Category Archives: Uncategorized

What ails health care provision in Africa? Japheth Mati

Biases, distortions and patronising attitudes characterise much of the debate on Africa’s poorer performance in international health goals.

 Africa’s scorecard of achievement in most health indicators and in various international health targets is nothing to shout about.  At the same time, it is undeniable that biases, distortions and patronising attitudes have tended to characterise much of the debate on why it’s been this way.

A spread of daunting challenges stand in the way of effective provision of health care in African countries, some of these are linked to environmental factors- quite often facilitated by man, but others may relate to the intrinsic nature of the continent’s physical geography[i]. It has been suggested that Africa’s stride across the equator in a north-south axis may have important impacts on its topography and climate, including accommodation of nearly a third of the world’s desert land[ii]. To a considerable extent, these geographical features help explain the ecology of tropical diseases in Africa.

The sub-Saharan Africa (SSA) bears the highest burden of disease, globally.

Africa is home to several Tropical Diseases that continue to stifle its social and economic development; among these are malaria and the so-called “Neglected Tropical Diseases” (NTDs): African sleeping sickness (Trypanosomiasis), yellow fever, bilharzias (Schistosomiasis), Kala-azar (Leishmaniasis), Lymphatic filariasis, Trachoma, and (though not confined to the tropics), HIV and AIDS and tuberculosis.

The Global Burden of Disease Study 2010[iii] revealed that whereas the biggest contributor to the world’s health burden used to be the high mortality in infants and children under 5 years, now the disease burden is caused mostly by chronic diseases- cardiovascular, metabolic and musculoskeletal (arthritis) disorders, cancer, mental health conditions; and injuries. But while this is increasingly true across most regions of the world, SSA stands out as a notable exception.

In Africa, harsh environmental factors, poverty, famines and hunger, political conflict leading to internal and external displacement of persons, continue to play roles in facilitating spread of infectious diseases, childhood illnesses, and maternal causes of death, accounting for as much as 70% of the burden of disease. In addition, the region is characterised by the gross socio-economic inequalities, wide gaps between the ‘haves’ and the ‘have-nots’. The result is that African countries have to simultaneously cope with the double burden of communicable and non-communicable diseases.

Africa has been plagued by conflicts since the colonial era and continuing long thereafter. The negative effects of war on the health of populations are well documented, especially the destruction of infrastructure, and the interruption, neglect or abandonment of essential public health services. For instance, the ten-year civil war in Sierra Leone (1991 – 2002), left the health infrastructure virtually non-existent, with rates of infant and child mortality counting among the highest in contemporary world[iv]. Effects of conflict may also account for the difficulties experienced in controlling the Ebola virus disease in Sierra Leone and Liberia.

Besides mortality and morbidity, conflict has wide-ranging consequences on the health and well-being of populations, which include: rape, torture, post-traumatic stress, sexually transmitted infections (including HIV/AIDS) and long-term mental health problems.

Rapid population growth rates

Generally, rapid growth of population is associated with challenges that negatively impact on provision of health services, poverty, hunger, and inadequacies of social services and infrastructure being but a few of them. The annual Population growth rate in SSA reduced slightly from 2.8 percent in 1990 to 2.5 percent in 2010, and has sustained this rate since then. According to World Bank data, the region’s total population is projected to double by 2036. This implies diminishing opportunities and resources, particularly for the most vulnerable members of society: women, children, the poorly educated and the unemployed. It further implies more famines, exacerbated by expanding conflicts over shrinking resources.

The health care demands of a rapidly increasing population far outpace available resources, with inevitable deterioration in the quality of care that is provided. A vicious circle manifests when the underperforming health care systems minimise access to family planning services, thereby fuelling further population growth.

At the national level, rapid population growth normally translates into reduced GDP per capita. As a result, in many sub-Saharan African countries including Kenya, healthcare is predominantly funded by households through out-of-pocket spending. A household without a health insurance may be forced to pay huge medical bills for treatment of an ailing family member, exposing it to financial catastrophe and impoverishment. In 2007, about eleven percent of Kenyan households experienced catastrophic health spending, with 4 percent being impoverished. This was particularly so among the poorest households[v].

From the public health perspective, the high fertility rates that drive rapid growth of populations are also associated with high maternal morbidity and mortality rates. Pregnancies that are too close together do not allow enough time for the mother to recoup nutrients that are expended during pregnancy and breastfeeding, which may precipitate a condition referred to as maternal depletion syndrome.

