Medical genetics in developing countries in the Asia-Pacific region: challenges and opportunities

Advances in genetic and genomic technology changed health-care services rapidly in low and middle income countries (LMICs) in the Asia-Pacific region. While genetic services were initially focused on population-based disease prevention strategies, they have evolved into clinic-based and therapeutics-oriented service. Many LMICs struggled with these noncommunicable diseases and were unprepared for the needs of a clinical genetic service. The emergence of a middle class population, the lack of regulatory oversight, and weak capacity-building in medical genetics expertise and genetic counseling services led to a range of genetic services of variable quality with minimal ethical oversight. Some of the current shortcomings faced include the lack of awareness of cultural values in genetic health care, the variable stages of socioeconomic development and educational background that led to increased demand and abuse of genetics, the role of women in society and the crisis of gender selection, the lack of preventive and care services for genetic and birth defects, the issues of gene ethics in medicine, and the lack of understanding of some religious controversies. These challenges provide opportunities for both developing and developed nations to work together to reduce the inequalities and to ensure a caring, inclusive, ethical, and cost-effective genetic service in the region.     

Maternal height and child mortality in 42 developing countries

Previous research reports mixed results about the association between maternal height and child mortality. Some studies suggest that the negative association might be stronger in contexts with fewer resources. This hypothesis has yet not been tested in a cross‐nationally comparative design. We use data on 307,223 children born to 194,835 women in 444 districts of 42 developing countries to estimate the association between maternal height and child mortality and test whether this association is modified by indicators at the level of the household (like sex, age and twin status of the child and socio‐economic characteristics of the mother and her partner), district (regional level of development, public health facilities and female occupational attainment) and country (GDP per capita). We find a robust negative effect of logged maternal height on child mortality. The effect of maternal health is strongest for women with least education and is more important in the first year after birth and for twin births. The indicators of development at the district and country level do not modify the effect of maternal height. Am. J. Hum. Biol. 2009. © 2008 Wiley‐Liss, Inc.     

Lymphedema following cancer therapy: overview and options

This summit focusing on lymphedema following cancer therapy was held during the 7th International Symposium on Cancer Metastasis through the Lymphovascular System. It was unique for the inclusion of patients with lymphedema joining physicians, therapists, healthcare professionals, and researchers to highlight what is known and more importantly what is unknown about the current state of research and treatment in the United States. The session opened with an introduction to lymphedema and then explored the incidence of multiple cancer-related lymphedemas, imaging tools and techniques useful for the diagnosis of lymphatic system abnormalities, and the new findings concerning the genetics of cancer-related lymphedema. It closed with a review of advocacy for patients and healthcare professionals and both conservative and surgical treatment options, followed by a panel discussion and questions. The session provided important information and updates which will be of value for improving the rehabilitation and overall support of patients with cancer-related lymphedema.     

Road safety - threats and opportunities for poor countries

Chances are that everyone reading this will either have lost a close friend, relative, or work colleague in a road traffic crash in the last couple of years. Chances are, the reports said it was an “accident”. There might even have been police reports giving the “cause of the accident.” Now, think about the meaning of the word “accident” - most people would agree it is an unpredictable event, one for which you could not possibly have prepared - it just happened. Now, think again. Can we predict what will happen when a cyclist''s unprotected head hits the concrete at 100 kms an hour? Can we predict what will happen when a powerful car races down a road a few meters away from the entrance of a primary school, just as the kids are leaving school? Can we predict what will happen when a matatu (commuter mini bus) driver gets behind the wheel at dusk, after a few bottles of alcohol, heading for a destination six hours away? And can we predict what will happen when a mosquito bites a baby, just after feeding on a person sick from malaria? Well - chances are, the first three scenarios will be called accidental, and the last one will be targeted for prevention! The truth is, all four are perfectly predictable, and preventable. The more than 3, 200 persons dying on the world''s road every day have become predictable - we know they will happen, we know where they will happen, and what kind of people will be involved. Yet the majority of communities and governments still call them accidental, and make no concrete provision for their prevention.On April 7 2004, the WHO and its partners will commemorate World Health Day. This time round, the theme is “Road Safety is no Accident.” Road traffic injuries are a huge public health and development problem that kills between 800 000 and 1.18 million people, and injures or disables another 20 to 50 million more every year¹. Data from the WHO and World Bank show that without appropriate response, these injuries will rise dramatically by the year 2020, particularly in rapidly motorizing countries. In addition, apart from the enormous impact on families and communities, road traffic crashes are costing governments between 1 and 3 per cent of their gross domestic product². Health facilities are over-burdened with victims of road traffic crashes, over-stretching their already meager health budgets.Once we acknowledge that Road Safety does not happen by accident, (and that road safety is the state where we have “no accident”) then we are well on the road to finding solutions. The systemic approach being recommended by the WHO moves from defining the burden of the road traffic injuries (size, nature) to understanding the factors that increase risk and vulnerability, to designing interventions, testing them for effectiveness, and finally, to getting the effective interventions implemented wherever they are needed.     

