Social Media as a Tool for Patient Empowerment in Developing Countries

When I was in India recently, I spent time with one of my relatives. While I was there, he came down with a minor cold, and walked to the doctor’s office just down the road. I stayed at home until he came back. When he did return, he had with him a packet of various pills all mixed together. None of them were labeled, nor did they come with a set of instructions. He didn’t know what any of them were, just that his doctor gave them, so he took them.

A week later, I found myself talking to the servant that had come to clean our apartment. Her son had been ill for sometime, and I knew something about the condition from which he had been suffering, because someone had explained to me earlier. Yet when I talked to her soon after she had come back from meeting with her son’s physician, the way she tried to explain his condition to me struck me as completely inaccurate, given the condition in question.

In other instances, I have seen relatives sitting in the doctor’s office. Oftentimes they don’t say anything, and don’t ask anything, instead simply nodding in agreement. Yet when they were out of the office, the questions and doubts start flying. Usually the condition in question remained nebulous even after the appointment, or the procedures were not explained fully. Other times, they would take a decidedly cynical stance when it came to evaluating the doctor’s suggestions, believing that they were more interested in extorting as much money as possible instead of actually treating the condition.

To my eyes, at least in developed countries, patients seem to be more empowered in the context of the doctor-patient relationship. In the ideal scenario, the patient and doctor work together for a solution, with the patient actively engaging the doctor with questions and concerns, and the doctor giving the due attention and compassion. The patient may also have access to additional information through the internet.

Yet in developing countries, including India, many patients still to cling strongly to the doctor-patient hierarchy. What the doctor says, goes, in most cases. In areas with dense populations, few physicians, or a combination of the two, giving the patient the time they deserve can be a formidable task. Among those with less education, a lack of basic medical literacy can further complicate matters.

I recently attended NYMCSPAD (New York Medical College Student Physician Awareness Day). The theme for the day was Social Media in Medicine. All of the speakers–who are very active in social media applied in healthcare and medical education–discussed their personal experiences using social media, as well as advice on how to effectively use social media. One of the points that really stuck out is that patients who continue to ascribe to the “traditional” doctor-patient hierarchy are likely to be left behind. I thought back to my relatives and other people I know who are still content being passive, and not actively taking charge of their care.

There is no denying that social media has taken hold globally. Its value as a tool for patient education and empowerment is slowly being realized in the United States as well as in other countries. Patients, in many cases, vet their doctors by searching for them on social media sites to learn more about them and what they do. Social media is also being embraced in developing countries among physicians, medical students, and public health workers alike. However, I still believe there is still more work to be done to promote patient empowerment in those countries.

The doctor-patient hierarchy–though in many cases a cultural mainstay especially in developing countries–presents a very real barrier when it comes to tightening and improving the healthcare system. According to the World Health Organization, patient empowerment can allow for a more efficient use of resources. Poor medical literacy is another barrier that makes patient empowerment that much difficult among patients who are unsure about the particulars of their own health. While for many in developed countries, information is quite literally at one’s fingertips thanks to smart phones, the same is not necessarily true for the majority of people in developing nations.

While the knee-jerk reflex for many is to develop an app that can be used on smart phones, it doesn’t solve the whole problem, especially considering that smart phones aren’t as pervasive a presence in most of the world as they are here. In India, there are about 20 million smart phones available, but given that there are just over a billion people in India, it represents a very small percentage of the population. However, there are over 900 million cell phones in use. Similar trends are true for other developing nations, with cell phones being available to at least 50% of the population in many cases. Cheap cell phones are often readily available to the majority of the population. I have often observed the very poorest toting a cell phone.

Facebook, Twitter, and other social media platforms are all useful in their own right. Among social media tools, Twitter seems particularly well suited as a way to improve medical literacy and increase patient empowerment in developing countries. While most users use Twitter through Twitter apps and clients on their smart phones and computers, even those with cell phones can send and receive tweets. Before I got my first smart phone back in 2009, I used my regular cell phone to tweet.

So who would these patients tweet or follow? Doctors, medical organizations, medical schools, and other research institutions are just a few that come to mind. The issue with developing nations on the whole is elevating the patient so that they are on an equal playing field with their doctors. They need to feel like they can ask questions of their healthcare providers, that they can trust these providers, and be well-informed about their health and any prescribed treatment. While part of this can be solved by trying to impress upon the patient that the doctor is a partner in their healthcare, part of it can also be solved by improving the patient’s medical literacy.

Medical literacy has been of particular interest to me ever since I took a class on immigrant health for my public health program. A lack of medical literacy can contribute to a whole litany of problems, including early deaths. The issue in many developing countries is not only the lack of medical literacy but the lack of literacy in general. Combining this with the fact that many still cling to preconceived notions and superstitions can further complicate things. Here, the use of a non-written medium, such as Youtube, can be used to effectively transmit information about various aspects of healthcare. The use of video allows for not only circumventing text entirely, but easily adapting the content to the local languages and cultures. Given the likely poor access to technology in poorer communities, the onus is on physicians and public health officials to make this information available to them.