Haphazard and Unrealistic planning- not addressing greatest need

The fundamental challenge facing African governments in their efforts to fulfil the mandate of providing health care for all citizens, may be traced back to the time of independence when they mostly chose to inherit the colonial, European model, of health care, where curative care was overly emphasised, while primary health care took low priority (apart from immunization to stall epidemics).

MAGADI with AMREF 1-2 July '08 032b

A community member explains health education message chart, Magadi, Kenya

Also perpetuated was the inequitable distribution of health facilities and services, which were predominantly sited in urban centres with little consideration for rural areas, which lacked meaningful infrastructure. It is no wonder that the World Health Organization has estimated that up to 80 percent of the populations in some African countries rely, almost entirely, on traditional systems of medicine to meet their primary health care needs[i]. In such scenario the greater majority of the population benefit little from the national health services.

The above is a clear example of planning which is not based on reality on the ground, one that does not address where the highest burden of ill-health exists. The practice of evidence based planning and priority setting which has increasingly caught up in recent years, aims to address situations such as these. Evidence based planning is particularly important where resources are limited; it is particularly important to invest in public health and health promotion strategies that are effective.

Under-resourced health care systems

Despite the Abuja pledge of 2001 to allocate at least 15% of the annual budgets to health[ii], generally, the health sector in sub-Saharan African countries remains grossly underfunded. More than a decade later, only a couple of countries can claim to have achieved the target, the majority including Kenya, are as yet to achieve the goal.

All the same, the gross amounts allocated to health have been rising in most countries. For example, between 2007 and 2011, the gross allocations to Kenya’s Ministry of Health more than doubled, from KES21.7 billion in 2007/08 to KES45.2 billion in the 2011/12 budget. But of concern is the trend in the prioritisation of health, which has not kept pace with other areas of expenditure as the economy has expanded.  Over the same period, the overall gross Government expenditure rose from 353.8 billion to 815.6 billion[iii], a more than 230 percent increase. But, the share for health as a proportion of overall government expenditure declined from 6.13 percent to 5.54 percent, way below the 15% pledged in the Abuja Declaration.

Deficient budgetary allocation to health, coupled with inefficient and corrupt systems are the ultimate explanation for the disappointing performance in the public health sector, and what breeds the multitude of the perennial complaints levelled against it. More importantly, it is the root cause of denial and violations of the right to health as enshrined in national constitutions.

Human resource constraints

Efficient delivery of health care services demands availability of a viable workforce composed of well trained health professionals, and in adequate numbers. This is a prerequisite to having an effective health care system. On the other hand, most Sub-Saharan African countries continue to experience serious human resource constraints, not just with regard to doctors but also nurses and midwives, and indeed all health workers in general.

Most of them are operating with an extremely low doctor to population ratio, an average of just 1.3/10,000 compared to countries such as India (6.0/10,000), Brazil (19.2/10,000) and the United States (28.0/10,000)[iv].  In fact, some individual countries on the continent have physician to population ratios as low as 0.1-0.2/10,000. According to the World Health Organization (WHO), in order to achieve coverage of the primary healthcare needs, a country should have a minimum of 23 health workers (doctors, nurses, and midwives) per 10,000 population, a ratio few Sub-Saharan African countries can claim to possess.

For example in East Africa the country with the highest ratio of doctors, Kenya, can only claim 1.8 doctors per 10,000 people (Uganda1.2, Rwanda 0.6, Tanzania 0.1). Uganda has the highest ratio of nurse/midwives with 13.1 per 10,000 people (Kenya 7.9, Rwanda 6.9, and Tanzania 2.4). In terms of ‘health workers’ ratios Uganda leads with 14.3 per 10,000 (Kenya 9.7, Rwanda 7.5, Tanzania 2.5) [v]. Thus, none of these selected East African countries has the human resource that WHO considers prerequisite to achieving national and international health goals.

The shortage of health workers in sub-Saharan Africa is attributable to a variety of reasons, including inadequate investment in training, both pre- and in-service; internal and external migration (‘brain drain’), premature retirement, morbidity and premature mortality. In many countries the current pre-service training activities are insufficient to maintain absolute numbers even at their current levels, and mostly not enough to keep pace with population growth[vi].

Out-migration of doctors and nurses is particularly a serious drain on the economy; loss of returns from investment on their education and training has been estimated at around US$ 518,000 per doctor and US$ 339,000 per nurse[vii]. A recent survey of medical schools in sub-Saharan Africa has shown that within five years of graduation, as many as 26% of graduates had migrated out of their country – 80% emigrating outside of Africa. Of those doctors remaining at home, they were largely concentrated in urban centres, whether in public or private practice, specialist or general practitioner[viii].