A nonelectrical incubator for developing countries

A nonelectrical human incubator for premature infants has been designed and built for use in rural areas of developing nations where electricity is not readily available. This incubator may be operated using kerosine or gas as the source of energy. The unit uses an automatic self-activating regulator which controls the flow of hot water through a simple heat exchanger; the air in the incubator is heated by natural convection, and the humidity is adjusted by water evaporation. The temperature inside the incubator can be maintained to within±0·3°C of the desired level. The unit operates for extended periods of time with little or no supervision.     

Laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities

With an estimated 9.4 million new cases globally, tuberculosis (TB) continues to be a major public health concern. Eighty percent of all cases worldwide occur in 22 high-burden, mainly resource-poor settings. This devastating impact of tuberculosis on vulnerable populations is also driven by its deadly synergy with HIV. Therefore, building capacity and enhancing universal access to rapid and accurate laboratory diagnostics are necessary to control TB and HIV-TB coinfections in resource-limited countries. The present review describes several new and established methods as well as the issues and challenges associated with implementing quality tuberculosis laboratory services in such countries. Recently, the WHO has endorsed some of these novel methods, and they have been made available at discounted prices for procurement by the public health sector of high-burden countries. In addition, international and national laboratory partners and donors are currently evaluating other new diagnostics that will allow further and more rapid testing in point-of-care settings. While some techniques are simple, others have complex requirements, and therefore, it is important to carefully determine how to link these new tests and incorporate them within a country's national diagnostic algorithm. Finally, the successful implementation of these methods is dependent on key partnerships in the international laboratory community and ensuring that adequate quality assurance programs are inherent in each country's laboratory network.     

Estimating impacts on developing countries of the decrease in U.S. training opportunities for foreign medical graduates.

Between 1973 and 1983, the number of foreign nationals from developing nations who entered the United States for graduate medical education decreased by approximately 90%. Many of those who would have studied in the United States if this decrease had not occurred would have returned home to serve their countries. To estimate the impact of this loss, a survey was conducted in six major cities in Latin America between 1983 and 1989. Selected local medical students interviewed 554 physicians who had returned home after U.S. training and 60 of their classmates who had not trained there. The findings indicate that the returned physicians had given approximately twice as much time to teaching, research, and medical administration as did those who had not left home. The authors maintain that this and related findings show how the curtailment of opportunities for training foreign nationals in the United States is detrimental to both the aspirations of developing nations and the influence of the United States in world affairs.     

Influenza vaccine: an effective preventive vaccine for developing countries

The Influenza virus A, B and C causes disease in humans, birds and animals. The Influenza type A causes moderate to severe illness in all age groups in humans while the illness caused by type B is of milder and it is primarily affects children. Among many subtypes of influenza A viruses, currently influenza A(H1N1) and A(H3N2) subtypes are circulating among humans. Influenza is a serious public health problem that causes severe illnesses and deaths for higher risk populations. Influenza virus is characterized by frequent mutations - antigenic drifts (minor antigenic change, both A and B) and antigenic shifts (major antigenic change, only A). The current human pandemic A/H1N1 is an example of antigenic shift. It slowly established circulation globally; subsequently endemic/seasonal viruses in both hemi-spheres are H3N2 and H1N1. The novel Influenza A (H1N1) 2009 virus was first identified by United State Centers for Disease Control and Prevention (US CDC) on 17th April, 2009 in samples from two Californian children. As of August 2010, 18,000 people had died globally due to the pandemic flu. The illness rates were highest in children and young adults (20-40% of the population), the hospitalization rates highest in children below the age of one. The case fatality rates varied tremendously and were estimated to be between 0.0004- 1.5% (0.05% in US, 0.025% in UK, lowest in children). The most effective way to prevent the disease or severe outcomes from the illness is vaccination. The Trivalent Inactivated vaccines (TIV) are of three types: whole virus, split-product, subunit surface-antigen formulations and they are grown in embryonated hen's eggs. Whole-virus vaccines, because of adverse reactions, especially in children, are not currently used. Most influenza vaccines are split-product vaccines, produced from detergent treated, highly purified influenza virus, or surface-antigen vaccines containing purified hemagglutinin and neuraminidase.     

