The Medical System in Ghana

Ghana is a developing country in West Africa with a population of about 25 million. Medical illnesses in Ghana overlap with those in developed countries, but infection, trauma, and women’s health problems are much more prominent. Medical practice in rural Africa faces extremely limited resources, a multiplicity of languages (hundreds in Ghana), and presentation of severe illnesses at later stages than seen elsewhere. Despite these limitations, Ghana has established a relatively successful national medical insurance system, and the quality of medical practice is high, at least where it is available. Ghana also has a well-established and sophisticated administrative structure for the supervision of medical education and accreditation, but it has proven very difficult to extend medical training to rural areas, where health care facilities are particularly short of personnel. Physicians are sorely needed in rural areas, but there are few because of the working conditions and financial limitations. Hospital wards and clinics are crowded; time per patient is limited. This article details some of the differences between medical practice in Ghana and that in wealthier countries and how it functions with very limited resources. It also introduces the medical education and training system in Ghana. The following article describes an attempt to establish and maintain a residency training program in General Medicine in a rural area of Ghana.     

Rural Clinician Scarcity and Job Preferences of Doctors and Nurses in India: A Discrete Choice Experiment

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.     

在黄土丘陵区土质路面种草

土质道路水土流失是所有人工生态系统中最严重的土地利用类型,土壤侵蚀模数是相同条件下林地的250倍,农村道路修筑破坏了区域生态景观的完整性,为景观生态修复理论与技术研究提供了重要的实验场地。广大山区农村田间地块道路在种植和收获季节以外长期处于闲置状态,这为植物的种植和生长提供了可能。1997～2001年,以中国黄土丘陵区陕西省延安市小砭沟小流域农田道路为背景,以防止和减轻路面汇流引发的水土流失对道路的破坏和修复农村道路景观生态系统为目的,采用小区径流监测、施工统计和定点观测的方法,在路面进行了为期5a的种草实验。研究结果显示,农田作业道路路面不仅可以种草,而且具有一定生态经济价值,在条播下,胡枝子、小冠花、无芒雀麦每km年产值可达1068.88～3150.27元;同时,路面牧草可承受适度的通行压力,禾本科牧草一般可承受300t·次/a以下车辆碾压;道路种植禾本科牧草后,除有机质外,土壤中其它营养成份均有不同程度的亏损,因此有必要补充各种肥料延长路面牧草使用年限和提高牧草防蚀能力;路面种草后径流量减少46.15%～69.30%,土壤侵蚀量减少54.53%～77.80%,建设成本仅为石子路的27.69%～35.99%,维护费用仅为土质道路的30.52%,是一种经济可行的技术途径。道路种草后,路面雨季泥泞、旱季尘土飞扬的劣质景观被蜿蜒的绿色道路景观所取代,形似镶嵌在绵延山谷中的绿飘带,这无论在理论还是技术方面都是生态修复学和景观生态学研究的重要方向之一。     

Local technicians in long-term research projects: evaluation of 25 years experience in an active tropical research station

Most field ecology is conceived and financed by scientists from urban areas but is actually carried out in rural areas. Field staff can either be imported from urban areas or recruited from local residents. We evaluated the advantages and disadvantages of involving rural residents as local technicians over a 25- year period at active field research site in Costa Rica. We defined "local technicians" as local residents with no university education who acquired significant experience in field data collection, data management and/or laboratory work. We analyzed the experiences of incorporating these technicians into field research in developing countries from the points of view of scientist and of the local technicians themselves. Primary data were written responses from to a standardized survey of 19 senior scientists and Ph.D. students,and results from standardized personal interviews with 22 local technicians. Researchers highlighted the advantages of highly-skilled technicians with minimal staff turnover, as well as the technicians' knowledge of local ecological conditions. Local technicians considered the primary advantages of their jobs to be opportunities for continuing education training in science as well as cultural enrichment through interactions with people of different cultures. The main challenges identified by researchers were the lack of long-term funding for projects and extended training required for local technicians. Local technicians can be of great benefit to research projects by providing high-quality data collection at reasonable costs with low staff turnover. Over the last 25 years the research model at the field station we studied has evolved to the point that most long-term projects now depend heavily on local technicians. This model of involving local technicians in long-term research has multiple benefits for the researchers, the technicians and the local community, and could be adapted to a variety of settings in rural areas of developing countries.     