There are numerous factors that drive the brain drain of health professionals. These include poor wages especially compounded by concurrent high inflation rates; poor working environment which is a common reason for job dissatisfaction; limited opportunities for self professional growth due to lack of functional facilities, equipment and supplies; and generally the lack of appreciation by the employers and the society. In some countries many of the graduating nurses may remain unemployed for years, despite the great demand for their services in public health facilities, an example of distorted prioritisation.

Corruption: the daunting challenge of combating sleaze

In most African countries, corruption has undoubtedly become the bedevilling monster behind underperformance in all development sectors, including health. The vice has been defined as abuse of entrusted power for private gain, in public and private sectors[ix]. Corruption is not just a curse in Africa; it is known to exist all over the world[x], even then, it is in Africa where the woes caused by its pervasiveness are most magnified. Corrupt practices may take varied shapes and shades, ranging from staff absenteeism, nepotism and cronyism, to irregularities in public purchasing and contracting processes, especially over-invoicing. Drugs and other items are ‘leaked’ from public health facilities to be sold privately- sometimes to patients admitted in the very same public hospitals.

The World Bank[xi] has used the term “Quiet corruption” to describe denial of public services that are due to poor people even though they are paid for. Examples of these are absenteeism among health workers, and the distribution of fake drugs while genuine ones are sold for profit.

Absenteeism occurs for various reasons, some of them legitimate or necessary, as when staff have to travel to headquarters to check why their salaries have not been paid. Staff can be absent because they are involved in personal engagements, including undertaking paid side jobs. Unfair hiring practices such as nepotism and preferential treatment to well connected individuals, promotions of undeserving staff at the recommendations of politicians, and others in positions of authority, are all expressions of corruption.

Clearly, effectively addressing corruption in African countries has become a development imperative.

An unresolved status of traditional systems of medicine

Human societies have since time immemorial, independently evolved and maintained systems of healing; Africans are not an exception. Despite efforts to suppress indigenous African medicine during the colonial era the practice still thrives throughout the continent. Traditional African medicine and African religion are intricately intertwined; illness, disease and misfortunes are understood within the context of African theology. Concepts such as these were obviously viewed as a serious threat to the work of early Christian missionaries, who preached that traditional African practices including medicine were sinful. As such, converts risked excommunication for engaging in the practice, whether as practitioners or patients.

Practitioners of western medicine have over the years, eschewed traditional African medicine dismissing its methods as primitive, superstitious and pagan. They failed to appreciate the philosophical underpinning of traditional African Medicine, in which good health, disease, success or misfortune, are seen as interrelated circumstances, which do not happen by chance but arise from actions of living individuals or ancestral spirits. Thus, traditional African medicine embraces two mutually reinforcing practices: African spirituality (divination) and herbal medicine.

In more recent years, traditional medicine has become more widely accommodated. This, in any case, was bound to happen considering that in most African countries, the penetration of ‘modern’ medicine remains such that large populations lack access to it, due to its relatively high cost and the concentration of health facilities in urban centres. As noted above, WHO’s estimates show that as much as 80% of the population in some African countries may depend on traditional medicine for their primary health care.

In fact, quite frequently, both systems of medicine (traditional and western) are used complementarily, with traditional therapies serving as a first-line treatment before modern drugs are sought. Within certain communities in Kenya, for example, majority of pregnant women will have consulted a traditional healer (mganga) who administered to them herbal preparations and potions to ward off evil spirits before making their first antenatal clinic visit[xii].

This should be strong reason why governments ought to address the unresolved status of traditional medicine, by setting up regulatory mechanisms for accommodation of the practice within the national health system. Such a measure, besides ending the unholy alliance with traditional medicine, should go a long way towards assuring safety and effectiveness of the practice.

[i] http://www.who.int/mediacentre/factsheets/2003/fs134/en/‎

[ii] The Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases 2001

[iii] Figures based on gross approved expenditure (2007/8 – 2010/11) and gross estimates (2011/12), and indexed to inflation at 2007 CPI.

[iv] http://data.worldbank.org/indicator/SH.MED.PHYS.ZS

[v] (http://kff.org/global-indicator/physicians/, http://kff.org/global-indicator/nurses-and-midwives/)

Yohannes Kinfu, Mario R Dal Poz, et al. The health worker shortage in Africa: are enough physicians and nurses being trained? Bulletin of the World Health Organization 2009;87:225-230. doi: 10.2471/BLT.08.051599

[vii] Kirigia JM, Gbary AR, Muthuri LK, Nyoni J and Seddoh A The cost of health professionals’ brain drain in Kenya. BMC Health Serv Res. 2006; 6: 89. Published online 2006 July 17. doi:  10.1186/1472-6963-6-89 PMCID: PMC1538589 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1538589/ Accessed 28 March, 2013.

