The Nuts and Bolts of Global Emergency Medicine

Ch 5. Tropical Medicine

Introduction

One of the goals of your global health participation and training should be delivering exceptional medical care to those you treat. To accomplish this, a traveling student or physician must understand the context of his or her practice. For many locations, the first step is developing expertise in tropical medicine. Consider an asthmatic patient who has been coughing and wheezing for one week. In non-tropical settings, a short burst of steroids is the cornerstone for managing acute asthma exacerbations. However, in a tropical setting, the same therapy could precipitate a life-threatening parasitic infection with Strongyloides stercoralis. Tropical medicine is very heavily focused on infectious diseases, many of which you may not be comfortable diagnosing or treating. For this reason, we offer this short introduction into tropical medicine and give you resources for further study.

Things to keep in mind as you read this chapter are:

1. Global health does not equal low-resource setting.
2. Medicine in low-resource settings does not equal tropical medicine.
3. Tropical medicine in one location does not equal tropical medicine in another.
4. There is no substitute for a focused study of the specific diseases seen in the specific location that you will work.

Some additional thoughts:

• A large proportion of global health includes work in low-resource settings and low-income countries, however this is not always the case. Practicing internationally in New Zealand is very different from practicing medicine in Sub-Saharan Africa.
• A large proportion of the low-income countries are located within 23.5 degrees of the equator, or what we would call “tropical”. The diseases here differ significantly from those areas outside the tropics due to different climate and development conditions. However, practicing medicine in rural Nepal is very different than practicing on the Thai-Burmese border. With this in mind, we will be speaking about medicine specifically in the “tropical” world.
• Tropical medicine encompasses different presentations depending on where in the world you are. For example, South American Trypanosomiasis is very different from African Trypanosomiasis and requires different treatment. In addition, treatment for the same disease may differ from location to location (even within the same country) due to differing resource availabilities and cultural practices. For example, Malaria treatment may be different in Ecuador than it is in Indonesia.
• An adequate understanding of the area or areas in which you will work is paramount to providing adequate care. We recommend that before any medical trip that you carefully research the local pathology and become familiar with their local diseases and treatments. The websites for local ministries of health, the WHO, and CDC can provide wonderful clinical information for the soon-to-be travelling student or physician.

In addition to being useful abroad, an understanding of tropical medicine will help you become a better clinician at home as well. As millions of people continue to travel and relocate across borders annually, probability suggests you will evaluate a patient in your ED who has recently returned from a lower-income country. As providers who work on the frontlines of U.S. healthcare and providers who are passionate about global health, it is our responsibility to be prepared to provide care to these patients and to educate our peers so they can do the same.

This leads us to the question that is often asked by students and residents considering making this a part of their life: “How much and what type of tropical medicine do I need and how do I access It?” We will attempt to answer these questions in this chapter.

How Much Tropical Medicine Do I Need?

Every individual reading this book will have different objectives that they are seeking to meet. In order to decide how much tropical medicine is needed, you should ask yourself two questions: “What are my goals, and where will I work?”

1) What are my Goals?

There are many ways to get involved in global health, and the extent of tropical medicine knowledge and training you need will vary. So first and foremost, identify your particular goal: “what do I need this information for, and what will I do with it?” Clearly the list of possible answers is endless, however, it is useful to break the answer into two parts. Are you planning on making global health your career, or will it be an adjunct to your career?

Career Track: Career possibilities are endless. Some wish to work in academics, emergency medicine development, policymaking, or research. Some aspire to move abroad and spend years serving at a hospital or clinic in a low-resource country. Others may work with the CDC, WHO, or Doctors Without Borders. In general, those who want to make global health a large part of their career will require a larger and more comprehensive amount of tropical medicine training. For those planning on a fellowship or an advanced degree such as an MPH, these programs will provide differing amounts of tropical medicine training depending on the program.

Adjunct Track: Others want global health to be a part of their career rather than the focus. This may come in various forms as well. You may want to participate in an annual medical mission trip sponsored by a medical school, residency, church, or other NGO. You may wish to respond to a single disaster or conflict. This will require a less comprehensive amount of tropical medicine knowledge and can be focused depending on the variety and location of the specific places that you work.

2) Where will I work?

The particular setting in which you are going to work will greatly affect the amount of tropical medicine experience you need. As stated earlier, it is always important to review the pathology of your specific destination prior to departure to gain specific knowledge about that area. The question “Where will I work?” is really asking two questions.

• Will I work in a variety of different locations, or will I primarily be working in a single type of environment?
• What type of environment(s) will I be in?

Amount of Variety

If you will be working in a large variety of locations, it will be necessary to have a large breadth of tropical medicine that covers many different locations and situations. The best way to obtain this knowledge is often comprehensive formalized tropical medicine training. This provides an extensive overview of tropical medicine concepts that can be applied to many different locations. However, if you are going to focus on a specific area of the world, then a more focused or self-study of specific diseases and location specific treatment approaches in your specific location may be more appropriate.