This is something I have thought about for a while, but revisited with renewed interest after attending NYMCSPAD. Do you know of programs currently utilizing these and other approaches that have been conducted to date? What are they? Do you have any other thoughts on how to promote patient empowerment in these regions? Comment away!

Early Puberty in Girls: What We Know and What The Government Has Done (Or Not)

Can you imagine puberty occurring at around the age of 6, or even younger?

It’s happening.

Puberty is the inevitable rite of passage that everyone will go through. There are changes in shape and mood, in appearance and outlook. Its onset at around age 10 or 11, and continuation into one’s mid-teens is considered normal, with most processes wrapping up by the time high school graduation rolls around.

Early onset of puberty in girls is starting to become the new norm, and has been profiled in a recent New York Times article. Girls as young as 4 or 5 have been sprouting pubic hair and demonstrating signs of budding. At that age, most children are barely capable of putting on clothes by themselves. They are only starting to learn how to navigate their way around their social circles, and falling into the routine of school, play, and homework.

Ladies, can you imagine having to contend with the mood swings and physical changes while dealing with the mean little girls who pull your hair and call you names. Can you imagine dealing with all of that while the boys still are considered “icky” and have “cooties?”

The risks are not surprising. There is a higher risk of drinking, substance abuse, eating disorders, depression, and engaging in risky sexual behaviors. The question is, how do we protect our girls?

While there are some means of slowing down these changes through pharmacological means, preventing early onset altogether is probably the best approach. There are several potential causes, among them family problems/stress, obesity, and exogenous hormones/xenoestrogenic compounds. While the first two causes can be controlled to some extent, the last one is not necessarily something that can be controlled by the average consumer.

Hormones are chemical compounds that are produced in one site (endocrine gland) and are transported to other target sites via the blood. We are exposed to hormones through our food supply, at least in cattle, where hormones are sometimes given to boost growth. Xenoestrogens (literally foreign estrogens) are compounds that occur outside of the human body, but mimic the effects of estrogen in the human body. Many plastics can be sources of xenoestrogens, notably ones that contain a substance called bisphenol A (BPA). A Twitter follower directed my attention to her blog post, which is a wonderfully informative piece on the role these hormones/hormone mimics may be playing. While some measures have been taken on the part of states and select companies to eliminate BPA from their products, it remains a ubiquitous substance, and it is believed that well over 90% of the U.S. population has at least trace amounts of BPA in their bodies. In the New York Times article, Frank Biro (a researcher in the field) believes that based on existing data that demonstrates that endogenous estradiol levels are very low in girls with early breast growth, nonovarian sources of estrogen are likely the culprit. Perhaps these could be estrogen/estrogen-like chemicals occurring outside of the body.

Research demonstrates that many xenoestrogens, including BPA, are active at nanomolar/picomolar concentrations (1). In rats, early exposure to BPA has been correlated with an early onset of puberty, as well as increased problems with fertility, including a condition resembling polycystic ovarian syndrome (2-3). One of the mechanisms of BPA’s xenoestrogenic activity was demonstrated in non-human primate endometrial cells, where BPA co-administered with estradiol decreased the expression of endometrial progesterone receptors (4). The presence of many endocrine-disrupting compounds has been discovered in the urine of young girls, and a correlation between prenatal BPA exposure and behavioral problems among girls has been shown, though the latter results should be taken with a grain of salt given the modest sample size (5,6). Nonetheless, the fact that any correlation was shown is cause for concern at the very least, and warrants further study.

According to the Milwaukee-Wisconsin Journal Sentinel, after lobbyists from the plastics industry met with officials in the Obama administration in early 2010, BPA was left out of an Environmental Protection Agency action plan drawn up to regulate chemicals identified as dangerous. Recent efforts to regulate or ban endocrine-disruptors such as BPA, or research endocrine-disrupting chemicals have stalled at different stages:

1. In the 111th Congress, Senator Chuck Schumer (D-NY) sponsored bill S.753.IS, called the “BPA-Free Kids Act of 2009.” It died in the Senate.

2. The same bill was sponsored in the House (H.R.4456.IH) by former Representative Anthony Weiner (D-NY). It died in the House.

3. Representative Louise Slaughter (D-NY) sponsored the “Environmental Hormone Disruption Research Act of 2009″ (H.R.4160.IH). It died in the House.

4. The “Ban Poisonous Additives Act of 2011″ was introduced in the Senate by Senator Dianne Feinstein (D-CA). It has yet to be referred to committee.

5. As of January 25, 2011, the “Ban Poisonous Additives Act of 2011″ that was introduced in the House by Rep. Ed Markey (D-MA) has been referred to committee, but nothing has transpired since then.

The apathetic attitude of the government towards endocrine-disrupting agents can only spell disaster for future generations. Though research to date does strongly suggest that these are dangerous substances that can cause dramatic effects in the way the body functions, more research is needed to further understand how they may be affecting normal development. This necessitates government support. The fact that many politicians appear far more passionate about regulating women’s health rights, rather than protecting our children from a very real public health threat, is appalling and a sign that our priorities need serious rethinking.