A survey of Sub-Saharan African medical schools, Human Resources for Health 2012, 10:4  doi:10.1186/1478-4491-10-4 http://www.human-resources-health.com/content/10/1/4

[ix] (http://www.transparency.org/topic/detail/health).

http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/hen-summaries-of-network-members-reports/how-does-corruption-affect-health-care-systems,-and-how-can-regulation-tackle-it

[xi] http://www.lse.ac.uk/IDEAS/publications/ideasToday/06/worldBank.pdf

[xii]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003.

[i] Jared Mason Diamond, 1999, quoted in James R. Moore, 2014, Shattering Myths about Africa: How Geography, Diseases, and Hunger Hinder Africa’s Economic and Social Development. American International Journal of Social Science Vol. 3 No. 2; March 2014. http://www.aijssnet.com/journals/Vol_3_No_2_March_2014/1.pdf

[ii]Osei, W.Y. (2010). Human-environmental impacts: Forest degradation and desertification. In S.A. Attoh (Ed.), Geography of Sub-Saharan Africa (pp. 63-90). New York: Prentice Hall.

[iii] http://www.who.int/pmnch/media/news/2012/who_burdenofdisease/en/index1.html

[iv] ‘Sierra Leone’s long recovery from the scars of war’, Bulletin of the World Health Organization: Volume 88:2010, http://www.who.int.

[v]Kimani, D. and T. Maina. 2015. Catastrophic Health Expenditures and Impoverishment in Kenya. Washington, DC: Futures Group, Health Policy Project.

Advertisements

Regulation of Traditional Medicine in Kenya: Kenya’s Health Bill, 2015- Japheth Mati

In our post of January 9, 2015 entitled “What prospects for complementary use of African and western systems of medicine? we called on African governments to establish appropriate regulatory mechanisms for accommodation of traditional medicine within the national health care system. This was in consideration of the fact that WHO’s estimates show that up to80 percent of the population in some places rely on traditional medicine for their primary health care.

Already, evidence exists that shows that in Kenya traditional medicine and modern (western) medicine are frequently used complementarily, with traditional therapies serving as the first-line treatment before modern drugs were sought. As such, there was urgent need for mechanisms to  ensure safety and effectiveness of traditional medicine.

So, we say kudos to Kenya’s National Department of Health for publishing the Health Bill, 2015, which among other measures seeks to establish regulatory mechanisms for the practice of traditional medicine. The relevant sections are:

  • Clause 42 (1) and (2): “The national government department of health shall formulate policies to guide the practice of traditional and alternate medicine. The county executive department for health shall ensure implementation of any policies thereto.”
  • Clause 42 (1): “There shall be established regulatory body by an Act of Parliament to regulate the practice of traditional and alternative medicine.
  • Clause 47: “The national government department of health shall develop policy guidelines for referral mechanisms and a system of referral from practitioners of traditional and alternative medicine to conventional health facilities…….”

We salute the Initiative by Kenya’s First Lady towards improved maternal and child health outcomes in Kenya. Japheth Mati MD

Image

The “Beyond Zero Campaign” launched on 24 January 2014 under the stewardship of Kenya’s First Lady, Margaret Kenyatta, seeks to improve maternal and child health outcomes in Kenya. Her enthusiasm and commitment to the success of the Initiative, including the pledge to raise funds for it through participation in the forthcoming London Marathon, is completely unprecedented in Kenya’s history. We salute this initiative by the First Lady of Kenya.

The Strategic Framework for the engagement of the First Lady in HIV control and promotion of maternal, newborn and child health in Kenya, which was unveiled on World AIDS Day 2013 focuses on the following five key areas: (i) Accelerating HIV programmes, (ii) Influencing investment in high impact activities to promote maternal and child health and HIV control, (iii) Mobilizing men as clients, partners and agents of change, (iv) Involving communities to address barriers to accessing HIV, maternal and child health services and (v) Providing leadership, accountability and recognition to accelerate the attainment of HIV, maternal and child health targets.

In an earlier post under the title “What’s in the way of achieving improved maternal health in Kenya” it was observed that there is sufficient knowledge of the causes of maternal deaths, and how they can be prevented. It is known which interventions work and which do not. What appears to be the main barrier is the lack of commitment to act; to prioritize reduction of maternal mortality, and to reflect this in resource allocations to the health sector, and to maternal health services, in particular.

