The United Nations has made global public health a top priority. At April's anti-AIDS summit in Abuja, Nigeria, UN Secretary-General Kofi Annan spelled out what is needed in order to launch a serious attack against AIDS, malaria, and tuberculosis: at least $7 billion per year. The initial $200 million that President George W. Bush has offered to kick in is not nearly enough, but it is a start. And so is the recent political pressure for pharmaceutical companies worldwide to lower their prices--particularly for AIDS drugs--in third-world countries.
While this is a salutary set of developments, containing an epidemic requires more than money and discounted pharmaceutical sales. It is an enormous medical, political, and social challenge. If Western public-health strategies are not carefully conceived--and if they do not take into account practices in developing nations--they could end up causing more problems than they solve.
Indeed, if there is one thing AIDS has taught us, it is to be wary of interactions between medical technology and local sociocultural factors. As the journalist Edward Hooper argues in his exhaustive book The River, while social upheaval, war, urban migration, and changes in social practice in newly independent African nations undoubtedly played an important role in amplifying the AIDS epidemic, the unwitting linchpin in the development of this devastating disease may have been the introduction of modern medical technologies--like hypodermic syringes and blood banks--into a setting where the use of these technologies was poorly understood. Had it not passed through several individuals via contaminated syringes and blood bank specimens, the AIDS virus may never have evolved into a highly infective and lethal pathogen in humans--and it may not have spread like wildfire from continent to continent.
Could such a thing happen again? In a way, it's happening even now: In poor countries, inadequately trained doctors and a lack of drug regulation have led to patients' overexposure to certain antibiotics and thus have rendered treatments ineffective. When common bacteria become drug-resistant, they pose a serious threat not only in low-income countries--where they account for a large proportion of mortality and morbidity (the consequences of disability from disease)--but also in the wealthier Western nations. In a world where the economy of most countries is critically dependent on international trade and travel, infectious diseases can quickly assume global proportions. Microbes do not respect national boundaries. Thomas Monath, a "virus hunter" at the U.S. Centers for Disease Control in Atlanta, put this in perspective in the cable TV documentary series The Coming Plague, a Time Inc.-CNN production that first aired in 1997. "Unless something is done to get control of the way we use antibiotics," Monath warned, "we are going to have an absolute disaster." And that "something" will require not just a general understanding of the way policy and practice intersect in the world of public health but an intimate knowledge of local processes in the remotest of villages.
Medicine Men
I gained some personal understanding of how local medical practices can affect global public health when, in the summer of 1999, I traveled with my brother Jishnu, a graduate student in development economics at Harvard University, to a village in northern India called Salang. We had obtained grants to study illness and delivery of health care there. I was investigating the prevalence of various illnesses in the village, the health care options available to villagers, and how these choices ultimately affected outcomes. While large-scale studies of disease in third-world countries had been published, these were based on surveys and questionnaires, not on direct observation. Because cultural practices play such a large role in the effectiveness of health care, we felt that immersion was the key to understanding. Salang was convenient not only because of its location in the foothills of the Himalayas, away from the searing heat of the plains, but also because of my brother's long association with the village from the time he had helped with earthquake relief several years ago.
When I introduced myself to the headman in Salang, he told me that the villagers had ready access to health care. There was a primary health center (PHC) three miles away and a pharmacy next to it. Three doctors were affiliated with the PHC, and a qualified nurse-midwife provided immunization and prenatal care. Consultations were free. While there were no advanced diagnostic facilities at the PHC, there was a referral hospital 26 miles away with a new X-ray machine, various specialists, and an emergency room. The availability of these services seemed to contradict what conventional wisdom in Western public policy assumed: that a shortage of doctors and medicines was solely responsible for the poor health of third-world villagers.
People who fall ill in villages like Salang may initially try folk remedies. These are widely known, particularly to the village elders, and include practices such as tying a cloth band tightly around the abdomen for belly pain or applying a heated iron tong to an arthritic joint. Ointments concocted from herbs and tree bark may be applied to strains and sprains. By and large, however, patients visit doctors for any illness they consider to be more than trivial.
Of the practitioners available, there are those who have been formally trained in medical schools to practice Western biomedicine and those who use biomedical pharmaceuticals (such as antibiotics and steroids) but have not received any formal training. In addition, there are practitioners of traditional medicine such as Ayurveda (a formalized system based on Vedic scriptures). The phenomenon of untrained physicians is well known in India. In fact, according to a study conducted in the late 1980s by Indian social scientists, they outnumber trained ones by a ratio of 3 to 1. Another study found that 18 percent of the doctors without training were "just literate," 23 percent were formally educated through middle school, and 54 percent were high school graduates.
