A Pasante Life: following a first year Mexican physician during their social service year

It’s 8:45 PM in rural Chiapas, Mexico. A cool blanket wraps around the previously warm day in the small farming town of Honduras. With a syringe of medicine in his front pocket pasante Dr. Ivan Martinez does a steady jog up a steep hill to see about a patient’s chronic pain. Nestled into the Sierra Madre Mountains there are few flat places. As we’re nearing the top of the hill he gives me a summary of the patient’s history and how he’s approached the case so far. At the door he’s immediately and warmly greeted by four of the patient’s family members. They are each eager to provide Dr. Martinez with a different perspective on the patient’s illness. He hears from everyone as he does an extensive physical exam. Around twenty minutes later a decision is made and the medicine is administered. We quickly drink a sweet coffee the patient’s wife had placed at the patient’s bedside. Dr. Martinez has been thinking about dinner for a couple hours now, but he also needs to secure a projector from the local 7th Day Adventist pastor. He is planning to invite the community for a movie night. He’s hoping to show a film that might facilitate discussions on mental health, a major contributor to local morbidity. An hour later with projector secured and a couple “mini consults” completed he takes a breath, “Cenamos (dinner)?”

This is the day to day of a pasante who has reached the halfway point of his social service year. While responsible for the entire town’s healthcare, he has only been Dr. Martinez for about 6 months. As a safety-net in the Mexican healthcare system first year physicians are placed at rural locations without otherwise easy access to a doctor. For most patients pasantes are the entry point to all medical care. While, Dr. Martinez’s ultimate interest is in psychiatry this year he is managing everything from pregnancies to Parkinson’s disease. Referrals to specialists are possible but are also difficult and expensive. This means that patients are managed locally whenever he can. There is a single room in the clinic with three shelves of medicines to choose from. At least half of these are not the standard government supply but are supplemented by the Partners In Health (PIH) affiliate Compañeros En Salud (CES).  Despite the limitation in options the treatments are frequently adequate and simplify many visits. This can be helpful with so many patients to see and most decisions left only to Dr. Martinez. It is a stark contrast to first year physicians in the U.S. who have heavy supervision, with exhaustive options on treatment, laboratory testing, and consult teams. While at times it would be nice to have more help, there is an empowerment to the sole responsibility of a patient’s care. It is clear that Dr. Martinez is this community’s physician.

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Dr. Ivan Martinez walks back to the clinic with a father and daughter while discussing their recent illness. Impromptu consults are common.

As Dr. Martinez makes his way through Honduras some may wonder if he is also running for office. At over six feet (a foot taller than most patients) he stands out and rarely misses an opportunity to offer a broad smile and conversation to the many patients we pass going to and from the clinic. Frequently, he is securing medical and dinner appointments simultaneously. Like many pasantes Dr. Martinez lives with a local family, but gets his meals at various homes in the community. He says all of this interaction helps him to know the complete picture of the patient. With multiple generations living on the same street or under the same roof he often doesn’t need to take a family medical history. As one observes these interactions it is hard not to be reminded of the romanticized picture of the old country doctor. Yet his job has significant challenges. Aside from his lack of experience his patient population also confronts him with poverty, insecurity, and varying levels of education. More than 75% of the population earns under $5 a day. Most patients walk to appointments or have limited access to transportation. Some are close but others live miles away. He has to close the clinic at some point in the evening but it is difficult to tell some patients to come back another time.

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While Beautiful the Sierra Madre mountains offer serious challenges for patient transport and the delivery of emergency medical services.

In high resource settings physicians are now being trained to be more cost conscious. This means more thought in regards to the tests and procedures they order. They are trained to ask themselves why they are ordering a test or procedure and how the result would change management.  For pasantes this thinking extends far beyond making sure tests are clinically relevant. At times the questions and answers are sobering. A young mother’s symptoms suggest a potential aneurysm in the brain, a condition that can be rapidly fatal. The diagnostic approach is an emergent head CT scan. Yet several steps lay ahead. The closest CT scanner is five hours away. Perhaps if he can get the patient to the closest centro de salud (a slightly bigger clinic) he can transport the patient in their ambulance. Someone from the community secures a car and after making it the centro de salud the question becomes if the family will be able to pay for the CT scan. It is pointless for the one ambulance in the community to be used if they ultimately can’t pay for the scan. As family members are on the phone with friends and relatives scraping together these funds the pasante starts to think what if we do find an aneurysm? Will there be a neurosurgeon and funds to repair it? If not why are we asking this family to pay for a scan? All the while uncertainty of the patient’s diagnosis remains.