The health budgets in most African countries, Kenya included, do not demonstrate that health is rated as a high priority among other national needs. This is often the result of failure by governments to recognise the importance of health in development, so that expenditure on health is not perceived as a critical economic investment alongside spending on education, agriculture or industries. Yet, health is a critical resource, without which investment in all other sectors would go to waste. Further, poor health creates critical barriers to economic production.

Within the health sector, lack of equity in planning and distribution of resources for health results in inequitable access to health care services: Physical access (e.g. distance to the nearest health facility); Affordability (when fees charged for services are unaffordable); Acceptability (where people lack confidence in the services provided and decide not to utilise them). People who are denied access through the above barriers often turn to out-of-pocket expenditures on their health care. Ironically, evidence reveals that the poor bear the heaviest burden of out-of-pocket health expenditures, irrespective of where they seek health care.

From available evidence it is obvious that local and international health goals cannot be achieved without emphasis on equitable expansion of access to basic services for all. Policy makers and planners must begin to accept the existence of, and to act on, the vast inter- and intra-regional health disparities in Kenya. It was the expectation that devolution would create opportunities for better prioritization of needs at the grassroots, and, through better knowledge of community needs, formulate more focused interventions. 

Engaging with communities as envisaged in key area (iv) of the proposed Strategic Framework is indeed a critical focus, considering that proximity to health facilities and services, is no guarantee they will be utilised. For example, there are several areas in Kenya, both rural and urban, where communities will prefer traditional medicine as their first line of health care before modern drugs are sought. There is evidence to show that within certain communities in Kenya, majority of pregnant women will have consulted a mganga (traditional healer) who administered to them herbal preparations and potions to ward off evil spirits, before making their first antenatal clinic visit[1]. These women perceive antenatal care services available at health facilities- dispensaries and health centres, and those provided by TBAs and herbalists, to be complementary, and generally, they seek both types of care interchangeably. This may have negative effects, for example, due to delays in early diagnosis and management of antenatal complications, resulting in poor pregnancy outcomes.

https://africahealth.wordpress.com/2010/10/27/what%E2%80%99s-in-the-way-of-achieving-improved-maternal-health-in-kenya/

Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf


[1]Family Care International: Care-Seeking During Pregnancy, Delivery, and the Postpartum Period: A Study in Homabay and Migori Districts, Kenya, September 2003 http://www.familycareintl.org/UserFiles/File/SCI%20Kenya%20qualitative%20report.pdf

“What do women want?”

What do women want?” This rather vague question, sometimes attributed to the famous psychoanalyst Sigmund Freud (1856-1939), still crops up in today’s male-oriented societies where women occupy a second place in terms of recognition. Yet, within the context of the axiom “your health is in your hand”, this is surely a pertinent question.  It becomes equally appropriate when it is recognised that current status of health is, to a considerable degree, determined by past events, related to behaviour and the social milieu, and that today’s lifestyle has considerable bearing on tomorrow’s health status.

The scope of actions that individual women may take to protect their health will, obviously, vary according to where they live and what resources are available to them. Regrettably, majority of world’s women still live in societies where they not only occupy a second place in terms of recognition, many are condemned to play subservient roles in society, where they labour under the yoke of gender discrimination and denial of their reproductive rights. For these women, the various international instruments touching on reproductive rights, as well as the national constitutional guarantees of equality and non-discrimination, have little meaning in their lives.  They remain governed by a separate set of laws based on religion or custom, as they continue being tormented by several harmful practices, some having serious negative impacts on their health and social well-being.

But, irrespective of their status, women should want empowerment to make sound choices that have a direct and immediate impact on their reproductive health; a source of accurate information that is relevant to their immediate problem. They want basic tools for self direction and growth; knowledge of themselves: soma and psyche, their bodies’ rhythms, their sexual and reproductive health and how to protect it. They need to learn how to avoid and prevent sexually transmitted infections and unplanned pregnancy; they must be encouraged to seek knowledge of their own individual condition, ways to promote their own health, and to embrace positive health seeking behaviours.

Under circumstances such as these women would surely need a resource that provides the much needed information, but which is presented in such a style that it can be understood without a medical background.  A source that addresses some of the relevant concerns of women from age of sexual maturity to old age, seeking to empower them with information and knowledge that can assist them in making decisions regarding their sexual and reproductive health.