Management of medical technology in developing countries

To help developing countries to improve their medical use of physical technology, it is essential to study their difficulties and real needs. The greater severity of equipment problems in the third world, relative to the developed countries, indicates the important influence of an established technological culture. Strategies such as the training of technicians cannot succed in the absence of this culture unless effective national policies to manage technology are implemented. The training of high-level staff in medical technology management must be a priority for international action. Below this level it is necessary to train engineering graduates, rather than technicians, to manage and maintain equipment.     

Meeting the challenge: providing anesthesia services in rural hospitals.

Although the volume and intensity of surgery done in rural hospitals are not sufficient to support a fully trained staff anesthetist, it is not practicable for all surgical, anesthesia and obstetric services to be provided by specialists in referral centres. As the study reported by Chiasson and Roy in this issue shows (see pages 1447 to 1452), general practitioners (GPs) with limited additional training in anesthesia already play an important role in the provision of these services in rural areas. To ensure that there is a continued supply of physicians prepared to meet the needs of small communities, funding and opportunities for supplemental training in surgery, anesthesia and obstetrics must be made available to GPs.     

Urbanization and Mismatch with Protected Areas Place the Conservation of a Threatened Species at Risk

In this work, we report the predicted distribution of the threatened fluminense swallowtail butterfly, Parides ascanius (Cramer 1775), and correlate it to the presence of urban and protected areas within its range. The distribution was modeled using a genetic algorithm. The predicted distribution of the fluminense swallowtail shows high agreement within Rio de Janeiro state, in a near-continuous strip of 2,038,253 ha along the coastal lowlands, 17.8 percent of which is within urban areas. Only 8.7 percent (178,187 ha) of the remaining (nonurban) predicted model overlapped at least partially with protected areas (19 in all). Almost half of these protected areas also overlapped with urban areas, resulting in an additional loss of 58,751 ha. In seven of 19 protected areas, the distribution of P. ascanius was predicted by less than 50 percent of the models; five of the remaining protected areas are less restrictive reserves. Despite the wide distribution predicted by the models, only two of the observed occurrence points matched the predicted distribution within protected areas. Modeling threatened species distribution is a useful tool for highlighting gaps in networks of protected areas and should aid in planning to fill these gaps. However, in several developing countries with high biodiversity, there is insufficient basic biological information for many threatened species. In these cases, prospecting field studies are urgently needed.     

Exploring the influence of rural residence on uptake of organized cancer screening – A systematic review of international literature

Lower screening uptake could impact cancer survival in rural areas. This systematic review sought studies comparing rural/urban uptake of colorectal, cervical and breast cancer screening in high income countries. Relevant studies (n = 50) were identified systematically by searching Medline, EMBASE and CINAHL. Narrative synthesis found that screening uptake for all three cancers was generally lower in rural areas. In meta-analysis, colorectal cancer screening uptake (OR 0.66, 95 % CI = 0.50−0.87, I² = 85 %) was significantly lower for rural dwellers than their urban counterparts. The meta-analysis found no relationship between uptake of breast cancer screening and rural versus urban residency (OR 0.93, 95 % CI = 0.80–1.09, I² = 86 %). However, it is important to note the limitation of the significant statistical heterogeneity found which demonstrates the lack of consistency between the few studies eligible for inclusion in the meta-analyses. Cancer screening uptake is apparently lower for rural dwellers which may contribute to poorer survival. National screening programmes should consider geography in planning.     