Dr. Martinez does have some resources others pasantes do not. As a member of Compañeros En Salud he has more medication options, access to electronic clinical resources like Uptodate, and can provide logistical resources for those who need to travel for more complicated treatments such as continued cancer care. Additionally, he has educational sessions and occasionally in person help from fellows and residents visiting from institutions in the U.S. This extra opinion can help with revision of tough cases and offer a break from solo decision making. He said it took about three months to get comfortable in his role, which is interestingly about the time many U.S. first year physicians start growing into their role as interns. Perhaps his most valuable resource are the acompañantes. Largely members of the local community these individuals follow-up with patients in their homes, review medications, and often identify barriers to the patient’s care. They also help patients navigate the referral process.

The following day as the sun leaks through the cracked doorway of the town meeting hall a handful of patients begin gathering. They have come for Curso de Triángulos, a group therapy session that is part of the care for patients suffering from depression. In addition to pharmacologic treatment given in clinic the courses are designed to provide both therapy and a confidential community support group for mental health. Some are more vocal than others but Dr. Martinez manages to get everyone involved. Today he has placed four pieces of paper on the ground with the words situación (situation), pensamiento (thought), emoción (emotion), and acción (action). Patients physically walk through these aspects of an experience they’ve encountered. They process how their happiness is influenced by not only the event but their own reaction.

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At Curso de Triángulos patients complement pharmacologic therapy with group based support and exercises.

Through this process of slowly walking through a problem together they gain a deeper understanding of themselves and form a greater level of support for each other. This exercise mirrors the relationship of the pasante and the community. While imperfect at times the relationship is a close one built on many steady visits together both inside and outside the clinic. The pasantes guide the health care of the community and the patients guide the pasante’s learning. In a few months Dr. Martinez will move on and these same patients will walk again with another newly minted physician. Their health and the physician’s growth a partnership.

The New US Administration and Health Care – A Walkthrough

Late last year, I posted part 1 of my commentary of the US election and healthcare.

Since then, a wild array of things have happened. Amidst the chaos, my aim is to explore and explain recent executive orders and how they affect healthcare and delivery.

1) Executive order: “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal”

What’s that all about?

This executive order (signed on the eve of Donald Trump’s presidency, Jan 20th, 2017) essentially suggests that there has been a large economic burden secondary to the ACA. It asks that, wherever possible, all organizations be exempt from enforcing portions of the ACA that could lead to a ‘fiscal burden’.

How does that impact healthcare?

The executive order suggests that a repeal is inevitable. It is unfortunate that the executive order has left everyone, including insurers in the dark. Preliminary talks seem to suggest decentralizing Medicaid and allowing for interstate expansion of insurance in an attempt to create more options.

It seems clear that this order was largely politicized. While the ACA has it’s issues, it is not a clear black-and-white story. The politicized polarized discussion often disregards a number of basic facts.

  • Through the ACA, the number of uninsured has hit a record low.
  • It has allowed for Medicaid expansion with federal support in several states.
  • It granted insurance with pre-existing conditions
  • It allows for children to remain on their parent’s plan until the age of 26.
  • One harsh piece of criticism is that the number of options in the open market has declined, leading to the notion that health care is not affordable.
  • While premiums and deductibles have increased, reports suggest that they are not as high as the rate of increase prior to the ACA.

On a related note, the new administration pulled all the ACA ads (including ones that were paid for in full) due for the last week of open enrollment. In response to this, a gofundme account was created to help put some of these ads back up. This led to a decrease in the number of people who enrolled through healthcare.gov.

What’s the big deal?

Programs such as Masshealth receive significant federal support.  I fear that these planned changes will result in destabilization of Masshealth and similar programs. Although it may offer more options for coverage, it is unlikely to offer ones that are in the best interests of patients.

Unfortunately, I’m left with beliefs instead of facts, as, we don’t have any solid proposed plans to allow for educated opinions. It is disturbing that the current administration believes in limiting current healthcare without offering a meaningful replacement.