Obviously books and other media cannot, and shouldn’t, take the place of direct consultation with the doctor; on the other hand, they can enable a woman to have a better understanding of her medical problem and to ask their doctors more useful questions. It is their right to know all the facts that pertain to personal health care decision making.

A new addition to books that answer to the above concerns can be found at https://www.createspace.com/4183612

“What do women want?” This rather vague question, sometimes attributed to the famous psychoanalyst Sigmund Freud (1856-1939), still crops up in today’s male-oriented societies where women occupy a second place in terms of recognition. Yet, within the context of the axiom “your health is in your hand”, this is surely a pertinent question. It becomes equally appropriate when it is recognised that current status of health is, to a considerable degree, determined by past events, related to behaviour and the social milieu, and that today’s lifestyle has considerable bearing on tomorrow’s health status.

The scope of actions that individual women may take to protect their health will, obviously, vary according to where they live and what resources are available to them. Regrettably, majority of world’s women still live in societies where they not only occupy a second place in terms of recognition, many are condemned to play subservient roles in society, where they labour under the yoke of gender discrimination and denial of their reproductive rights. For these women, the various international instruments touching on reproductive rights, as well as the national constitutional guarantees of equality and non-discrimination, have little meaning in their lives. They remain governed by a separate set of laws based on religion or custom, as they continue being tormented by several harmful practices, some having serious negative impacts on their health and social well-being.

But, irrespective of their status, women should want empowerment to make sound choices that have a direct and immediate impact on their reproductive health; a source of accurate information that is relevant to their immediate problem. They want basic tools for self direction and growth; knowledge of themselves: soma and psyche, their bodies’ rhythms, their sexual and reproductive health and how to protect it. They need to learn how to avoid and prevent sexually transmitted infections and unplanned pregnancy; they must be encouraged to seek knowledge of their own individual condition, ways to promote their own health, and to embrace positive health seeking behaviours.

Under circumstances such as these women would surely need a resource that provides the much needed information, but which is presented in such a style that it can be understood without a medical background. A source that addresses some of the relevant concerns of women from age of sexual maturity to old age, seeking to empower them with information and knowledge that can assist them in making decisions regarding their sexual and reproductive health.

Obviously books and other media cannot, and should not, take the place of direct consultation with the doctor; on the other hand, they can enable a woman to have a better understanding of her medical problem and to ask their doctors more useful questions. It is their right to know all the facts that pertain to personal health care decision making.

A new addition to books that answer to the above concerns can be found at https://www.createspace.com/4183612

How sad it is that inventors cannot control the eventual application of their work: The flipside of innovations in diagnostic and therapeutic technologies in medicine. Japheth Mati MD

It is fair to conclude that the technological revolution of the twentieth century was unprecedented in human history. Medicine was one area of tremendous progress, especially considering that at the dawn of that century Surgery, in particular, was a dicey procedure to undergo. It was before the arrival of safe anaesthesia, blood transfusion, antibiotics, and other life support paraphernalia we often take for granted. Admittedly, a lot of today’s surgical procedures predate the 20th century, but they were far from being safe. Take Caesarean section, for example, around 1860s the mortality rate associated with the operation in Great Britain and Ireland, was 85%[i]. Major strides in mortality reduction had to await advances, especially in three key areas: Anesthesia, Blood transfusion and Antibiotics.

Anesthesia: In the 20th century, the safety and efficacy of general anaesthesia was improved by the routine use of endotracheal intubation, advanced airway management techniques, and better anaesthetic agents that made “bite the bullet” become obsolete!  Blood transfusion: The discoveries by Karl Landsteiner, of human blood groups (1901) and the Rhesus factor (1937), markedly improved the safety of blood transfusion. Antibiotics: Antibiotics are a creation of the 20th century, starting with the sulpha drug Prontosil in1935; Penicillin[ii] (1942), Streptomycin (1943); Tetracycline (1955); Nystatin (1957); to be followed by others, including the semi-synthetic antibiotic Amoxicillin (1981).

As I marvelled over these and other 20th century great medical scientific and technological feats, one question kept nagging me: does the way we mainly use these inventions today conform to the original purpose of their creators?

Thinking slightly outside of medicine, one can for example compare the opposites in the employment of nuclear technology: on the one hand, its value as a source of efficient energy to drive industry, and on the other its use as a weapon of  mass destruction. Though not to the same degree of departure, in medicine, a considerable number of today’s most celebrated technologies are used in manner that is at variance with the inventor’s original intentions, to the extent that some inventors have had occasion to publicly express regret over the ‘misuse’ of their work.

