Letters to the Editors

NewsShare useful and informative

Dear Editor:

I found the on-line NewsShare publication to be easy to use and informative.

It would be really great if the Society could produce position papers on various topics and then publish them in the Journal and mention them in NewsShare.

Topics for position papers that haven’t already been done could include:

• consensus on preventive measures for altitude sickness;
• indications for rabies pre-exposure prophylaxis,
• antimalarial prophylaxis (despite the data, I find it harder and harder to use mefloquine for shorter trips).

It would also be most useful if we could generate a list of countries where antimalarials are available OTC or per MD’s prescription, and at what cost.

For example, I just got a call from a traveler in Cambodia who said that Malarone could be bought OTC for 50 cents a pill. Others have told me that Mefloquine is available in Ecuador and in some other countries for 19 cents a pill, and ditto for chloroquine in Mexico. Obviously, it would be very important to know if such medications are equivalent to ours, i.e. trustworthy.

It would also be very interesting to know why we have to pay such exorbitant prices for these drugs in the U.S. I sometimes have to prescribe mefloquine when I would like to use Malarone, because of cost. If any of your readers have any information or comments on these subjects, I would like to hear from them..

Thank you for the good work. This society is the most useful one I have belonged to.

Kathryn Love, MD, USA

Medical Tourism – Treating patients for their good – or your own?

Dear Editors:

We are expatriate doctors living at 3900 meters in the Mount Everest region of Nepal and running a health care system serving a population of 10,000. The area is remote, mountainous, and roadless, with the villages scattered along high valleys. Over the past 32 years a health system of one hospital and eight health clinics has been established so that most residents are now within an hour’s walk of a clinic or hospital.

The area is popular with tourists. Last year 19,000 visitors came into the Sagarmatha National Park where Mount Everest, the hospital, and five of the eight health clinics are located. Inevitably, there area many doctors and other healthcare professionals among them.

Although the presence of the hospital is well publicized, many doctors touring the area hold ad hoc clinics along the trail. They often conduct their clinics just 100 yards from the local villages’ health clinic. At a time when we are developing the skills of the local resident health workers and increasing the confidence that the local people have in them such misdirected good will undermine progress in the existing health system.

It is inappropriate arrogance to assume that anything that a Western doctor has to offer his less developed neighbor is progress. These tourists are often working outside their trained specialty or have little concept of how that specialty applies to Nepal. They frequently don’t understand local illness presentation, culture, or language. They often offer inappropriate treatment because they think they “must give something.” Such consultations provide little possibility for follow up and the local health providers are left to pick up the pieces with no record of the consultation. If an unregistered Nepali doctor on holiday in the United Kingdom offered general medical consultations in a shopping center there would be a public and professional outcry. The problem is extended when applied to nurses, paramedical staff, and medical students.

Furthermore, legally these doctors are on difficult ground. The Nepal Medical Council is striving to develop and maintain a professional body and requires all doctors who practice in Nepal to register with the council. For certain services, such as family planning, practitioners are required to have Nepali training certificates. This is setting a standard of medical professionalism that is required and respected in the West, so it should be respected in Nepal.

We are seeing the development of medical tourism/exotic travel to a developing region with a brief opportunity to practice medicine on local residents. This seems to occur on two levels. Firstly, doctors travel independently to areas that seem to have no system of health care and, while there, perform good acts. We see this regularly with trekking doctors who give residents short courses of antibiotics, which is fine until you consider tuberculosis control and resistance. Recently, a chest physician gave one of our long term psychiatric patients an injection, but we don’t know what it was. On the other hand, the acts performed in a life or limb threatening emergency are justified, but there should still be follow up with the nearest local provider.

The second level, which is more alarming, is the development of adventure holidays sold to groups of doctors specifically for the purposes of research or providing health care. The most recent example was an American group of two subspecialists and a selection of house officers and medical students who actively sought out patients along the trail without making any prior contact with the hospital and health posts along the way. They brought an ultrasound machine and a microscope. Can you realistically treat chronic disease after a single consultation? But working with the senior doctors we might have used the equipment and instruction with lasting benefit.

Medical work overseas can be constructive. It takes little effort to find out what health care exists in an area and for doctors to work with or refer to the local system. For more long term work there are numerous agencies in industrialized countries which recruit doctors to work in developing countries.

A fundamental principle of medical training is “first do no harm.” If as a doctor or other health care professional you cannot resist the lure of medical tourism and insist on the casual or opportunistic treating of local residents, consider whether you are treating the patient for your own good or for theirs, and whether your actions may actually do more harm than good.

Rachel A Bishop and James A Litch,
Codirectors and Physicians,
Kunde Hospital, Solukhumbu District, Nepal
(This letter first appeared in the BMJ- the British Medical Journal. It is reprinted here, with permission.)