Dr. Gupta (not his real name) was the most popular of the trained physicians at Salang's PHC. At least two days a week, he was the only doctor there. Just before noon one day, I visited the clinic and found Dr. Gupta seated behind a huge desk. Crowded into his office were about 20 patients: men, women with their husbands, and women with infants. Some 20 more waited outside the room. The doctor motioned for me to sit. "I'm sorry," he said. "Huge number of patients today."
He called out the name of the next patient. A young woman shyly stepped forward.
"What's the matter?" Dr. Gupta asked.
"My stomach hurts all the time," she said.
"Ever had diarrhea in the past, two to three times a day?"
"I think so."
Dr. Gupta listened cursorily with his stethoscope to the woman's lungs, heart, and abdomen. He then quickly palpated her abdomen.
"Liver amebiasis," he said. He prescribed metronidazole and then advised her not to eat beans, rice, or spices.
"How did you know?" I asked him.
"As you can see, here there are no diagnostic tests. One has to rely on the story and what one knows about the diseases that are present here. Her liver was a little enlarged."
Dr. Gupta went through all the patients, spending about three to five minutes on each. For every one of them, he wrote a prescription. Most of the drugs were not available in the hospital pharmacy (where they would have been free), so the patients had to buy them from a nearby pharmacist. In addition, the doctor prescribed injections for about 90 percent of the patients. A two-year-old with a three-day history of cough was given B complex and a gentamicin intramuscular injection--not because the doctor suspected pneumonia, but as a placebo.
"These people think nothing has been done until they get an injection," he said.
The untrained practitioner in the village, 55-year-old Rauthan Guruji, is the principal of the Government Inter College, a high school in Bhatwari. In his younger days, he wanted to be a doctor, but this was not acceptable to his father. Instead, he studied chemistry in college and went on to become a teacher. He had, in the distant past, shadowed a physician in Dehra Doon. From that time, he had kept a meticulous notebook that listed drugs for numerous diseases. A very calm and austere-looking man, with a reassuring and empathizing tone in his voice, he is often approached by the villagers for prescriptions.
Guruji--which means "teacher," a term of respect in local parlance--is undoubtedly a gifted healer in some ways; his patients trust him. Nonetheless, he does not have the education to use the tools of biomedicine properly. His doctoring represents a rampant misuse of antibiotics: Someone with a fever may be given a single injection of amoxicillin; a lack of appetite may be treated with penicillin.
When I spoke with him about treatment of tuberculosis, I discovered that he didn't know that the standard approach is multidrug therapy. He found it puzzling that streptomycin by itself doesn't work as well as it once did. (Although such practice was common in the 1970s, streptomycin is almost never used alone for TB, since the bacterium becomes rapidly resistant if it is the only drug used.) His conclusion: "The treatments in the old days were always so much better than these newfangled pills they come up with these days."
A lack of drug regulation in Salang allows patients easy access to antibiotics that Guruji prescribes. In fact, the pharmacist in Bhatwari--where many prescriptions are filled--sometimes prescribes antibiotics to sick villagers himself. "I have training from pharmacy school," he told me. "So when I see patients with certain symptoms, I know what to give them. So someone with cough and fever is given ampicillin. Of course, if it is more complicated, I tell them to see the doctor." As for how long a course he prescribes, he said: "It depends on how much they can afford. Sometimes I give them a few capsules, sometimes an injection."
Dr. Gupta perhaps has a better understanding than Guruji does of the diseases that they are treating; nonetheless, both doctors use aggressive and inappropriate interventions, such as antibiotic injections. This is downright alarming, considering the fact that disease-causing bacteria are becoming more and more drug-resistant. Antibiotics disrupt synthetic processes in the bacteria that allow bacterial cells to extract nutrients from the environment, manufacture proteins, and replicate. Initially, with the discovery and manufacture of different classes of antibiotics that targeted particular bacterial processes, it seemed that humans were winning the race against bacteria. But many strains have developed with resistance genes, which direct the manufacture of proteins that degrade the antibiotic, prevent the uptake of the antibiotic into the bacterial cell, or alter the bacterial proteins targeted by antibiotics. Curiously, genes that confer resistance in bacteria existed in nature before the first antibiotic was discovered. From the point of view of the bacteria, however, it is advantageous to possess resistance genes only in the face of constant exposure to the antibiotic.
When we take antibiotics, all susceptible bacteria residing within us rapidly perish. This includes both our normal, harmless bacteria and those that cause disease. With a lack of competition for nutrients, surviving bacteria that may harbor an antibiotic-resistant gene keep on multiplying and soon become a dominant part of the population. Every time we take an antibiotic, we provide a selection pressure for resistant bacteria to emerge. If the benefits of the antibiotic outweigh this risk, then we can justify the use of the drug.
