As a student in School of Public Health I learned one basic fact of life; new ideas in most fields including medicine usually benefit the most advantaged in society the most. This lesson will follow me when I started practicing medicine as a physician in Baltimore City. In the clinics and the wards in which I practiced I discovered some of the many reasons why new ideas were more beneficial for the wealthy, better educated and the well connected;
- These new medical interventions are usually expensive
- The disadvantaged are also less informed and cannot demand for these and the offer may not be made
- Doctors may decide some patients do not have the support system needed to manage potential complications
- Minorities and low income individuals usually to have other conditions that may make such procedures non-ideal
- Sometimes new procedures or medications may only be available in clinical trials and disadvantaged minority individuals are poorly represented in studies and clinical trials
I would not be lying if I told you that I have encountered every single one of these barriers in various situations in my clinical experience. I must brag a little that I have been able to surmount many of these hurdles mostly by asking two basic questions; “why not?” and “how can we make this happen?” Some of my biggest successes have been when I have been able with loads of assistance by colleagues to get the system out of the way of patients. My most painful failures are when I have failed to help patients get out of their own way when I knew the system could help them. Whilst my failures in trying to make systems change have been bigger and probably would have benefited more if successful my tears are abounds when I cannot get one individual accept a great idea or procedure that could be beneficial to them.
I still remember the 57 year old man who would not allow me to refer him for a kidney transplant. He said “I feel this is not for me, I would not like to take this from some another person who deserves it more”
I could not convince him to change his mind, a few years later in another practice his wife remembered me and informed me of his passing. I cannot tell if she came looking specifically for me, but the second practice was about 20 miles from where I used to see her husband. In a city like Baltimore with a bad public transport system most low income patients do not travel that far for medical care.
In this post I would like to focus on a problem that keeps recurring. I was moved to write this post because just last week I learned that some of the new antiviral drugs for Hepatitis C were not as effective in strains of the virus common in people from many African Countries including Cameroon, Uganda and Democratic Republic of Congo. The irony is that some of these medications identified as not being effective in these strains may be licensed and marketed as being able to treat all strains and in some cases doctors would use this drug without doing a test to determine if it would work.
I believe problems like this usually happen for two reasons;
- Most studies do not recruit in some populations because of the cost and uncertainties of doing research in some countries
- Some populations have a culture of avoiding clinical trials as much as possible.
Whilst volunteering to be in a clinical trial is usually a personal and individual choice, the individuals who does this is indirectly helping first his society and humanity at large. In todays world as certain groups exclude themselves more and more from such trials, the less effective the medications developed are going to be at helping their group.
I would like to switch gears and focus on the current Malaria Vaccine Program Roll out in Ghana. If you discover a Malaria Vaccine and need to develop a program for implementation I guess New York City and London will be great for such a vaccine?!!. Ghana, Kenya and Malawi are involved in a Malaria Vaccine roll out organized by the WHO unfortunately in the past few weeks there have been negative stories and conspiracy theories. One such story suggested the vaccine was to sterilize Africans. I know I would love to discover a drug that can be injected once and will sterilize men women and even children whose sex organs are yet to fully develop.
The WHO chose countries most likely to be capable of this performing this pilot program successfully and can show benefits in implementation. I remember a similar story on an Ebola Vaccine study by Janssen Pharmaceuticals which was was moved to another country because of negative publicity.
Even though this recent event was not for a candidate vaccine I would like to disabuse people minds about clinical trials. If we want to ensure we get the full benefits of new advances in medicine we would need to participate. This is a basic law of nature and if we don’t get involved in these studies the drugs would end up on the market only for us to find out later they do not work as expected in our people.
A word to the wise, is in the North.
By Dr. Leonard Sowah, a physician in Baltimore, Maryland