It’s the intention in this post to review briefly selected diagnostic and therapeutic innovations that have exerted great impact on medicine in general, and the practice of obstetrics and gynaecology in particular, especially beginning the second half of the 20th century.

The review covers the following diagnostic and therapeutic techniques: amniocentesis and amniotic fluid sampling, prenatal cytological sex determination, prenatal blood DNA sex determination, obstetric ultrasound, and in-vitro fertilisation technique. Each one of the above innovations has performed beyond expectation, finding greater utilisation for purposes far removed from the original intention at the time of their discovery. These “other” uses are examples of what can be referred to as ‘the flipside of scientific and technological innovations in medicine’. In sympathy with their cause, we are left to wonder: “If only inventors were endowed with wisdom to foresee the ends to which their creation might end up being applied!”

 Amniocentesis

Amniocentesis is the process of removing a sample of amniotic fluid – the medium in which the fetus floats in the mother’s uterus, to be analysed for markers of certain disorders of the fetus. This procedure is credited to the work of Douglas Bevis, a British obstetrician and gynaecologist at St. Mary’s Hospital in Manchester in early 1950s. Later, following the discovery of ultrasound (see below) it became possible to undertake ultrasound-guided amniocentesis with greater accuracy and safety.

Amniocentesis ultrasound guided image

Ultrasound guided amniocentesis

Amniocentesis and amniotic fluid sampling (AFS) permits the monitoring of fetal wellbeing in utero, especially in the management of Rh-isoimmunisation. It is frequently used in the estimation of fetal lung maturation, and in the diagnosis of genetic disorders such as Down’s syndrome (mongolism) and sex-linked diseases such as haemophilia.

In 1949 Canadians Murray Barr and Ewart Bartram had discovered sex chromatin (a mass of chromosomes, also called “Barr Body”), which is found only in female cells. Thus, finding the sex chromatin in fetal cells obtained through AFS permitted identification of a female child. Later through tissue culture techniques it was possible to identify the actual male and female sex chromosomes in cells, thereby improving accuracy of sex determination using cytogenetic technique, which remains the gold standard. There are now over 500 hereditary diseases that can be diagnosed through amniocentesis and other diagnostic techniques[i].

The technique of amniocentesis reigned supreme till the tail-end of the 20th century when in 1997 Dennis Lo and colleagues (both in Oxford UK and Hong Kong, China) published their seminal paper[ii] reporting the presence of fetal DNA in maternal blood, thereby opening the door to a new non-invasive technique that avoided the risk (albeit very small) of abortion following amniocentesis. The new DNA test, which employs the more advanced Polymerase Chain Reaction (PCR), has the added advantage of being performed at an earlier gestational age- as early as 7 weeks, much earlier than was possible with ultrasound scan (see below) which could only demonstrate male fetus at 11 weeks earliest, and not so reliably. An important downside of DNA PCR test is the cost involved.

The potential to determine fetal sex has opened the door to abuse of these tests. The ‘flipside’ of prenatal sex diagnosis has been its utilization in selective abortion of female fetuses, to the extent sometimes, of posing demographic imbalance as has been feared for India[iii] and China[iv]. In this regard the test changes from enhancing the wellbeing of the fetus to selecting it for destruction. A complete turnaround!

Ultrasound scanning

Prof Ian Donald[v] (1910-1987), the Regius Professor of Midwifery at the University of Glasgow (1954 -1976), and a tough Scot who endured three open-heart valve-replacement operations, is the celebrated Father of Medical Ultrasound, a technology he pioneered beginning the late 1950s. His first major publication on the subject appeared in the Lancet in 1958, which contained the first ultrasound images of the fetus ever published[vi].

The potential to reveal information on the growing fetus in the womb was soon realised and the use of ultrasound spread quickly, improving the safety of pregnancy and childbirth, and allowing for the much more effective detection and treatment of fetal abnormalities. Since the 1970s ultrasound scanning has become a routine part of antenatal care. And as the science of ultrasound developed, so did its applications. Ultrasound scanning is now used in numerous other areas of medicine, with recent advances in technology enabling three-dimensional images to be produced.

Ian Donald hommedia

Professor Ian Donald

A less discussed dimension of Ian Donald’s work is what fundamentally may have driven him to develop the technology. In this regard, he seems to have considered obstetric ultrasound to be more than simply a means to visualise the fetus in utero; instead, he saw the technology as providing a chance to ‘individualise’ the fetus. The technology made it possible for the fetus to be recognised, or at least spoken of as, an individual, a reality. This view comes out clearly from the description he uses in the following 1978 presentation to a lay audience[i]:

Here’s the baby see how he jumps … This baby is about a 12 week pregnancy … She [the mother] certainly cannot feel these movements but there is no doubt about the reality, … now you see it move its hand up to its face you see his head is up here and his chest is down here then he throws his legs out and his arms … You see his hands come up like that. And you see his face here, the back of his head … It is rather like a child on a trampoline, tremendous strength, energy and vitality.)