The effect of landscape structure on dispersal distances of the Eurasian red squirrel

Landscape structure can affect dispersal and gene flow in a species. In urban areas, buildings, roads, and small habitat patches make the landscape highly fragmented and can inhibit movement and affect dispersal behavior. Similarly, in rural forested areas, large open areas, such as fields, may act as barriers to movement. We studied how landscape structure affects natal dispersal distances of Eurasian red squirrels (Sciurus vulgaris) in an urban area and a rural area in Finland, by monitoring juvenile red squirrels with radio telemetry. We observed extremely long dispersal distances—up to 16 km—in the rural study area, but shorter distances—on average only half a kilometer—in the urban study area. The landscape structure affected the eventual dispersal paths; in the rural landscape, dispersers favored spruce dominated areas and avoided fields along their dispersal route, although they occasionally even crossed wide fields. In the urban landscape, squirrels preferred areas with deciduous or coniferous trees. The movement steps made by dispersers were longer in the more hostile landscape compared to forested areas. Despite these effects on movement path, the landscape structure only had a minor effect on straight line dispersal distances moved from the natal nest. In other words, individuals moved longer distances and were likely to circumvent barriers in their path, but this did not affect how far they settled from their natal home. This result indicates that, although landscape structure has obvious effects on movement, it still may have only a small effect on other aspects of the population, for example, gene flow.     

Teaching and training in geriatric medicine in the European Union

In 1993 about 20% of the population in the 15 'old' member countries of the European Union (EU) was over 60 years of age and this percentage will increase to more than 25% in 2020. These developments play a key role for the investments in education and training to meet societies needs for health care services. In 2002 about 25% of the medical students in the 'old' EU did not receive any education in geriatric medicine. A question is who will provide the services for older people in related areas, like social care, community care, acute care in the hospitals, long-term care, permanent care and care for psychiatric patients? Geriatric medicine has been recognized as an independent specialty in 8 of the 15 member countries of the 'old' EU. In all EU member states the governments are autonomous regarding all aspects of health care services, including the recognition of specialties and specialist training programmes. A two years training in internal medicine has been recommended in the EU, followed by another four years of training in geriatric medicine. The specialist training has a hospital oriented character, however, it includes also community care and other institutionalised care like nursing homes. The curriculum should contain: biological, social, psychological and medical aspects of common diseases and disturbances in older people. A problem in many EU countries is the shortage of well trained researchers and leading persons for academic positions for geriatric medicine. In a number of countries chairs at the universities remain vacant for long periods of time or even disappear. Good services in the health care for older people need a high quality curriculum and training programme.     

On the Worrying Fate of Data Deficient Amphibians

The ‘Data Deficient’ (DD) category of the IUCN Red List assembles species that cannot be placed in another category due to insufficient information. This process generates uncertainty about whether these species are safe or actually in danger. Here, we give a global overview on the current situation of DD amphibian species (almost a quarter of living amphibians) considering land-use change through habitat modification, the degree of protection of each species and the socio-political context of each country harboring DD species. We found that DD amphibians have, on average, 81% of their ranges totally outside protected areas. Worryingly, more than half of DD species have less than 1% of their distribution represented in protected areas. Furthermore, the percentage of overlap between species’ range and human-modified landscapes is high, at approximately 58%. Many countries harboring a large number of DD species show a worrying socio-political trend illustrated by substantial, recent incremental increases in the Human Development Index and lower incremental increases in the establishment of protected areas. Most of these are African countries, which are located mainly in the central and southern regions of the continent. Other countries with similar socio-political trends are in southeastern Asia, Central America, and in the northern region of South America. This situation is concerning, but it also creates a huge opportunity for considering DD amphibians in future conservation assessments, planning, and policy at different levels of government administration.     