I hope that things change. I hope that politicians will realize that addressing public health issues should always trump entertaining the whims of corporations. I hope that the government won’t continue to bow to pressure from industry lobbyists, and will eventually recognize the danger of these substances and pass the appropriate legislation to fund research and ban them from commonly-used products. If I have daughters, I want them to grow up in a world I know is safe, so that they can enjoy being girls, and won’t start the trek towards womanhood at the behest of foreign chemicals, but when they are good and ready.

1. Wozniak AL, Bulayeva NN, and Watson CS. Xenoestrogens at Picomolar to Nanomolar Concentrations Trigger Membrane Estrogen Receptor-α–Mediated Ca2+ Fluxes and Prolactin Release in GH3/B6 Pituitary Tumor Cells. Environ Health Perspect. 2005; 113(4): 431–439.

2. Fernández M, Bourguignon N, Lux-Lantos V, Libertun C. Neonatal Exposure to Bisphenol A and Reproductive and Endocrine Alterations Resembling the Polycystic Ovarian Syndrome in Adult Rats. Environ Health Perspect. 2010;118(9): 1217–1222.

3. Nah WH, Park MJ, Gye MC. Effects of early prepubertal exposure to bisphenol A on the onset of puberty, ovarian weights, and estrous cycle in female mice. Clin Exp Reprod Med. 2011;38(2): 75–81.

4. Aldad TA, Rahmani B, Leranth C, Taylor HS. Bisphenol-A exposure alters endometrial progesterone receptor expression in the nonhuman primate. Fertil Steril. 2011;96(1):175-179.

5. Wolff MS, Teitelbaum SL, Windham G, Pinney SM, Britton JA, Chelimo C, Godbold J, Biro F, Kushi LH, Pfeiffer CM, Calafat AM. Pilot Study of Urinary Biomarkers of Phytoestrogens, Phthalates, and Phenols in Girls. Environ Health Perspect. 2007;115(1):116-21.

6. Braun JM, Kalkbrenner AE, Calafat AM, Yolton K, Ye X, Dietrich KN, Lanphear BP. Impact of Early-Life Bisphenol A Exposure on Behavior and Executive Function in Children. Pediatrics. 2011;128(5):873-882.

So I Don’t Come Across As a Whining, Rabid, Med-School Reject

Here is some stuff to justify that last post.

I am doing my MPH as well as my MS.  My MPH has given me a lot of insight as to what is wrong with the system, which is a lot.  Public health gives people a birds eye view of health dynamics in a population, and for me, I’m doing my MPH at a school that is set in an ethnically-diverse, low SES community.  You want to talk about how the healthcare system is failing?  Just look there.  Everyone’s on Medicaid, but Medicaid does not equal good treatment by doctors.  Compare the facilities of a public hospital to a private hospital and you’ll see what I mean.  Doctors need to stop worrying about how much they are going to be paid, and the system shouldn’t shortchange hospitals accepting Medicaid patients to begin with.  The insurance system is a mess, but that’s for another post.

In an article by Forbes, it says “within the next 15 years, the United States will experience a shortage [of physicians] of between 90,000 to 200,000 physicians,” owing mostly to the problems that the system has now, like health insurance, the ridiculously long training period, and other things like malpractice insurance and the astronomical medical school debt.  The shortage probably wouldn’t affect urban areas, given the concentration of doctors per square mile, however given that rural areas are already hard pressed for enough doctors, this will devastate them.  I already touched on how long the training period is in the last post.  Malpractice insurance is more a function of the fact that doctors have become easy targets for suits, more than anything, though could also be related to the fact that the pressures that they face increase the number of mistakes that they make.  Yet why do medical students have to pay through their (insert orefice here) to become doctors?

This relates back to my “why does education cost so much” post.  While I could rant myself about how the costs of medical school, like undergraduate institutions, are rapidly outpacing inflation, I found a blog that does a better job at explaining it than I ever could.  The point is made that given the insane cost of medical school, and subsequent debt, specialization seems all the more lucrative, not because it is inherently interesting but because one can pay their loans off faster.  Thus we are left with a dearth of primary care physicians, and specialists who are not totally vested in what they do.  Now, primary care physicians are themselves leaving the profession in droves.  So what does that leave us?  It leaves us with a huge problem.   Yes, they are increasing class sizes at medical schools, yes they are even creating new medical schools, but is it too little too late?  Other things need to be addressed, the cost of studying, the time period allotted for medical education, etc.

This is not about me whining about not being in medical school yet, I’m applying soon enough, and I’ll deal with it as it comes.  This is not about sour grapes, I haven’t lost anything yet, and even if I have, I’m not going to whine about the fact that other people got there before me.  They deserve it, wholeheartedly deserve it.  Yet if I can’t be opinionated, if medical students can’t be opinionated, and if doctors can’t be opinionated, we have a problem.  This is not about me blowing steam without solid facts.  The facts are there.  We’re losing doctors, and we’re not replenishing them in areas where they need to be replenished.  Above all, though, our healthcare is not equal across region or society.  Not remotely.

So getting back to my previous thesis, something’s got to change.