PERSONAL PRACTICE

Experience of working fora medical NGO,a contribution to global childhealth?JBM van Woensel

AbstractPaediatrics has strongly globalized during the recent decades. Increased

collaboration between healthcare workers and institutes beyond national

borders is needed to establish and sustain improvement of paediatrics.

The growing medical technical progression is mainly applicable in the

high-income countries. In contrast, in resource-limited settings the high

mortality mainly caused by conditions that are either preventable of treat-

able with low-cost interventions. Experiencing this increasing gap by

working in a resource-poor setting is will make a modern paediatrician

a well-balanced doctor.

Keywords globalization; international collaboration; non-governmental

organization

Case 1

A previously well 7-year-old Somali girl who had been a resident in

the Netherlands for 3 years was admitted to our hospital. One

month prior to review she progressively lost her appetite, devel-

oped general malaise and started to lose weight. On physical

exam she was very cachectic and had generalized lymphadenop-

athy. Further work-up showed a large retropharyngeal abscess

with vertebral destruction at level C2 on a CT-scan of the chest.

She was admitted to our PICU after surgical decompression of the

abscess. Analysis of an aspiration sample demonstrated acid-fast

bacilli and disseminated tuberculosis was diagnosed. Remarkably

none of the four resident physicians involved in he post-operative

care of this patient had ever seen a child with tuberculosis before.

Introduction

The impact of globalization over the last few decades was initially

cultural and economic. However with the rapid pace in commu-

nication and increased movement of populations medicine and

healthcare have also become globalized. There are several factors

that have been responsible for this. Firstly paediatrics in resource-

poor settings is becoming increasingly complex due to emergence

of new infectious diseases which cross international boundaries.

This has led to rapid diagnostic testing, development of new

therapies and changing guidelines for treatment and prevention

for these illnesses. Secondly, socioeeconomic changes and

urbanization have contributed to an increase of life-style related

non-communicable diseases in many low-income countries.

Thirdly, travel and increased migration have contributed to an

increasing number of patients with ‘exotic’ diseases in high-

income countries. Finally there has been significant globaliza-

tion of paediatric research.

Increased collaboration between healthcare workers and

institutes beyond national borders is needed to establish and

sustain improvement of global paediatrics. The purpose of this

review is to demonstrate this collaboration in global child health

from the scope of patients, medical doctors and organizations.

JBM van Woensel MD PhD is a Paediatric Intensivist in the Paediatric

Intensive Care Unit/G8ZW, Emma Children’s Hospital/AMC, Amsterdam,

The Netherlands.

PAEDIATRICS AND CHILD HEALTH 22:11 496

Patients

Childhood mortality in low-income countries has decreased since

the 1970s but despite this over 10 million children under 5 years

of age die every year primarily from gastroenteritis and pneu-

monia. Both these conditions are either preventable or treatable

with low-cost interventions. Most of these children would have

had antecedent serious illnesses such as measles or conditions

associated with micro-nutrient deficiency and anaemia. In addi-

tion (re-)emergence of infections due to avian flu, Ebola virus

and West Nile virus and multi-drug-resistant tuberculosis forms

a serious threat to children living in low-income countries.

Tropical diseases in children involving rarer bacterial and para-

sitic diseases have been largely ignored and yet continue to

remain a major source of severe morbidity and also mortality.

Strong international collaboration and exchange of knowl-

edge, skills and resources are needed to further increase our

insight in epidemiology, prevention, diagnosis and treatment

options of old, new and neglected diseases in order to improve

child health in low- and middle-income countries.

Increased travel, trade and migration have, among other

factors, contributed to the transnational spread of infectious

diseases. For example, the number of patients with tuberculosis

has increased in the Netherlands during the recent years. This

can entirely be explained by an increase in immigration from

endemic areas. In 1999 an outbreak of West Nile virus infection

was reported in New York.

Although the absolute number of the patients with former

known ‘exotic’ diseases in high-income countries is low, it is

very relevant that healthcare professionals have knowledge of

early recognition, diagnosis and treatment of these diseases.

Case 1 illustrates this very clearly.

On the other hand, demographic and social changes in particular

increased urbanization in developing countries are accompanied

by an increase in non-communicable diseases in which children

are not spared. For example, obesity among children is becoming

epidemic in many urban areas in low- and middle-income

countries.

All these developments are illustrative for the dynamics and

increasing international character of medicines including paedi-

atrics and underscore the need for strong collaboration between

paediatricians in order to sustain improvement in global child

health.