A Shipping Container-Based Sterile Processing Unit for Low Resources Settings

Deficiencies in the sterile processing of medical instruments contribute to poor outcomes for patients, such as surgical site infections, longer hospital stays, and deaths. In low resources settings, such as some rural and semi-rural areas and secondary and tertiary cities of developing countries, deficiencies in sterile processing are accentuated due to the lack of access to sterilization equipment, improperly maintained and malfunctioning equipment, lack of power to operate equipment, poor protocols, and inadequate quality control over inventory. Inspired by our sterile processing fieldwork at a district hospital in Sierra Leone in 2013, we built an autonomous, shipping-container-based sterile processing unit to address these deficiencies. The sterile processing unit, dubbed “the sterile box,” is a full suite capable of handling instruments from the moment they leave the operating room to the point they are sterile and ready to be reused for the next surgery. The sterile processing unit is self-sufficient in power and water and features an intake for contaminated instruments, decontamination, sterilization via non-electric steam sterilizers, and secure inventory storage. To validate efficacy, we ran tests of decontamination and sterilization performance. Results of 61 trials validate convincingly that our sterile processing unit achieves satisfactory outcomes for decontamination and sterilization and as such holds promise to support healthcare facilities in low resources settings.     

Population Migration: Implications for Lymphatic Filariasis Elimination Programmes

Human population migration is a common phenomenon in developing countries. Four categories of migration—endemic to nonendemic areas, rural to urban areas, non-MDA areas to areas that achieved lymphatic filariasis (LF) control/elimination, and across borders—are relevant to LF elimination efforts. In many situations, migrants from endemic areas may not be able to establish active transmission foci and cause infection in local people in known nonendemic areas or countries. Urban areas are at risk of a steady inflow of LF-infected people from rural areas, necessitating prolonged intervention measures or leading to a prolonged “residual microfilaraemia phase.” Migration-facilitated reestablishment of transmission in areas that achieved significant control or elimination of LF appears to be difficult, but such risk can not be excluded, particularly in areas with efficient vector-parasite combination. Transborder migration poses significant problems in some countries. Listing of destinations, in endemic and nonendemic regions/countries, and formulation of guidelines for monitoring the settlements and the infection status of migrants can strengthen the LF elimination efforts.     

The Importance of a Social Science Research Agenda in the Management of Protected Natural Areas,with Selected Examples

The advent of the modern protected area movement began in 1872 with the creation of Yellowstone National Park in the United States. For a century thereafter, as more nations began to set up protected area systems, the movement was largely western-dominated and adhered to ‘fences and fines’ forms of conservation. As many more developing nations gained independence in the latter half of the twentieth century, it was increasingly recognized that strict forms of conservation based on western ideals of nature could not be sustained in the long term. Specifically, many rural people in developing countries are dependent on local natural resources, and the conservation rules put into place in many protected areas frequently forbade all extraction and in many cases all entry except for tourism or research. This created a climate of increasing park-people conflicts that in many cases compromised conservation goals and led to a refocus in protected areas management and research in the social sciences worldwide. Here I describe survey and non-survey based protocols developed to study the effectiveness of protected areas in the societal realm. Policy gap analyses, rapid rural appraisals, key informant and focus group surveys and structured and semi-structured social surveys are described. Such studies can allow managers to plan for interventions where needed and can aid in designing appropriate local development projects in an effort to ameliorate park-people conflicts. I finish with a preliminary social research protocol, tested in May, 2009, for Yachang Orchid Reserve, Guangxi Province, the People’s Republic of China.     

A survey of Canadian rheumatology training programs, 1968 to 1978.

The committee on manpower of the Canadian Rheumatism Association retrospectively surveyed Canadian rheumatology training programs for the period 1968 to 1978. There were 133 trainees during that period, who accounted for a total of 201 trainee-years. Most trainee-years were taken up by first-year trainees, especially in the first half of the decade under study. Although three training centres accounted for two thirds of all the trainee-years, there was a progressive increase in the proportion of trainees attending other centres. The majority of trainees were Canadian medical graduates. More than one third of the alumni of these programs held full-time academic positions, and more than three quarters had some academic affiliation. One third were spending at least half of their professional time in teaching and research, but only 71 were spending half or more of their practice time in rheumatology in Canada. The remainder had established residence abroad or were spending at least half of their practice time in areas other than rheumatology. The rapid expansion of Canadian training programs has not been paralleled by a proportionate increase in rheumatologic manpower in Canada.     