But there are a number of additional complications to consider. As Stuart Levy--a professor at Tufts University and one of the foremost researchers in the field of antibiotic resistance--has pointed out, boundaries between categories of bacteria are dissolving. Transferable genetic elements known as plasmids and transposons that often carry genes for antibiotic resistance can jump from one type of bacterial cell to another. So resistance could transfer from harmless bacteria, which may have acquired these elements through previous exposure to antibiotics, to disease-causing bacteria.
Another basic but pervasive glitch is that patients don't always follow directions. Taking only two days' worth of antibiotics instead of the entire 10-day dose may not fully eliminate the disease-causing bacteria. A few remaining bacteria with only a low level of resistance may, through a process called amplification, develop high-level resistance--not just to the antibiotic taken by the patient but also to other antibiotics. This phenomenon, known as multidrug resistance, is a major problem associated with tuberculosis. It's exacerbated when healers like Guruji prescribe one medication as the sole treatment for TB or when patients fail to complete an entire course of antibiotics.
The more time I spent in Salang, the more I was puzzled by two issues: Why did the villagers continue to visit the untrained doctor when there was a trained doctor available free of charge at the PHC? And why did Dr. Gupta treat patients with inappropriate antibiotics even when he knew they would not be beneficial?
Answers to both questions lie in the particular characteristics of health and illness, and in the inability of patients to discern the quality of a doctor accurately. Jishnu and I set up our own clinic in the village. Seventy percent of our patients came to us with illnesses that would eventually have disappeared on their own. But "watch and wait" was hardly the satisfying prescription they sought. Jeet Singh, a tired-looking man in his sixties who was nicknamed "Panama filter" for his cigarette-smoking habit, came to our clinic with a chronic cough that usually produced whitish sputum. I diagnosed him with a viral syndrome, gave him some Tylenol and cough syrup, and told him to return the next day. We saw him two days later. Singh said that he had gone into town to buy tobacco and had stopped to see the pharmacist. He produced from his pocket a couple of capsules of amoxicillin, a few tablets of Analgin, and a few multivitamin pills. "I have pneumonia," he said. "The pharmacist told me so."
It's hard for the villagers to believe that the doctor has done much if no visible action is taken. Any intervention they can associate with a cure is thought of as good doctoring. Likewise, in the absence of intervention, especially in the event of a negative outcome, the doctor is labeled as callous and incompetent. Hence, placebos, à la Dr. Gupta. In India's most rural villages--where there is little if any laboratory backup to confirm a diagnosis made on the basis of the physical exam, and where following up on patients who may live in distant villages without any telephones is next to impossible--patients see drugs as concrete proof of medical intervention.
Also, healers influence one another. The untrained and trained doctors are essentially in competition. Because patients have no easy way to measure the quality of treatment, the trained doctor often prescribes at least as aggressive an intervention as the untrained doctor does. Otherwise, patients are likely to go elsewhere--as mine did on several occasions when I advised rest and hydration but no drugs to patients I thought had viral illnesses.
My conclusions were verified by Jishnu's research, which incorporated findings from the Survey of Living Conditions (a project of the World Bank) and the Weekly Morbidity Data Set (issued by the Institute of Socio-Economic Research on Development and Democracy in Delhi). Using economic analysis, Jishnu found that when patients cannot correctly assess the quality of care they are receiving, they tend to "stay with a winner" and go to providers with whom they have previously experienced cures. If the proportion of self-limited illnesses (those that have a high rate of cure without any medical intervention) in a population is high, patients place too much weight on the quality of the doctor and too little weight on the self-curing nature of the illnesses. Such distortions lead to heavy spending on minor illnesses, a reluctance to switch away from poorly trained providers, and, subsequently, continued inappropriate use of pharmaceuticals by these practitioners.
In the Balance
One of the biggest lessons I've learned is that fighting biomedical battles in third-world countries is a complex enterprise. There's more to it than throwing a bunch of resources their way. Sensitivity to cultural context is essential. In India the traditional concept of illness as an imbalance between two opposing principles, such as hot and cold, was once addressed by local healers. Ulcer symptoms, thought of as too much heat, were cured with advice: Patients were to avoid hot foods and eat cold ones. Relief meant that a balance had been restored. Biomedical drugs were easily adopted into local ideas of disease and cure, as a new means of achieving balance. But the concept of bacteria causing disease or the idea that one might need a full course of treatment--not just enough pills to make the symptoms disappear--doesn't naturally fit into this ideological framework. One villager in Salang asked me to look at his sister's medication because she'd forgotten whether to take the tablets before meals or after. They were drugs for the treatment of TB. "I had been taking them for a while," she said, "but then I forgot them here during my last visit, and since I was feeling better, I stopped taking them for a few months. Lately, I have not been feeling well, so I should take them again."