2) Executive Order: “Protecting the Nation from Foreign Terrorist Entry Into the United States”aka The Travel Ban

What’s that all about?

This ban [signed Jan 25th, 2017] called for a 90 day ban on legal immigrants from seven predominantly Muslim countries and a 120 day ban on refugees.

How does that impact healthcare?

This ban affected ~60-100,000 individuals. It has the potential to affect ~10,000 practicing physicians who went to medical school from the seven named countries, 1800 current residents and fellows. The ban, along with the administrations comments of prioritizing Christian refugees over Muslim refugees is troubling. Not only is it founded on unconstitutional principles of discriminating by religion, it sets a bad precedent for the future under this current administration.

Further data, suggests that ~20-30% of the US medical workforce consists of immigrants.

What’s the big deal?

Limiting, or discriminating against certain sects of legal immigrants causes untold harm and fear among the immigrant population, and, will likely affect mental health.

Most underserved and rural areas receive care from immigrant health care workers. Recent data also suggest similar, if not slightly improved outcomes for patients treated by international medical graduates. Reducing the immigrant pool of healthcare workers, or, threatening them with travel bans, will disproportionately affect underserved and rural portions of America.

3) Presidential Memorandum Regarding the Mexico City Policy

What’s that all about?

The Mexico City Policy memorandum [also known as the ‘global gag rule] is a policy that prevents US federal funding for Non governmental organizations that provide preventive medicine services that include offering abortions or referring patients to centers that perform abortions. This time, unforunately, it was expanded further to block all global funding, affecting up to 9.5 billion dollars [instead of the previously reported 600 million USD of foreign aid]

How does that impact healthcare?

Regardless of your personal beliefs, it is scientifically proven that abortions are necessary in varying circumstances, and, when performed under medical supervision, reduce the risk of illegal abortions [which amount to increased maternal infections and death].

What’s the big deal?

The global gag rule is an unfortunate political policy that adversely affects millions of vulnerable women, as, it also bans resources allocated for all other services provided by NGOs that have some association, however loose, with abortions. It can only serve to widen inequity to satisfy political agenda.

4) Federal Employee Hiring Freeze 

What’s that all about? 

On Jan 23rd, it was announced that there would be a federal hiring freeze, effectively ceasing all further federal employment [“except for the military”].

How does that impact healthcare?

It appears that this wasn’t well thought out, as, it brought up major concerns over the functioning of VA Hospitals.

  • Patients were worried that they would have long wait times to see health care providers.
  • Hospital staff were worried that they would not be able to sustain or improve health care delivery.
  • Training programs and residents were concerned about their future ability to work at VA’s, given that they are employees that have annual contracts.

Should we still be concerned?

Thankfully, on Jan 27th, Robert Snyder, the acting Secretary of Veteran Affairs, signed a memorandum, essentially acknowledging that an exemption should apply for the VA.

With regard to medical training, he specifically wrote “Given the critical role that VA plays in training the Nation’s health care providers, the above exemptions should be interpreted in a way that does not disrupt ongoing health profession training programs and residencies within VA.”

Bottom line, exceptions to the federal freeze will apply to the VA Hospital for a number of positions, including medical officers, physician assistants, nurses, pharmacists, physical and occupational therapists, all health profession training programs [including residents], and a number of allied services and essential staff.

Surprisingly, I was unable to find attending physicians of varying subspecialties on the list of exceptions. I presume that they are included under the title of Medical Officers, but, that remains to be seen.

In addition: Here’s a link to brief excerpts of the President’s conversation with pharmaceutical experts. Although it suggests a poor understanding of drug development, I appreciate his call to reduce drug costs, especially given the recent increased price of Narcan to 4500 dollars.

To sum up,

The way things are going, we will have an increase in inequity internationally due to the global gag rule, and, will likely have wider gaps in coverage among the most vulnerable members of American society.

It is up to us to continue to voice our concerns, as medical professionals; committed to healing and to reducing inequity. 