Perhaps because of these experiences, Ian Donald came to hold quite strong views against abortion, being a lead campaigner against the 1967 Abortion Act in the UK. He is known to have employed the ultrasound imagery as a powerful persuasive resource in urging women to continue with their pregnancies. In his view the only indication for abortion was a very grossly deformed fetus; no consideration in cases of mild or moderate handicap. Indeed Ian Donald even went to the length of attempting to save a fetus in an ectopic pregnancy – a heroic surgical endeavour which failed miserably, but which nevertheless, justified an audience with Pope John Paul II, an occasion he described as ‘the crowning event of my life’[ii].

Personal idiosyncrasies apart, there is absolutely no argument that Ian Donald’s work has contributed immensely to better outcomes in many medical disciplines, away from his own field of obstetrics and gynaecology. However, in a rather ironical way, ultrasound scan happens to be the most reliable way of diagnosing not only early pregnancy, but also of ensuring the uterus has been completely evacuated, following both spontaneous abortion and induced abortion (especially medical termination of pregnancy).

By the 1970’s, Ian Donald had become aware of the truth, that the ends to which technology is put cannot be determined by its originators. He somewhat despairingly wrote, “My own personal fears are that my researches into early intrauterine life may yet be misused towards its more accurate destruction”[iii]. Indeed, Ian Donald had come face to face with the flipside of his own scientific and technological innovation in medicine!

 In vitro fertilization

Patrick Christopher Steptoe (1913 – 1988), a British obstetrician and gynaecologist, along with biologist/ physiologist Robert Edwards, were the pioneers of the technique of in vitro fertilization for infertility treatment. Louise Joy Brown, their first ‘test-tube baby’, was born on 25 July 1978, the product of great perseverance- it took them 10 years before they had their first successful birth. Edwards was awarded the 2010 Nobel Prize in Physiology or Medicine for this work, however because the Prize is not awarded posthumously, Steptoe was not eligible for consideration.

Since Louise Brown, there have been over 4 million babies worldwide conceived through IVF. Despite a steady stream of ethical and moral questions arising from IVF, to date, the lives of many women and couples across the globe have been enriched by a child conceived through one or other of the various modifications of the original IVF technique introduced by Steptoe and Edwards. This reproductive technology has made and continues to make tremendous advancements in basic reproductive biology and embryology. It has enabled us to understand the human reproductive processes and especially fetal development, in a way that has never been possible in the past[iv].

At the same time, the world of IVF almost everywhere has become a very competitive market-place, resulting in many treatment centres going to great lengths to ensure a pregnancy is achieved. The temptation is high to transfer large numbers of embryos to the uterus, which results in pregnancies of high multiples, some of which may be lost through spontaneous abortion, or subjected to ‘fetal reduction’ procedures (euphemism for abortion).

The technique of IVF has become an essential source of ‘spare embryo’ for stem-cell research, which gives hope to many people dying from today’s incurable diseases. But, still, this is far beyond Patrick Steptoe’s imagined application of their technique.


[i] I. Donald (undated but after 1978) ‘Predicting ovulation’, unpublished lecture, tape-recording in BMUS Archive).

[ii] Malcolm Nicolson, Ian Donald – Diagnostician and Moralist http://www.rcpe.ac.uk/library/read/people/donald/donald.php

[iii] I. Donald (1972) ‘Naught for your comfort’, Journal of the Irish Medical Association, 65, 279-89.


[ii] Lo YMD, Corbetta N, Chamberlain PF, Rai V, Sargent IL, Redman CW, et al. Presence of fetal DNA in maternal plasma and serum.Lancet1997;350:485-7.

[iv] en.wikipedia.org/wiki/Abortion_in_China

[v] Prof Ian Donald was my supervisor at the Queen Mother’s Hospital in Glasgow in 1969.

[vi] I. Donald, J. MacVicar, T. G. Brown (1958) ‘Investigation of abdominal masses by pulsed ultrasound’, The Lancet, 1, 1188-95.


[ii] Fleming, Florey, and Chain shared the 1945 Nobel Prize for medicine for their work on penicillin.

 

 

%d bloggers like this: