Transcript

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF:

I'm Dr. Linda Benskin, and I am a wound specialist at this point in life. I do independent research, mostly wound care, but other things as well for remote and conflict areas of tropical developing countries. I spent 5 years working in a remote conflict area of West Africa doing all kinds of medical, not just wound care. I treated everything that a normal general practitioner doctor would treat. 

It's not just in West Africa, of course, we've also spent time in Southeast Asia and South America and various other places. The problem isn't really mostly provider driven. It's due to a provider shortage and the fact that, even if there were a lot of providers, they tend to be located in the major metropolitan areas, and there are a lot more people living in rural areas who don't have good transportation in developing countries. So the people in those more remote areas have limited access to healthcare professionals. And a burgeoning business has built up over the decades of drug peddlers and both those that go on bicycles door to door and those that work out of village markets, who sell various and sundry drugs of all kinds, including pain relievers and antibiotics. So the big problem in my mind is that completely uneducated people have full access to a wide range of drugs that in more developed countries are only available by prescription, and they really have no clue what they're getting or how much they're getting or why they're getting it. And so whatever is out there is what's going to be taken and often in small enough quantities that they don't actually kill the germs. 

Yeah, so we can identify the problem real easily. The problem is figuring out how to solve that problem. Oftentimes these countries have even more strict laws about prescription medications than what we have in the United States, Europe, or Australia. But those laws cannot obviously be well enforced out in those remote areas. So what happens is you have this disconnect between what the law is and what actually happens. And so people who want to fix the problem tend to want to change the laws or change the policies of the government, and that's not really going to address the root cause. So if you want to address the root cause, I think the better way to do that is to provide village health workers in those remote and conflict areas who have a basic understanding of the reasons for antimicrobial resistance and the reasons for stewarding those resources. 

And in order for those village health workers to have any credibility. And I spoke to the Minister of Health in Ghana and got our village health worker program approved. And my reasoning was they were saying, oh, we don't want people with so little education being able to prescribe antibiotics. And I said, if you allow them to prescribe 2 of the safest, most common, most inexpensive antibiotics that are out there, then you don't get resistance to all the other antibiotics. And they have the credibility. If they use those antibiotics correctly for the diseases for which they're indicated, then they can treat those things in the village. They'll help drive those bicycle peddlers out of business and they can refer patients who need more complex diagnosis and treatment to the big city where there are doctors, and the villagers are more likely to go for those cases because they have someone to help them know whether or not it was a wasted trip, it could have been treated at home or not. 

Well, there's always pressure, whether you're in a developing country or you're in New York City, wherever you are, there's always pressure when a patient comes to you, and they have a problem, and they're feeling uncomfortable, you want to give them a prescription so that they feel like you have done something. And I think that's where the antimicrobial stewardship issue comes in, is having the relationship with your patient that allows you to have credibility when you say, actually, no, you don't need a prescription medication for this. These are the things you need to do. And I think that it helps a lot. What I did in my practice when I worked in West Africa is that I put on the prescription pad the lifestyle changes or the other things that they needed to do, the breastfeed the baby every 2 hours because they have a viral diarrhea. And that I think helps the patient get that feeling that you did pay attention to them, you did hear them, and you did something proactively for them without giving them a prescription for a medication that they don't actually need. So I think a lot of it in our country is that our providers don't have the time to form those relationships. A lot of times we now have these large practices where patient doesn't even see the same pediatrician every time they come for a well check. And we really need to rethink that structure because that structure doesn't breed trust, and I think it leads to a lot of carelessness in prescribing. 

But yeah, I have friends who've worked extensively in India. And in India, these people who sell prescriptions are often called doctor, even though they might not even have a high school education. And they become friends with people and people trust them. They build relationships. And oftentimes the medications that they give people help them. And so people are more likely to trust them than a complete stranger who is a healthcare professional. And I think that reflects kind of poorly on us that we have not done a better job of creating those relationships and establishing that trust and giving that free advice that you need to give to be a part of the community so that the community trusts you and listens to you. And that's where I circle back around to my Village Health Worker program. So I've actually written an article that is basically a concept analysis of a village health worker that has recently started getting a lot more attention. 

But the idea is you have to very carefully choose these people, and they need to be people that are altruistic because you want them to primarily teach prevention so that the people don't get sick and need antibiotics. And so that they recognize that if someone does get a viral illness that can be treated with conservative measures. So they need to be chosen very carefully. And I give a lot of data from other programs showing what the qualifications of a village health worker ought to be. And then we need to work with the ministers of health, who tend to be a bit suspicious of lay health workers because they were really burned by the healthcare for all program that the World Health Organization put out back in the 1970s and 80s, where they actually made village health workers feel like they were doctors, and they overstepped and started doing things that were very inappropriate, including minor surgeries, for someone with very limited education. 

So I think when you make your boundaries clear and you give people good limited education, and you choose people very carefully for these roles, you can have very good success. An example of good success probably is in Laos, where they had village health workers whose sole area of care that they were allowed to practice in was malaria. And they gave them the ability to prescribe malaria medications, which can be quite dangerous if they're used inappropriately. But they taught these people how to use them with the understanding that the malaria medications were already out there in the villages, and people were using them indiscriminately. So they gave these people the tests that they needed to make sure the people actually had malaria. And then they gave them the ability to prescribe and the actual physical pills to give the people if they had malaria. And malaria has dropped to such low levels that people are no even requiring a prophylaxis if they're travelers to those areas, whereas that used to be practically, that was the leading cause of death in these areas. And they did that all through good antimicrobial stewardship using lay people who were minimally trained but were given appropriate resources.

References:

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Bang AT, Baitule SB, Reddy HM, Deshmukh MD, Bang RA. Low birth weight and preterm neonates: can they be managed at home by mother and a trained village health worker? J Perinatol. 2005;25(Suppl 1):S72-S81.

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Benskin LL. Incorporating wound care in a Christian village health worker training program. Presented at: 41st Annual Wound, Ostomy and Continence Nurses Conference; June 2009; St. Louis, MO. J Wound Ostomy Continence Nurs. 2009;36(3S):S39-S40.

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