Primary care is the missing link in global health

Sitting on a dusty wooden bench in the rural Sacred Valley in Peru with the Andean mountain range serving as a scenic backdrop, it dawned on me that I was the first physician that my 43-year-old Peruvian patient had ever seen.

After treating his acute diarrhea, I was faced with his elevated but asymptomatic 162/89 blood pressure. I knew he needed treatment, but my concern was whether or not to start him on a blood pressure medicine without follow up. Medications often need to be titrated, and side effects need to be monitored.

What if he was exquisitely sensitive to the anti-hypertensive meds thus causing hypotension and light-headedness? What if he couldn’t afford the medicine in the long run and thus abruptly stopped it and developed rebound hypertension? Why give a month supply of medication if he will not have access to them after I left Peru? A low-dose anti-hypertensive probably would not be unreasonable; however, as physicians we must also remember to “do no harm” and at least consider the potential consequence of each action. This would be a straightforward and reflexive decision in the United States, but not here in rural Peru.

That was my first day participating in the Peru Health Outreach Project (PHOP) this summer, an annual medical mission organized by Cleveland Clinic and Case Western Reserve University medical students.

The following week, I left the Sacred Valley and traveled with others of the PHOP group to collaborate with the Peruvian American Medical Society in the Peruvian city of Chincha. Here I had the luxury of being at a clinic where I could start an anti-hypertensive with the comfort of knowing my patient had access to follow up. However, I soon realized that even here at this fantastic clinic with full-time generalists and specialists there was a significant challenge treating chronic diseases.

I distinctly recall asking for pulmonary function tests and a basic non-urgent EKG on a patient to assess for suspected lung and heart abnormalities. The director of the clinic responded by stating that those services were not available at this time and that I should “treat them like you are at war.” In other words, resources are scarce, and the priority is to focus on acute issues .

I’ve never been in war, but I imagine you’re not worried about keeping blood pressure below 140/90 in a hypertensive patient or controlling a diabetic’s blood glucose levels. Clinically, this patient had stable angina requiring at least aspirin therapy, but she complained of epigastric burning. What if I gave aspirin and it triggered a life-threatening gastrointestinal bleed from peptic ulcer disease? Again, I may be causing more harm than good.

When people think about the global health gap it is thought of as the disparity between rich and poor. The gap that I was witnessing in Peru was the missing link between acute care and prevention – a lack of primary care and chronic disease management to be precise.  The global health community has traditionally focused on two aspects of healthcare delivery: acute care and prevention. On one end of the spectrum, acute care is of course a necessity, as urgent problems with potentially life-saving interventions require immediate attention.

In most developing countries, there is at least some larger referral center that a patient can be sent to for an emergent complaint (granted the proximity of this center is rarely to be desired). On the other end of the spectrum, prevention has received an abundance of attention. After all, wisdom suggests “an ounce of prevention is worth a pound of cure.” Prevention is often funded well by donors and is easier to implement and more measurable from a systems delivery perspective than chronic disease treatment. Sticking a needle one time in a patient for a vaccination is easier and cheaper than managing a person’s brittle diabetes for 50 years.

In the developing world, infectious disease and maternal and child health complications have traditionally dominated morbidity. However, our world has changed. Drivers such as urbanization and western influence have led chronic diseases such as diabetes, asthma and coronary artery disease to become the dominant illnesses in the developing world. The World Health Organization expects deaths from non-communicable disease to continue to rise, predicting a 15% increase this decade. It is expensive to treat chronic diseases, and sadly this means that the poorest countries will have the most difficult time bearing such costs.

In an ideal world, we would be able to prevent diseases before they start. “Ideal” is the key word. In the U.S. or any other developed country nobody has been able to achieve this goal, so how can we expect to do the same in resource-scarce settings?

Chronic diseases are inevitable and here to stay in global health, but the challenge with managing chronic diseases is the burdensome cost and effort to treat. It is reasonable to teach a volunteer community health worker with minimal medical knowledge to hand out a pill or condom. However, expecting them to identify symptoms or monitor for side effects of medications is not realistic. Treating chronic disease means creating a workforce with real medical training and knowledge of disease, creating a robust primary care infrastructure, providing sustainable access to essential medicines and integrating innovative technology to adjunct the process and decrease costs.

Fortunately there is hope. Prominent leaders such as Paul Farmer and his organization Partners in Health are tackling these issues. They have rigorously trained a cadre of community healthcare workers to treat these diseases, and they developed an outcome-based delivery system to coordinate and monitor care. Organizations such as Toronto’s University Health Network’s Centre for Global eHealth Innovation are creating mobile apps to interface with blood pressure and blood glucose monitors. Steps are being made, but much more work must be done to penetrate every global village.

Each medical mission I have participated in has been an incredibly rewarding experience. While I know I am helping, the bottom line is that people need a primary care system that provides follow up, which I, as an outsider, simply cannot provide during a short trip. Developing countries and those of us interested in global health development must consider how to help create these chronic disease management systems before the primary care gap grows wider.

Vipan Nikore is an internal medicine resident physician and the President and Founder of the youth leadership non-profit Urban Future Leaders of the World (uFLOW).

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