PERSPECTIVE protecting global health workers from harm

Courting Danger while Doing Good — Protecting Global Health Workers from Harm Claire Panosian, M.D.

ntil the morning of February For starters, despite the fact that for international service now avail- U26, 2010, the name Eddie he had completed previous “clean able to undergraduates and other Roach meant nothing to me. water” assignments in Haiti, volunteers of all ages. By the time Then a desperate e-mail brought Burma, and Cambodia and taken they take my global health semi- the 32-year-old self-described previous trips to Africa, Roach’s nar, many students majoring in “global health missionary” into knowledge about malaria was international development have my life. Weeks earlier, Roach had sketchy, and he feared possible already worked abroad, often in been distributing handheld water side effects from preventive med- health-related programs. Patients purifiers in rural Uganda; now, ication. Second, he was focused with no formal health care skills according to his friend’s SOS, he on saving other people’s lives, have provided post-disaster care was in a Nevada intensive care not protecting his own. in Asia and Haiti; church groups unit awaiting dialysis and ex- In the past decade, interest in have journeyed to sub-Saharan change transfusion. Diagnosis? global health has surged — not Africa to comfort patients with Severe and complicated Plasmo- just among medical students, res- HIV–AIDS and their children. dium falciparum malaria. idents, and seasoned physicians, For many years, I have also The critically ill Roach had provided pre- and post-travel care actually sought help well before to medical and international de- he lost consciousness in his velopment professionals. Today, friend’s upstairs bedroom. Hav- this group includes not just aid ing become sick during his last workers and researchers headed days in Africa, he wanted to stop overseas but also many doctoral in London on his way home, but students, medical trainees, and an airline agent declined to change practicing physicians. Unlike lay his ticket. On the next leg of his volunteers, professional health journey, a flight attendant ob- care workers often know about served that Roach had a fever the vaccines they need and about and chills and suggested that he the vectorborne threats in the re- might have malaria. After land- gions where they’re headed, but ing in Los Angeles, he visited a they may still avoid taking pre- walk-in clinic. “Do I have ma- but among lay humanitarians as cautions. For example, according laria?” he asked. No, he was told well. The growing number of to a report on one group of ex- when his urine showed red cells. applications for overseas travel patriate workers that was return- You have a kidney stone, maybe grants and the increasing propor- ing from missions for the Inter- a urinary tract infection. Take this tion of medical students com- national Committee of the Red antibiotic, just in case. pleting international health elec- Cross in sub-Saharan Africa, 35% Finally, he reached Lake Tahoe, tives are two indicators of the of the participants had not tak- fell into a feverish sleep, and new enthusiasm.1 In 2009, 29.9% en the recommended malaria pro- didn’t wake up. Three weeks later, of graduating U.S. medical stu- phylaxis.3 In addition, both lay Roach was discharged from the dents had had an international and professional aid workers are hospital. His dialysis catheter health care experience, reflecting sometimes careless or naive about came out the following month. a 35% jump over a 5-year period.2 other overseas risks, whether from Today, if he could turn back But these numbers only hint environmental hazards, health the clock, Eddie Roach would at larger trends. As a tropical care–associated injuries, or road faithfully down antimalarial pills medicine specialist who also accidents. in Uganda. But when he began teaches on a university campus, Take the simple act of wading his trip, his mind was elsewhere. I am struck by the opportunities or swimming in fresh water,

2484 n engl j med 363;26 nejm.org december 23, 2010 The New England Journal of Medicine Downloaded from nejm.org at PARTNERS HEALTHCARE on April 15, 2011. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved. PERSPECTIVE protecting global health workers from harm

