Clinical considerations and ethical deliberations from a rural Caribbean clinic
Dr Josie Reynolds recently contacted RuralGP.com to offer to write about her experiences and observations from rural Jamaica. We’re delighted to feature the first of these articles here…
As doctors, we are most comfortable with our diagnoses when we have investigative results to confirm them. This is especially true for those trained in high-income countries, as more and more sophisticated laboratory tests and imaging have become part of everyday practice.
But in rural, remote settings, particularly those of low and middle income countries, the practicality and cost of diagnostic testing can become a barrier to treatment. This barrier is intensified in the management of sexually transmitted infections by the taboo and stigma that surround these conditions.
Because of this it has been argued that a syndromic approach to STI management can be more appropriate to tackle the burden of disease. Syndromic management of STIs works by grouping symptoms and signs of disease into syndromes and treating based on the most common causative pathogen(s), e.g. vaginal discharge syndrome, lower abdominal pain and male urethritis syndrome.
This practical approach in the most resource poor environments can help to tackle high burden of disease, therefore reducing significant morbidity, infertility and increasing spread of infection. In these settings there is a strong argument for forgoing the lab tests and treating empirically.
But what about those settings that fall somewhere in the middle?
At what point is it more appropriate to treat following laboratory testing?
Are there any markers that indicate the tip of balance in favour of a laboratory-based approach?
Picture a rural Caribbean health clinic. The mountainous community can seem remote based on the terrible conditions of the roads, but in fact as the crow flies there is only 10 miles to the capital city. There is also fairly regular transport by bus to the city Mon – Sat, and a public run clinic in town which provides free STI testing and treatment (all be it slow).
Community members, however, have very little disposable income and primarily lead subsistence lifestyles. With this in mind, working as a primary care physician at the clinic, I was not keen to send people away without treatment in case they did not go to get testing & treatment and the infection continued to spread. Syndromic management, therefore, seemed the way to go…
But the more I thought about syndromic management – STI management without any laboratory testing – the more negative implications I could think of:
- Contact tracing – this is still possible, but do you treat all sexual contacts even if symptom free? This could expose numerous people to the risk of unnecessary medications when there is no guarantee that they have the disease.
- Missing concomitant STIs e.g. HIV – it’s not uncommon for STIs to come in pairs and symptoms are frequently vague or non-existent. Treating syndromically without testing misses the opportunity to pick up some of the more serious infections that may be present simultaneously.
- Contributing to antibiotic resistance – as one of the biggest threats to modern medicine, antibiotic resistance cannot be ignored. Whilst syndromic management may be the pragmatic approach, the greater picture needs to be considered.
- Relaxed approach – could syndromic management give patients the impression that STIs are not very serious as no testing is required? Could this apparently relaxed approach translate into less incentive to prevent reinfection?
- The subtle symptoms – for the barn-door cases, where signs & symptoms are clear and fit neatly into the box, this approach is straight-forward. But what about the grey areas? Or the patients which don’t follow the usual pattern?
- Impact on doctor-patient relationship – with a less evidence-based approach and therefore greater risk of treatment failure, is there a danger of loss of trust or breakdown of relationship between the healthcare provider and patient?
- Reliable statistics – guidelines for syndromic management often mention adding in treatment for certain infections, e.g. gonorrhoea, if there are high levels in the region. However, in low-middle income settings, the epidemiological data is less likely to be complete and therefore recorded levels may be misleading.
I found myself in a struggling health system, but provisions were not non-existent – should I accept the flaws of the approach and treat syndromically or encourage patients to overcome the barriers and receive a better standard of care overall?
I realised too that part of my reserve for syndromic management linked into a deeper notion: by accepting syndromic management as routine are we reinforcing the idea that disadvantaged people deserve second rate healthcare?
Or perhaps my scientific-based training was blinding me to the benefits of syndromic management? Was my personal desire to get to the bottom of the cause preventing me from putting the important things first?
Either way, it appears to me that a more sophisticated set of guidelines is required from the Global Health Sector to reflect the variations in development of health systems worldwide, rather than a binary choice which may work for some, but not for all.
What do you think? What would you do in a similar situation? Which factors would tip the balance in your decision?