 

Refugee Health and History

I have been fortunate to work at Boston University Medical Center, a true global medical experience,  for the past ~3 years.  One unique aspect of my training experience has been my time within the refugee clinic.  We provide both, a basic health assessment for refugees who recently immigrated and an initial primary care visit for their complex social histories (trauma hx, psychiatric hx, immigration hx, etc.).  FYI – current CDC guidelines for the medical screening of newly arriving refugees

Now building on my exposure within the refugee clinic and given the current state of our geo-political climate, I thought it would be prudent to look at the history behind refugees in the US.  Now this blog post is not (entirely) meant to spark a discussion on immigration or nationalism but more just to enlighten one on how we have gotten to the current state of affairs.

***Disclaimer *** – The history and formation of refugee law is probably a topic one could spend a lifetime reading on/learning about.  Thus, I do not intend to even graze the surface of all that can be said, but  I merely am looking to learn and share some of the information I found while personally reading on this topic. ***Disclaimer ***

Definition of a Refugee

UN 1951 Refugee Convention set the initial definition: “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.”

1946 – IRO and WW2

The first “refugees” to enter our country were organized by the IRO – International Refugee Organization  –  a division of the United Nations created in 1946 to deal with the “problem of refugees and displaced persons created by the Second World War and its immediate aftermath.” Looking back these refugees were mostly Europeans and certain estimates say that around 250,000 to 400,000 Europeans came to the United States during that time period.

UNHCR in 1951

Then as the IRO disbanded, the United Nations High Commissioner for Refugees (UNHCR) was created in 1951 at the UN General Assembly during its fourth session under resolution 319. 

UNHCR.png

Initially the UNHCR was created on a short term basis to deal with the crisis post world war 2 as an extension of the IRO.  However, as time passed more and more issues arose which lead to the continuation of the organization.  For example, in 1956 the Hungarian uprising, as a result of the cold war, lead to upwards of 200,000 refugees fleeing to Austria and Yugoslavia.

Expanding the Definition – Africa

In the 1960s as countries began industrializing and expanding, many colonized nations faced growing internal uprisings, specifically in Africa. This lead to an increasing number of refugees in those regions.  During that time, the Organization of African Unity convention expanded on the definition a refugee to include “to persons forced to cross national boundaries because of ‘external aggression, occupation, foreign domination and events seriously disturbing public order in either part or the whole of their countries of origin or nationality.”

1980The Refugee Act of 1980 

Finally, as a response to the large numbers of displaced people during/after the Cold/Vietnam wars (respectively), the US passed The Refugee Act of 1980.  This created the Office of Refugee Resettlement within the US government, which standardized the resettlement process for refugees entering the USA. Furthermore, the law set a soft cap (#hospitalist) on the total number of refugees allowed to enter the country in a given year.

This table from the US State Department breaks down the US admissions of refugees by year and by region from 1975 to 2015.   Of note, before the enactment of the refugee act of 1980 – we had upwards of 200,000 refugee admissions.  To the other extreme, our lowest number of refugees admissions came in 2002 (just after September 11, 2001).   It will be interesting to see how these numbers change with the new presidential administration – given that Trump won with a nationalist platform.

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Reflections and Observations:

  • As the definition appropriately states – the boom and bust of refugee resettlement lies in the instability or stability of our geopolitical or social climates.
  • The definition of a refugee has evolved.   Initially defined as those who are under internal pressures (for a myriad of reasons) to leave their country to those who are undergoing external pressures (“foreign domination”).
    • My time in refugee clinic has really enhanced my understanding of these definitions as I have gotten first hand stories of persecution from both types of pressures
  • One surprising observation is that the global conflicts, which cause great divisions among countries, have actually lead to an increase in flow/support for refugees. Countries seem to mobilize together and create greater resources for refugees to resettle and be safe
  • The refugee act of 1980 created a standard annual number of refugee admissions that has slowly become the target goal. In addition, as can be observed in the graph above, the variation in yearly refugee admission numbers has significantly decreased.

Looking at the current state of affairs

The UNHCR has some astonishing figures and statistics on their website.  The graphic (below) and link could probably be covered in another blog post – so I will leave you with it to mull over.  Overall, my big picture takeaway is that this problem (refugee resettlement) has skyrocketed into a whole new problem.  Thus, we must adapt again and create a new more realistic inclusion system for this vastly growing population.  However, in lieu of the nationalist movements across the globe, I am fearful that the international response will not favor refugees. Time will tell.

Jan GH Readings

As we approach the Trump inauguration, there remains little news about his approach to foreign aid – the first article featuring words from Newt Gingrich is not reassuring, but I think the nature of Trump approach remains quite uncertain. The second explores what might happen based on the Heritage Foundation’s prior publications.
This series of articles on UK foreign aid discusses a likely attempt by the new government to reduce foreign aid – the UK being one of few countries that have managed to hit the 0.7% of GNI target for development aid that was previously arrived at. The first, an editorial from the director of Oxfam-UK, lays out guiding principles for improving UK aid going forward – notably not including marked budget cuts.
It does not seem farfetched that the more nationalist governments in the UK, US, and potentially other European countries later this year will broadly act to reduce foreign aid, despite it constituting a relatively minor (1-5%) portion of budgets for most countries.
On a more positive note, this was a very interesting idea for slow-release medications, one that I could readily seeing being used for a number of infectious conditions, and one that would greatly simplify adherence for low-resource settings.
So at least a positive note to end on.
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Choosing Charities

I’m often asked during the holidays by friends or family what charities they should direct their annual donations to, given my own involvement within the world of global health. While I won’t put myself forward as an expert, I have spent quite some time thinking about the topic, both in terms of my NGO and in terms of where I direct my own donations.

I broadly divide charitable donations into two approaches – those aimed at a specific cause, and those aimed at doing the “most good” in the world. I think both have a role to play, and I divide my own donations between the two.

The latter, utilitarian approach to donation is championed by a movement called Effective Altruism that has sprung up over the last decade or so. Proponents include Peter Singer and Thomas Pogge, and a primary organization is Giving What We Can, which encourages people to pledge a proportion of their income towards highly effective charities (disclosure: I have taken this pledge, though I’m not very active in the group). The rationale here is that $100 spent on malaria prevention in sub-Saharan  Africa can prevent a number of cases of malaria, potentially even a death, while the same $100 spent on providing shelter to the homeless in Boston will likely only provide coverage for 1-2 individuals for one night. Does this mean we shouldn’t support the underserved closer to home?  Of course not…but it does raise questions about where the best place to spend our charitable donations is. GiveWell is an organization associated with this movement that rates charities both by impact (how much mortality/morbidity saved per dollar spent?) as well as capacity (can they spend more dollars to the same amount of impact?), as well as the usual criteria of fiscal responsibility and transparency.

This approach does great at capturing the impact of programs rolling out disease-specific interventions – often termed “vertical” programs – but has a lot more difficulty capturing organizations that do advocacy (potentially releasing more funds from governments or forestalling global crises like climate change) or “horizontal” programs that strengthen overall health systems (such as Zanmi Lasante in Haiti).  Too, there’s something to be said for supporting your local community, whether it is groups working in your neighborhood or charities that your friends volunteer for. So while I appreciate the importance of thinking about the impact different charities provide, I don’t take a hard line and think of this as the only criteria to consider.

Ultimately, giving money to help others is a beautiful practice, and I’m broadly happy if friends or family do it at all – when you look at what anyone reading this post has relatively to many of our fellow humans, it is a small gesture indeed to give something away.

I do think that diversifying your charity portfolio makes sense, and personally give about 60% to GiveWell charities that provide high-impact interventions (my charity bonds, with a known, good return on donation), about 30% to groups doing advocacy work (my charity stocks, with a potential for marked return but also for marked failure), and 10% to groups associated with friends or emotional connections (where donation is less about impact, and more about supporting those I love).  As the holiday season moves forward, I encourage everyone to consider their own approach – and, as always, do some basic research on any charity you’re giving larger amounts to to ensure they have appropriate transparency of their finances and appropriate distribution of funds into programs (CharityNavigator and CharityWatch are two I use).

 

 

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Cooking-up Social Movements

I’ve been thinking a lot lately about what drives issues into the American  conscious. Why do people care so deeply about certain issues while ignoring others? What drives dramatic social change? To be clear I am not speaking about a social media phenomenon that captures the internet for a few months like the Ice Bucket Challenge or Stop Kony 2012. These campaigns were enormous by viral internet standards and had some real consequences. Yet today they are simply echoes of internet legend. In global health HIV stands out as the modern standard for an effective social movement. HIV mobilized everyone from small communities to corporations to governments. These were efforts that often crossed political and ideological barriers. Despite this success (which continues to be imperfect) the global health community often struggles to advocate a message that resonates to the wider population. There is an undeniable and immoral level of inequality in healthcare, but how do we form a greater social awareness. What are the ingredients that one needs to cook up a batch of social change this holiday season? After looking at several social movements over the past few months I had come up with my own recipe:

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I was unimpressed with my first few batches. Something was missing. Therefore, I went in search of a master chef. I came across lectures from Stanford sociology professor Doug McAdam who explained through the lens of the civil rights movement that it is not as simple as the ingredients in the recipe. Successful social movements understand circumstances and take advantage of other currents in flowing society. In other words, selection of one’s ingredients in the right season can mean as much as the ingredient list itself. In the lecture below Dr. McAdam explains how the cotton industry, a diverging Democratic party, stubborn sheriffs, Russia, the Cold War, and savvy leaders who knew how to strategize through all of it led to the successes of the civil rights movement. Recognition of factors affecting how we can mobilize for greater health equity will be critical to our social movement.

Have your own favorite dish? Share your ingredients for a successful social movements below.

Breast Cancer Screening in a Global Context: The Security of Early Detection and the Inequity of Implementation

One of my family members was recently diagnosed with breast cancer. A few days after her diagnosis, she sent me her pathology reports. They said that her cancer was ductal carcinoma in-situ, invasive, high grade (grade 3), estrogen positive, and HER2 positive. I’m certainly no oncologist. Most days I’m really just trying to wrap my head around general medicine. But it sounded like her cancer was potentially an aggressive one. That night, I got on my computer in attempt to educate myself about her pathology. Her cancer was in its early stages, but the fact that it was high grade meant it could spread quickly. The ER positivity was a good thing, but the HER2 positivity meant that she would probably need chemotherapy. I was certainly scared. But I was also relieved because it was detected early on. Because of that, her prognosis was good.

In contrast to my family member, for other people in many other parts of the world, there’s no such thing as the security of early detection. The statistics reflecting this are somewhat staggering. Breast cancer is the most common cancer in women in both in the developing and the developed world. However, the differences in survival rates are profound – 80% in North America, Japan, and Sweden, 60% in middle-income countries, and 40% in low-income countries.1 Both late disease presentation and lack of access to diagnostic and therapeutic options contribute to this dismal disparity.2

The conundrum of access to screening and treatment is certainly not new to global health. The Breast Health Global Initiative has opted to tackle the issue by creating a set of four recommendations for breast cancer screening and treatment based on the level of country resources. Below is a table that walks through the different “levels” and the types of tests and treatments recommended for each.

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Table adapted from Yip et al “Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries.”

As I read through this table, what struck me was the stark difference between the clinical implications of these recommendations. A clinical breast exam has a sensitivity of 54%. In contrast, mammograms are the only screening modality shown to reduce mortality of breast cancer. They have a sensitivity of 85%. The different sensitivities of these two tests translates into significant diagnostic and therapeutic outcomes,  the most significant one being that it’s much more common for women in low and middle income countries to die from breast cancer.

At first glance, the BHGI recommendations seem inherently inequitable. The WHO defines equity as the “absence of avoidable or remediable differences among groups of people.” This definition begs the question of whether or not the differences in the BHGI recommendations are in fact avoidable. One of their main goals is to create guidelines that are feasible for countries to carry out. This is certainly a step towards equity, but it is far from equitable. Women in high resource settings have the security of early detection, while women in low resource settings simply become more aware of why early detection is important.

In low and middle-income countries, breast cancer is becoming more common. This is thought to be from multiple factors, including changes in dietary habits, childbearing patterns, and exogenous hormone exposure.3 With this trend, we would be remiss to not continue investigating how to make the BHGI recommendations truly equitable and to give all women the opportunity to seek timely treatment that will allow them to survive breast cancer.

  1. WHO: Breast Cancer, Prevention and Control. http://www.who.int/cancer/detection/breastcancer/en/
  2. Anderson, BO et al. “Breast Cancer Issues in Developing Countries: An Overview of the Breast Health Global Initiative.” World J Surg (2008) 32:2578-2585.
  3. Yip et al. “Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries: Early Detection Resource Allocation. Cancer. October 15, 2008/Volume 113/Number 8.
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