Village health workers’ role in primary prevention of diseases

plumeria (frangipani)

Villagers in many developing countries rarely see doctors or nurses. In fact, a fraction of medical graduates and nurses of English speaking parts of Africa or southern Asia, often emigrate to wealthy countries (Canada, USA, UK and Australia) as they are attracted by better pay and working conditions. Those doctors who, instead, remain in their home country tend to stay in the cities and not in rural areas.  Similarly, nurses are rarely tempted by rural villages. Doctors and nurses, however, are not necessary to improve rural health in developing countries. Two very successful programs in desperately poor parts of India’s Maharashtra State which were described in an interesting report appeared in the New York Times show that people with no or little formal medical training do successfully substitute for doctors and nurses. Once properly trained, these ordinary women and men help prevent most rural sickness by teaching people very simple acts such as the use of clean water, waste-disposal systems and more diverse farming. As a matter of fact, village health workers do have a huge impact on the health and prosperity of the community they serve. They visit pregnant women repeatedly, attend births, teach mothers about how to keep their babies healthy and check in on the children often.  They teach new mothers how to feed and care for their babies and how to treat diarrhea and fever. Children get regular immunizations, and tuberculosis,  scabies and leprosy are properly and effectively prevented. The main role of these health rural workers is teaching the community some essential preventive measures. Their potential role also in the prevention of HIV infection and cancer of the cervix uteri in young women should be properly and adequately stressed. They can really induce a major behavioral change in sex habits of the population by means of interpersonal communication activities. Health workers should be trained on this topic too and prevention of tumors should become a novel goal of these programs.

AIDS prevention in Zimbabwe

tropical nymphaea

According to the United Nations, about 33.3 million people worldwide are infected with HIV and the majority of those live in sub-Saharan Africa. The virus can be controlled with cocktails of drugs, but there is no cure and nearly 30 million people have died of HIV-related causes since the disease first emerged in the 1980s. The good news is however that the disease has taken a dramatic downturn in Zimbabwe, a country where its incidence was among the highest in the world. In fact, people infected with HIV were 29% in 1997 but ten years later, in 2007, they were 16%. How was it possible? The answer is: primary prevention. Zimbabweans have primarily been motivated to change their sexual behavior because of increased awareness about AIDS deaths which heightened their fears of catching the human immunodeficiency virus that causes it. The behavioral changes associated with HIV reduction consisted mainly in reductions in extramarital, commercial, and casual sexual relations, and associated reductions in partner concurrency. These changes were probably aided by prevention programs utilizing both mass media and church-based, workplace-based, and other interpersonal communication activities. The main lesson emerging from these data which were published in the PloS medical journal online is that, unless prevention efforts can be made more effective, there will ultimately be no victory in the fight against HIV/AIDS. This lesson is for all countries worldwide.

targeted therapies for advanced cancer or primary prevention of tumors: ethical and economical issues.

Targeted terapies have significantly changed the treatment of cancer over the past 10 years. These drugs are now a component of therapy for many common malignancies, including breast, colorectal, lung, and pancreatic cancers, as well as lymphoma, leukemia, and multiple myeloma. They are a sort of smart bombs designed to target the cancer cells and block or slow the growth of certain types of cancer minimising damage to healthy cells . Most of them, however, improve survival by only a few weeks or months but they don’t cure cancer.

Targeted therapies are incredibly expensive. For example multidrug colorectal cancer treatment regimens containing bevacizumab or cetuximab cost up to $30,790 for eight weeks. In the United States, sales of erlotinib, a drug which is able to prolong survival by few months in a selected fraction (no more than 20%) of lung cancer, totalled $457 million in 2008 (Annual report to shareholders, 2008. Genentech). This is the reason why their use is an opportunity and a threat to every system that simultaneously seeks to improve the health of its members or citizens and to work within ever-tightening budget constraints.

These considerations open additional ethical issues. It is better to invest on a minimal increase in time survival for a patient with highly advanced gastrointestinal or pulmonary cancer or, instead, on the primary prevention of some preventable tumors when this is feasible?. Carcinoma of the cervix uteri represents a good example of preventable tumor. There is, in fact, compelling evidence that vaccination against human papilloma virus (HPV) in young girls allows total prevention of the tumor. Gardasil, the HPV vaccine, is currently being offered for approximately $120 per single dose. Three doses are required over a 6-month period, making the total cost for the HPV vaccine about $360. With the same amount of money which is required to treat a patient with advanced colon cancer administering the above multidrug treatment regimen ($30,790) we could pay for a vaccination campaign against HPV for 87,500 girls (!). While the patient with colon cancer will eventually die, the above population of future women will be be totally protected from carcinoma of the cervix uteri. I am well aware that biotechnological research in pharmacogenomics should not be stopped because it will eventually provide, in the future, the magic drug to stop cancer. At the same time, however, money should be used also for people of the third world to cope the emerging epidemic of preventable tumors at least because this will impact beneficially the life of the whole planet.