health Inequity.” An Introduction to Global Health Delivery: Practice, Equity, Human Rights, Oxford University Press, New York, NY, 2018.
  • Mutalib, Nur & Ming, L C & Yee, Esmee & Wong, Poh & Soh, Yee. (2016). Medical Tourism: Ethics, Risks and Benefits. Indian Journal of Pharmaceutical Education and Research. 50. 
  • 261-270. 10.5530/ijper.50.2.6.
  • http://ijper.org/sites/default/files/10.5530ijper.50.2.6.pdf
  • WHO. Maternal mortality evidence brief, 2019.
  • WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
  • Fournier P, Dumont A, Tourigny C, Dunkley G, Drame S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 2009; 87: 30-8
  • von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. Maternal-Fetal Medicine 2021; 3(2): 136-50.
  • Firoz T, Sanghvi H, Merialdi M, von Dadelszen P. Pre-eclampsia in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2011; 25: 537-48.
  • Milne F, Redman C, Walker J, et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005; 330: 576-80.

 

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs," in International Emergency Medicine Education Project, November 1, 2021, https://iem-student.org/2021/11/01/health-equity-medical-tourism-and-maternal-mortality-in-lmics/, date accessed: December 4, 2021

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