The key to improving medical care in the developing world isn't better doctors -- it's educating everyone else.
- By Charles Kenny<p> Charles Kenny is a senior fellow at the Center for Global Development, a Schwartz fellow at the New America Foundation, and author, most recently, of Getting Better: Why Global Development Is Succeeding and How We Can Improve the World Even More. "The Optimist," his column for Foreign Policy, runs weekly. </p>
In 2007, a team of World Bank researchers studying the quality of health care in developing countries visited a clinic in rural Tanzania. They watched as a mother brought her 9-month-old into the doctor’s office, carrying the child on her back. The mother stood in front of the desk and told the doctor that her daughter had a high fever. Without moving from behind his desk, where he could not see the girl, the doctor filled a prescription for malaria medicine and sent mother and child on their way. The World Bank research team stopped the pair and asked some follow-up questions. A nurse on the team quickly found the child was suffering from pneumonia, not malaria.
The doctor was not overworked; he saw 25 patients that day, comparable to the average primary care physician in the United States. And he was trained in diagnosing both malaria and pneumonia, both common diseases in Tanzania. Moreover, the health facility had the medicine to treat both diseases. But without the intervention of the research team, the child would have died. The World Bank’s research suggests the incident was hardly unique. On average, doctors in Tanzania take fewer than a quarter of the diagnostic steps needed to confirm malaria in patients showing symptoms. The average number of questions in an interaction with a public-sector doctor in India is precisely one: "What’s wrong with you?" MIT economists Abhijit Banerjee and Esther Duflo surveyed health care in Udaipur, India, and found that patients were given a shot in 66 percent of visits to private medical facilities — usually unnecessarily and usually steroids and antibiotics, which cause premature aging and exacerbate the problem of drug-resistant strains of bacteria, respectively.
A considerable proportion of deaths in the developing world — more than a third of them, according to the World Health Organization — are the result of just a handful of communicable conditions: pneumonia and other respiratory infections, diarrheal diseases, AIDS, malaria, and tuberculosis. There are plenty of reasons for this — not least low vaccination rates, poor sanitation, and limited access to treatment — but one big factor is the kind of misdiagnosis the girl in the Tanzanian clinic received: Even patients who are lucky enough to be treated are often misdiagnosed and have treatment prescribed incorrectly. That is why it is great news that a number of cheap diagnostic tools simple enough to be used by patients themselves are coming online.
There is no simple solution to the problem of getting doctors to do their job better in developing countries. Training and education alone certainly won’t cut it: The World Bank researchers found that three years of additional medical training improved diagnostic performance in Tanzania by just 1 percent, because all too often the problem is not lack of knowledge but lack of application. But if the supply side of the health-care equation is daunting, what about demand? Part of the solution might be to empower patients with more knowledge — to create better-informed consumers. And one way to do that is to provide access to cheap and simple diagnostic kits that would allow patients to test for common diseases themselves. If a doctor prescribes treatment for malaria to a sick child without proper diagnosis, and a home test has suggested that in all likelihood the child has pneumonia, then parents can demand a proper exam or go to a different doctor.
Diagnostic devices are big business worldwide. Diagnostic imaging — tools like X-ray machines and MRIs — alone accounted for nearly a quarter of global medical-device sales revenues in 2009, to the tune of more than $50 billion. But the tools are designed for rich countries, to be used by skilled technicians to uncover rich-world medical conditions — which is unsurprising, given that the United States, Germany, Japan, France, Italy, and Britain account for 70 percent of global sales. (Three-quarters of those medical devices that do end up in developing countries do not function and remain unused.) To empower medical consumers in poor countries, diagnostic technologies need to be very simple, hygienic, and cheap. Think of mobile-phone-based eye exams, cholesterol and glucose test strips, and the home pregnancy test.
Diagnostics for All (DFA), a nonprofit medical firm, is working on a range of such simple tests for use in the developing world. Its initial project is designed to spot the side effects of medicines used to treat people with tuberculosis and HIV/AIDS in developing countries. Around a quarter of the 2.8 million people in the developing world on AIDS medications are suffering liver damage as a result, compared with a 2 percent rate in the United States, thanks in large part to more active (but currently expensive) screening after which treatment regimens are changed. The DFA test, targeted to cost 10 cents or less, is a piece of paper that changes color, like a chemistry class pH tester, depending on liver toxicity — one color indicates the need for closer monitoring, another the need to change the treatment immediately. The company is also developing a test for spoiled milk and an aflatoxin test that will allow farmers to identify crops affected by mold that can cause stunting and liver damage. It will do so at one-twelfth the cost of existing tests.
DFA tests don’t require clean water, syringes, refrigeration, lab equipment, or skilled technicians. Users put a drop of blood, urine, or milk on the edge of the paper, and it is wicked to the test material printed on the card, which changes color if the milk is spoiled, the liver is damaged, or the crop has been affected by the mold that produces aflatoxin. They literally blot test material onto paper.
DFA’s CEO, Una Ryan, told me that the company is contemplating similar tests for fever and diarrhea. Given the quality of health-care services in many developing countries, that kind of information could be lifesaving. And if it empowers some patients to demand more from their health-care workers, it might play an important role in improving the quality of service provided to everyone else, too.