A Walk to Beautiful

From the leaflet sent by Médecins Sans Frontières, a story of an 11 year old, raped, who became pregnant and had a very difficult birth. She ended up with a dead baby and an obstetric fistula. Four years later she had surgery to repair the fistula, a breach between the bladder and the vagina, but in the meantime her adolescence had been a time of suffering, misery and rejection.

Many women in Africa suffer a fistula because of a difficult birth, the result of pregnancy in the very young, or of female genital mutilation. They can rarely get to a hospital in time: they are too far away, there are no roads, there are no qualified surgeons. As a result the women become incontinent, are shunned even by their families, and live a reclusive life.

Thanks to the blog Rebuilding Sierra Leone One Child at a Time, in my sidebar as SaLonePikin (shorter), I have found out about the film A Walk to Beautiful. It is a documentary:
It tells the stories of five Ethiopian women who suffer from devastating childbirth injuries and embark on a journey to reclaim their lost dignity. Rejected by their husbands and ostracized by their communities, these women are left to spend the rest of their lives in loneliness and shame. The trials they endure -- and their attempts to rebuild their lives -- tell a universal story of hope, courage, and transformation. See also The Fistula Foundation.

I recommend the SaLonePikin blog if you are interested in Africa in general, or Sierra Leone in particular, and it has recipes too!

The French health service is changing

When we first lived in France, about 15 years ago, I was taken aback by the differences in the health services between France and the UK. I kept having to remind myself that I couldn’t walk off without paying - I’d have to pay before I left the surgery.

GPs were very inclined to prescribe anything you wanted, or could possibly want. When one of my sons had tonsillitis I can remember coming away from the pharmacy with 440 FF (66 euros) worth of pills and potions. One of them turned out to be some sort of salt water gargle! Yes, the money was reimbursed (though not fully) but you had to collect the little stickers from the packets and send them off.

What is more, if you were so inclined, you could go to each and every doctor in the vicinity, presumably collecting prescriptions as you went along. You could also go to any specialist you wanted to without being referred by a GP. Seventy percent of costs were covered by the state and the remaining amount by top-up insurance.

I know things have changed. There are posters up in pharmacies assuring people that generic medicines are perfectly OK. You have to register with one GP, your medecin traitant. You have a carte vitale and are computerised. You can no longer take yourself off to a specialist without a referral, apart from gynaecologists, ophthalmologists, and dentists, without incurring a financial penalty. ( I’m intrigued to know why gynaecologists should be exempt.) The state no longer covers the full costs: there is a non-refundable charge of 1 (one) euro and any treatment costing over 91 euros has a charge of 18 euros. There is supposed to be a safety net for the most vulnerable.

All those years ago a friend’s husband fell from a ladder and damaged his back. He was hospitalised and received excellent treatment, but he was self-employed and they struggled with the loss of income and paying hospital bills. It took ages for the state and insurance payments to arrive. As my friend said, the authorities are very quick to take your money but very slow in giving any back. I don’t know whether this has improved or not - it would need to.

I gather from The Lancet the health service is still in considerable debt so Sarkozy is planning to introduce yet more measures: to increase the non-refundable charge from 1 euro to 10 euros; to control drug prescriptions further; to tighten up on excessive sick-leave; and to reduce the levels of state reimbursement when people self-refer to specialists.

It seems that medical staff are not happy.

DNDi

The Drugs for Neglected Diseases initiative.

I hadn’t heard of it before today. It is based in Switzerland, a non-for-profit organisation which develops drugs and systems for treating diseases which typically occur almost exclusively in developing countries.

Some of theses diseases such as malaria and tuberculosis are seen in developed countries as a result of travelling, but the drugs produced by the large pharmaceutical companies are generally too expensive for use in developing nations. Other diseases such as sleeping sickness, Chagas disease, leishmaniasis, normally never occur in wealthier nations so the drug companies have no incentive to manufacture them because the financial rewards are minimal.

The reason I came across it was because they have produced a new anti-malaria drug called ASAQ which is effective, simple to take and inexpensive. It will not be patented, so ensuring its availability to anyone who needs it.

• Malaria, is, with HIV/AIDS and tuberculosis, one of the three most important diseases in Africa according to WHO. It is a major cause of morbidity and mortality worldwide, and consumes 25% of household incomes in Africa.
• The disease is present in over 100 countries and threatens half of the world’s population.
• Every year, 350 to 500 million cases of malaria occur worldwide, with over 1 million deaths, affecting mostly children in sub-Saharan Africa.
• Malaria remains the single largest cause of death for children under five in Africa, where it kills one child every 30 seconds – this translates to the deaths of approximately 3,000 children every day.

Conscientious objection in medicine, or paternalism

I came across a paper in the New England Journal of Medicine entitled Religion, Conscience, and Controversial Clinical Practices. The essence of it was that a survey was carried out on a random selection of doctors in the USA and it was found that many don’t feel an obligation to let their patients know about treatments which are legal but which they find morally wrong, nor do they feel they need refer them on to another doctor who may not have such views. The article asks whether it is right that doctors should refuse any information to their patients, to discuss it, or to refer them on, and where should the balance lie between the patients rights and the rights of healthcare providers not to have to carry out practices against their principles.

I remember when I was a student it was generally known not to go to such and such doctor at the university because she was Catholic and absolutely refused to prescribe contraceptives. I also remember being sent away from a family planning clinic of all places and being told not to come back until I had had a baby! Why did she think I had gone there in the first place? Because I didn’t know how to do it? She thought it was time, after 4 years of marriage, that I should have a child. I managed to hang on there for another three years, having found a different clinic in the meantime.

As a result of those relatively trivial experiences (though they didn’t feel like it at the time), on reading the paper I immediately thought that it was totally unjustifiable for a doctor to withhold treatment and/or information for any reason.

Reading further I found this article in the BMJ where the conclusions are

"Values are important parts of our lives. But values and conscience have different roles in public and private life. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own."

It seems a reasonable view until you read one of the responses wondering whether he would have been able to have been a conscientious objector in Nazi Germany or Stalinist Russia. Then today I read NHS Blog Doctor: The extended role of the Health Care Professional which did make me think yet again. It really isn’t easy.