Spatial Heterogeneity and Risk Maps of Community Infestation by Triatoma infestans in Rural Northwestern Argentina

Background

Fifty years of residual insecticide spraying to control Triatoma infestans in the Gran Chaco region of northern Argentina, Paraguay and Bolivia shows that vertically coordinated interventions aiming at full coverage have limited effects and are unsustainable. We quantified the spatial distribution of T. infestans domestic infestation at the district level, identified environmental factors associated with high infestation and then explored the usefulness of risk maps for the spatial stratification of interventions.

Methods and Findings

We performed spatial analyses of house infestation data collected by the National Chagas Service in Moreno Department, northern Argentina (1999–2002). Clusters of high domestic infestation occurred in the southwestern extreme of the district. A multi-model selection approach showed that domestic infestation clustered in areas of low elevation, with few farmlands, high density of rural houses, high mean maximum land surface temperature, large NDVI, and high percentage of degraded and deforested lands. The best model classified 98.4% of the communities in the training dataset (sensitivity, 93.3%; specificity, 95.4%). The risk map evidenced that the high-risk area only encompassed 16% of the district. By building a network-based transportation model we assessed the operational costs of spatially contiguous and spatially targeted interventions. Targeting clusters of high infestation would have reached ∼80% of all communities slated for full-coverage insecticide spraying, reducing in half the total time and economic cost incurred by a spatially contiguous strategy.

Conclusions and Significance

In disperse rural areas where control programs can accomplish limited coverage, consideration of infestation hot spots can contribute to the design and execution of cost-effective interventions against Chagas disease vectors. If field validated, targeted vertical control in high risk areas and horizontal control in medium to low risk areas may provide both a logistically and economically feasible alternative to blanket vertical insecticide spraying when resources are limited.     

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti

Introduction

At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.

Methods

Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.

Results

A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.

Conclusion

Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.     

城市化对本土植物多样性的影响——以廊坊市为例

虽然城市化对生物多样性影响的研究在发达国家是一个重要的研究领域,但是在发展中国家这方面的研究不多。通过案例研究,分析本土植物多样性沿着城市化梯度的变化,及其与生境土壤因子的关系。在廊坊市,中国北部一个快速城市化的地区,沿着中心城区、城区、郊区、远郊区城市化梯度,每个梯度选取6个样地进行本土植物多样性调查,记录种类数、多样性和种类组成,并分析了多样性指数。与远郊区相比,中心城区失去了88%的物种,物种多样性下降了78%,城区物种多属于禾本科、藜科等耐践踏、耐土壤紧实度的物种。远郊区的本土植物属于45个科,科数大于城区物种。相似性指数表明,城区和郊区大部分物种相同,但是远郊区差异较大。DCCA分析表明,土壤总氮、有机质含量是影响物种城市化分布的主要因素。城市化促进了物种分布的匀质化。     

The model of response to viral haemorrhagic fevers of the National Institute for Infectious Diseases "Lazzaro Spallanzani".

Viral haemorrhagic fevers (VHF) are severe and life-threatening diseases caused by a range of viruses. However, only four agents of VHF are known to be readily capable of person-to-person spread: Lassa virus, Crimean/Congo haemorrhagic fever virus, Ebola and Marburg viruses. Diseases caused by these viruses are endemic only in few areas in the world, most notably Africa and some rural parts of the Middle East and Eastern Europe. Nonetheless, the increasing volume of international travel presents a greater likelihood for the importation of these infections or of suspected cases in non endemic countries. Four conditions can lead to the importation and to the subsequent recognition of VHF within Europe: 1) patients arriving as a result of a planned medical evacuation; 2) persons who became sick on route to their destination; 3) persons discovered ill when entering a country, for example during routine clinical examination at the airport; 4) persons becoming sick after their arrival. Public health implications and the risk of secondary spread of pathogens in the above reported circumstances are very different. Similarly, preparedness and response should vary. This paper summarizes the present knowledge on the four VHF capable of person-to-person spread, describes the high isolation area constructed at the Italian National Institute for Infectious Diseases Lazzaro Spallanzani in Rome to respond to the occurrence of VHF. A brief overview of procedures and equipment adopted is provided.