which in some tropical locales can icans abroad; currently, traffic The truth is that I’m all for result in the acquisition of schis- accidents involving some combi- overseas experiences. Such ven- tosomiasis. Dr. Terrie Taylor, a nation of cars, buses, motorcycles, tures changed my life when I was malaria researcher who has bicycles, trucks, and pedestrians young, and they continue to lived part-time in Malawi for 24 lead the list — particularly in change lives both here and years, has counseled hundreds of developing countries.4 Medical abroad. I’m also excited about medical students, residents, and workers must also be prepared for the new zeal to improve global other visitors on the risk of further potential causes of inju- health, which some observers see schistosomiasis and ways to be ry — namely, needlesticks and as a manifestation of unprece- “water-safe” in her second home. other occupational exposures to dented global altruism. Nonethe- Nonetheless, she recently told me, patients’ blood and body fluids. less, not everyone who wishes to “Lots swim in Lake Malawi — it Not long ago, I reconsidered work in developing countries is is irresistible. They generally buy this problem after meeting with a suitable candidate for such an locally sold praziquantel . . . four young residents. Having ar- assignment, and enthusiasm for and take it 3 to 6 months later.” ranged month-long electives at an international service should not Granted, the risk of getting African teaching hospital where blind anyone to its risks. One schistosomiasis in this situation many patients are infected with way to mitigate risks is to put in is small, and although the effica- HIV, each of the residents re- place a well-informed, carefully cy of post-exposure praziquantel quested a personal 28-day sup- structured process of screening, has never been formally studied, ply of antiretroviral drugs for pos- education, supervision, and pre- many people who are incubating sible post-exposure prophylaxis and post-travel care — for which schistosomiasis can abort infec- (PEP). One trainee, as further sponsoring organizations must tion with an ad hoc dose or two justification for such a cache, increasingly take responsibility. (assuming that they procure a added that she hoped to per- Disclosure forms provided by the author high-quality, non-counterfeit drug) form a lot of procedures during are available with the full text of this arti- or, at worst, end up with a treat- her stay. cle at NEJM.org. able case of granulomatous coli- My first reaction was to worry From the Program in Global Health, Division tis or cystitis. On the other about cost (a single course of of Infectious Diseases, and the Department hand, empirical treatment may PEP can be almost as expensive of Medicine, David Geffen School of Medi- come too late to prevent harm. as round-trip airfare to Africa), cine, University of California, Los Angeles. Sometimes I wish I could intro- but then I learned, to my surprise, 1. Panosian C, Coates TJ. The new medical duce certain risk takers to Dr. that health insurance would cover “missionaries” — grooming the next genera- Deane DeFontes, a former Peace the residents’ prescriptions. Next, tion of global health workers. N Engl J Med Corps volunteer who contracted I wondered whether African doc- 2006;354:1771-3. 2. Division of Medical Education. GQ Medi- schistosomiasis in Sierra Leone tors at the host facility were able cal School Graduation Questionnaire: all in the 1980s. DeFontes, who lat- to obtain similar treatment for schools summary report: final. Washington, er attended medical school at high-risk occupational exposures. DC: Association of American Medical Colleg- es, 2009. (https://www.aamc.org/download/ UCLA and now practices family Ultimately, after soliciting input 90054/data/gqfinalreport2009.pdf.) medicine in Oregon, is paraple- from colleagues, I acknowledged 3. Dahlgren AL, Deroo L, Avril J, Bise G, gic as a result of his infection. the wisdom of providing each Loutan L. Health risks and risk-taking behav- iors among International Committee of the Yet an impetuous dip in para- trainee with a supply of drugs Red Cross (ICRC) expatriates returning from site-laced waters — or exposure that, if unused, might be donated humanitarian missions. J Travel Med 2009; to any exotic blight, for that mat- to a house officer on site or to a 16:382-90. 4. Sleet DA, Wallace LJD, Shlim DR. Injuries ter — is not the greatest danger colleague back at home intend- and safety. In: Brunette GW, Kozarsky PE, facing modern global health work- ing to travel to a similar site. Of Magill AJ, Shlim DR, eds. CDC health infor- ers. Today, the road to the clinic course, making that decision was mation for international travel 2010: the yel- low book. Atlanta: Department of Health or the clinic itself may pose a the easy part: providing timely, and Human Services, 2009:209-14. greater hazard. For some years, reliable post-exposure counseling 5. Mohan S, Sarfaty S, Hamer DH. Human I have tried to remind all travel- and testing to overseas students immunodeficiency virus postexposure pro- phylaxis for medical trainees on internation- ers that injuries are the second and residents after a needlestick al rotations. J Travel Med 2010;17:264-8. leading cause of death (after car- or similar injury pre­sents a far Copyright © 2010 Massachusetts Medical Society. diovascular disease) among Amer- tougher challenge.5

n engl j med 363;26 nejm.org december 23, 2010 2485 The New England Journal of Medicine Downloaded from nejm.org at PARTNERS HEALTHCARE on April 15, 2011. For personal use only. No other uses without permission. Copyright © 2010 Massachusetts Medical Society. All rights reserved.