Strategies for greater impact in developing countries

Effective AIDS education programs are needed to prevent AIDS. They must integrate HIV/AIDS messages into basic health care services and adapted them to cultural norms and values. They should eliminate the mystery surrounding human sexuality. Effective AIDS education programs must examine control of communicable diseases and the relationship between gender issues and effective health care treatment. The infrastructure and resources to direct vertical HIV/AIDS programs generally do not exist in developing countries. All too often senior professionals accept positions in these vertical programs, which limits their ability to lobby for integrated HIV/AIDS programs. Donor organizations should make sure that all projects which they support have an AIDS component and work with other organizations to ensure that prevention and control of sexually transmitted diseases (STD)/HIV/AIDS is completely integrated into health care delivery services. All health workers should undergo AIDS prevention and control training. Supervisors should make sure that subordinates practice AIDS control. Benefit packages should not be offered to attract health workers. Just because nationals may make up an information, education, and communication (IEC) program does not mean that they will adapt the program to cultural values. Donors must provide appropriate educational strategies and programs to developing countries. Social change evolves from the culture. Health care workers must help find culturally appropriate education strategies. IEC has not reached its objectives in prevention and control of STDs. Communication mechanisms that allow human sexuality to be a subject of every day discussion without causing embarrassment, uneasiness, and outrage are needed.     

Preventing mother-to-child transmission of HIV: practical strategies for developing countries

The HIV pandemic has greatly affected women of childbearing age in developing countries and, thus, their offspring, through mother-to-child transmission (MTCT) of the virus. Scientific advances, most of them established by randomized clinical trials, have recently led to the development of practical strategies aiming to reduce the public health burden of MTCT of HIV. These advances came first in non-breast-feeding populations, for example, in Thailand and, more recently, in African populations, where breast-feeding remains the predominant mode of infant feeding. This article reviews major accomplishments in this area, outlines practical issues for program implementation, and suggests future research needs. Short-course zidovudine and short-course nevirapine in the peripartum period currently represent 2 valid options to reduce MTCT of HIV in developing countries if appropriate prenatal, obstetrical, and postnatal care is provided and if alternatives to breast-feeding are considered according to the local situation and the mother's individual decision.     

Global health priorities for developing countries: some equity and ethical considerations

Although the need to make health priorities equitable in addressing health disparities among populations of the world is widely acknowledged, there are presently no clearcut mechanisms for achieving this goal at the global level. This paper highlights some of the limitations associated with priority setting based exclusively on the interplay of burden of disease and cost-effectiveness analysis, and identifies occasions when equity considerations may favor conditions lacking immediate evidence on cost-effectiveness but associated with substantial burden in individuals and the society and for which optimal interventions are time bound. It also highlights the implications of overlooking conditions and issues that are deserving of high-priority status by global health actors and are in the longer-term interest of donor recipients. It concludes by exploring how representative mechanisms for societal preferences such as the periodic resolutions of the World Health Assembly backed by commitments of national governments provide a framework for making global health priorities more equitable.     

Democracy: the forgotten challenge for bioethics in the developing countries

Background  

Bioethics as a field related to the health system and health service delivery has grown in the second half of the 20^th century, mainly in North America. This is attributed, the author argues, to mainly three kinds of development that took place in the developed countries at a pace different than the developing countries. They are namely: development of the health system; moral development; and political development.     

Medical physics in developing countries: looking for a better world

Medical physics has been identified as one of the key areas that need to be developed to improve healthcare. However, the level achieved in developing countries represents a stark contrast to the level that exists in Western Europe or North America. The challenge for developing countries is to build the required infrastructures, to acquire the equipment, to attract highly qualified professionals and to develop education and training programs and political policies for effective and accessible care within budgetary constraints. The state-of-the-art technological developments in medical physics cannot be viewed as a uniform reality all over the world. There is, of course, a wide difference in emphasis and approach when dealing with developing countries, compared to developed nations. As quality assurance and cost-benefit guidelines in the practice of radiation therapy and diagnostic imaging are being developed and debated in developed countries, the perspectives of the availability and standards of healthcare taken for granted in these countries stand in stark contrast to the level administered in developing countries. In this contribution, the overall situation of medical physics in developing countries and the barriers to improvement are discussed, and some possible solutions and ways to bridge the gap between developed and developing countries are suggested.