As Dr. Gupta put it, "Six months is a long time to take medicines, particularly when you have to worry about cultivating land and taking care of your kids."
All of this is not to say that learning about biomedical theories of disease and related therapy does not occur in Indian culture. Progress in urban areas inspires hope. In a 1998 pilot study of health-seeking Delhi families with low income, the Institute of Socio-Economic Research on Development and Democracy found that patients themselves sometimes sought care in TB centers if they had symptoms such as ongoing fever or debilitating cough that had not responded to treatments offered by poorly trained practitioners. In one case, a migrant laborer's wife traveled from her village to the city because she felt that the local doctor was not treating her properly and she suspected that she might have contracted TB. In the city, she was examined in a specialized facility and provided with appropriate multidrug therapy for a period of six months. After she'd followed the course of treatment, she returned for another checkup, at which she was x-rayed, given another physical exam, and declared cured. This case shows that even if patients are indigent, empowering them with knowledge about the causes of disease and informing them about proper therapy can lead to positive outcomes. Unfortunately, the way things now work, many patients learn about the nature of their illness and seek effective treatment only after repeatedly visiting untrained providers and spending a lot of money. And by then, the disease often has progressed to such a late stage that a cure is difficult.
Here in the United States, far removed from villages like Salang, are we in any way affected by the health care practices in third-world countries? Spurred perhaps by medical reports of an emerging bacterial strain that is now resistant to the drug vancomycin--the last resort for treating bacterial infections--the popular press in this country has finally turned its attention to the phenomenon of bacteria becoming resistant to antibiotics. But such attention has focused almost exclusively on the problem here, with little examination of the situation in the rest of the world. History is replete with examples of the perils of such tunnel vision.
In the mid-1970s, for instance, it seemed that penicillin had defeated gonorrhea, one of the leading causes of infertility. But then a new strain of the disease emerged--one that produced an enzyme that could destroy penicillin. This strain rapidly spread throughout the world. Today, all the disease-causing strains of gonorrhea are resistant to penicillin. Through ingenious epidemiology, the resistant strain was traced to ill servicemen who had been stationed in the Philippines and had visited brothels in Vietnam. It turned out that in these brothels, penicillin was given freely to prostitutes as a kind of prophylaxis. Such long-term usage of the drug allowed the bacteria present in some of the women to adapt by acquiring genes that would allow them to survive in the presence of the antibiotic. More recently, in August of 1994, an alarm about a plague epidemic in Maharashtra, India, led people in urban areas to pop tetracycline (the antibiotic of choice) as if it were candy. Supplies of the drug were exhausted before a World Health Organization team determined that in fact there was no infectious-disease emergency.
Particularly when new medical technologies are introduced, the everyday health-seeking practices of low-income countries are a critical factor worldwide--both in the rise of new infectious diseases and in the re-emergence of diseases that have long been known to mankind but are now equipped with antibiotic resistance. Certainly, statistics should inform our policy making in the arena of global public health. But unless we also understand the processes at work at the level of family and community in the developing regions, our policies are going to be far off the mark.
So what can be done in Salang? Simply increasing the availability of antibiotics or even trained doctors in the region will not alleviate the problem of poor treatment of illnesses or the dangerous development of resistant strains of bacteria. And it would do little good to impose legislation that would criminalize drug-regulation offenders, for these practitioners have acquired a good deal of legitimacy in the eyes of the villagers. Such legislation would be ineffective at best; at worst, it would become mired in local politics--one more way for corrupt local officials and policemen to extract bribes.
Without changing behavior through learning processes that expand grass-roots knowledge about diseases and their cures, increasing the number of practitioners and making a new range of drugs more freely available could do more harm than good. Consider that tuberculosis may be cured in 90 percent of cases for about $30, but curing multidrug-resistant TB costs at least $2,000--and even then, the success rate is lower than 50 percent.
By examining data sets that follow illness and health care practices in a community over a long period, we can conclude that there is a disproportionate overuse of health resources for minor illnesses. Simply improving access to health resources is not sufficient to change health-seeking behavior or outcomes. And saturating the community with practitioners who have minimal training is bound to be counterproductive.
What's needed is a paradigmatic shift in the way we shape our global health policies. We must spend more money on training for providers who will practice in third-world communities. And we need to implement a system wherein untrained community-based practitioners can be supervised by more formally trained medical personnel. Finally, more community-based ethnographic studies must be conducted if we are to predict how new drugs and technologies will be used in third-world countries. Unless we do all of these things, there will soon be neither sufficient finances nor effective drugs to treat infectious diseases--here or abroad.