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PERSONAL PRACTICE

Healthcare professionals

Advances in technology and better scientific understanding of

mechanisms of disease have led to an enormous stride in the

management of very complex patients in the high-income

countries. The orchestrated progress in paediatric intensive

care medicine, oncology, transplantation medicine and molec-

ular biology have allowed for very sick children to survive and

contributed to the further decrease of childhood mortality in the

Western world. Alas this is at the expense of a huge increase in

medical costs. In the Western world scarcity of resources is less

pressing and clinicians can be advocate for their individual

patients’ medical needs without concern for other consider-

ations. At the same time this may lead to major ethical dilemmas

with ethically very difficult and complex situations as is

demonstrated with Case 2.

Case 2

A 2.5-year-old Caucasian boy was admitted to our hospital with

abdominal pain and was subsequently diagnosed with hepato-

blastoma. He was treated with chemotherapy prior to surgery and

admitted to our PICU after an extended hemi-hepatectomy. The

post-operative course was complicated by a very unstable circu-

latory situation. One day after surgery he had cardiac arrest due to

hypoxia after which he was successfully resuscitated. The

following day he went into hepatic failure due to thrombotic

episode involving his hepatic and portal veins. Despite throm-

bectomy his liver function did not improve. He subsequently had

a liver transplant. The boy survived, but became neurologically

very severely impaired due to brain ischaemia.

Case 3

Recently I had the opportunity to work with Medicines sans

Frontiers in Myanmar as a visiting paediatrician-intensivist. A

6-year-old boy was admitted with severe cachexia, extremely

distended abdomen due to ascites and severe dyspnoea. He was

suspected of tuberculous peritonitis and treated with anti-

tuberculosis therapy and oxygen. Nutrition support was

commenced. Limited laboratory precluded to confirm the diag-

nosis. There was no family and the boy was literally isolated day

and night in a separate room due to the TB. Every day at the end

of the day I took some time to sit beside him, holding his hand.

Upon my return from another project 3 months later I found my

young patient fully recovered. He took my hand this time, not

letting loose for the rest of the day.

In contrast, in resource-limited settings childhood mortality is

still very high and mainly caused by diarrhoea, pneumonia,

measles and malnutrition, conditions that are either preventable

or treatable with low-cost interventions.

The gap between low-income and high-income countries has

become wider and it is perhaps essential for all health workers

in the high-income countries to be aware of this. In the first

place because working for an NGO can be a major cultural shock

for a western physician. Working in as a field doctor with severe

resources limitation may help to educate the physician of the

major deficiencies in the availability of healthcare for the vast

majority of human beings. It comes as a major shock to the

newly arrived dedicated doctor that it is normal for many of

children not to have a house nor access to running clean water

from the tap or the possibility to see a doctor. Death from

relatively treatable conditions such diarrhoea or pneumonia

makes the individual initially feel helpless. Yet seeing that very

simple technology e.g. oxygen from a cylinder or oral fluids can

restore life to a moribund child can become an epiphany (see

Case 3).

Besides this awareness of the increasing gap between high-

and low-income countries may be helpful to count our bless-

ings and to realize that working as a doctor in high-income

countries indeed offers tremendous opportunities for our

children.

PAEDIATRICS AND CHILD HEALTH 22:11 497

Institutions and organizations

The number of medical non-governmental organizations (NGO)

has risen strongly concomitant with the globalization in the 20th

century. Many of these NGOs are involved in care for children. In

general, however, the involved staff members have had no

specific training in paediatrics and the organizations usually do

not employ its own paediatric advisor. The Global Child Health

Group (GCHG) is a group of paediatricians proficient in the field

of international paediatrics, which is based in the Emma Chil-

dren’s Hospital AMC in Amsterdam and affiliated with the

Amsterdam Institute for Global Health and Development

(AIGHD). Our goal is to make a contribution to the improvement

of children’s health across the globe by means of by setting up

training and education projects and scientific research. Through

the unique combination of know-how and experience, the GCHG

also functions as a centre of knowledge that can be consulted by

NGOs and policy makers. This has been very successful so far.

Conclusion

Paediatrics has become increasingly international during the last

decades. Strong collaboration between paediatricians beyond

national borders is needed. This will help to establish and sustain

improvement of global paediatrics in the broadest sense from the

point of view of the patient, clinician and institutions.

From a personal point of view I experienced that working for

an NGO several times made me richer. I learned much about very

interesting diseases and the differences in healthcare situations. I

hardly ever have felt it more rewarding being a doctor than in

a resource-poor setting saving lives with very simple interven-

tions and exchanging knowledge. I am convinced that literally

being faced with the tremendous gap there is in healthcare

situations made me a better doctor! So go young fellows, and

spend some time in working in a different setting! A

FURTHER READING

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diabetes and sub-clinical inflammation. Asia Pac J Clin Nutr 2008;

17(suppl 1): 172e5.

� 2012 Elsevier Ltd. All rights reserved.

PERSONAL PRACTICE

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Infect Dis 2004 Jul; 15: 199e205.

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� 2012 Elsevier Ltd. All rights reserved.