Type of environment

When we ask about the type of environment, we are really asking about the aspects of that environment that affect the type of pathology that you will encounter. We can think of this in terms of resources, climate, or urban development.

Resource-rich VS -poor: Will you be working in high-income, middle-income, or low-income countries? Higher-income countries generally need less tropical medicine knowledge. These countries tend to be more heavily urbanized and less tropical, decreasing the chance of seeing tropical diseases. Low-income countries, in contrast, have much greater diversity of locations leading to a larger diversity of pathology. Low-income countries also tend to have a larger proportion of tropical climates and a larger overlap between urban and rural. In addition, health literacy, sanitation, hygiene, and public health endeavors tend to be less developed making the populations more susceptible to tropical diseases. The resources available to fight these diseases will also be less in low-income countries on both the local, rural level and the national, urban level.

Tropical vs. non-tropical: This may seem oversimplified, however if you work outside of the middle 47 degrees of latitude, then you will encounter much less tropical medicine than in one located in the tropics. In addition, topography and climate determine whether you will need tropical medicine training. In general, the warmer and wetter the climate, the more likely you will be practicing tropical medicine. However, remember that medicine in the Peruvian Andes will be different from that of the Peruvian Amazon.

Urban vs. rural: In low-income countries the location and setting will influence your need for tropical medicine. For instance, you may work in an urban hospital, treating primarily “developed” world diseases, while just a few hours away, in a rural village you would see more tropical diseases.

Other Considerations 

For providers who are hoping to incorporate global health into their career, a good start is to obtain a working knowledge of travel health and field medicine. 

Travel Health

A curriculum related to travel health focuses on the health and well-being of international travelers. Topics include: epidemiology of travel-related diseases, vaccinations, healthcare risks, environmental hazards, and provision of medical care to travelers. 

Field Medicine

Field medicine focuses on the provision of medical care while working in the international setting. Topics include: tropical medicine, emergency medical care in severely resource-poor settings, improvised medicine, and patient transport. These are covered in other sections. 

How Can I Access Tropical Medicine? 

As you read through this section, please keep in mind that no book, website, or course can replace focused study and knowledge of the specific pathology and treatment patterns in each area that you will be working. This is still the most effective way to prepare for any clinical experience. 

Books 

There are a number of ways to obtain tropical medicine knowledge and training, as well as some simple resources that may be of value while practicing abroad. There are a number of high yield books available. All may be purchased online or from your local bookstore. There are also many country and location-specific handbooks that are available depending on where you are going, some of which are available from the local ministries of health or other governing bodies. We highly recommend that you research the availability of these, as they can be indispensable resources for you.

Tropical Medicine Courses/Certificates 

If your goal or interest involves formal training in tropical medicine, there are essentially two routes to accomplish that goal – the DTMH and The CTropMed. 

Degree in Tropical Medicine and Hygiene (DTMH)

There are several routes to obtaining a DTMH, however normally this is obtained by completing an accredited diploma course that provides an in-depth education in tropical medicine. Diploma courses range in duration from 9 weeks to 6 months and involve intensive classroom, laboratory, and in many cases practical experience. There are diploma course located all over the world, including the United States, Europe, South America, and Asia. Many of these courses have regional focuses. For example, while the Gorgas Course in Clinical Tropical Medicine covers most topics in tropical medicine, there is a stated focus on diseases of South America. In comparison, the London School of Tropical Medicine and Hygiene has courses focusing mainly on Africa and Southeast Asia. Individuals may want to seek out specific diploma courses to meet their educational goals.
As of January 2016, these Institutions have accredited diploma courses: http://www.astmh.org/ASTMH/media/Documents/ASTMHdiplomacourselistasof1-13-16_1.pdf

• Baylor College of Medicine, USA
• Baylor International Pediatric AIDS Initiative, USA
• Bernard Nocht Institute for Tropical Medicine, Germany
• Gorgas Memorial Institute of Tropical and Preventive Medicine, Peru
• Charité - University Medicine Berlin, Humboldt University and Free University Berlin, Germany
• Johns Hopkins Bloomberg School of Public Health, USA
• Liverpool School of Tropical Medicine, UK
• London School of Hygiene and Tropical Medicine, UK
• Mahidol University, Thailand
• Prince Leopold Institute of Tropical Medicine, Belgium
• Tulane University, USA
• Uniformed Services University of the Health Sciences, USA
• University of Minnesota/Centers for Disease Control and Prevention, USA
• University of Texas Medical Branch at Galveston, USA
• University of Virginia Health System, USA
• West Virginia University, USA

CTropMed

The Certificate of Knowledge in Clinical Tropical Medicine and Travelers’ Health (CTropMed) is sponsored through the American Society of Tropical Medicine and Hygiene (ASTMH). The CTropMed is a certificate rather than a diploma course. This certificate is obtained by passing an examination that is offered twice a year. Before taking this examination, one must complete both an approved tropical medicine course and complete 2 months of overseas work. See the ASTMH website listed below for specific details about requirements and qualifying courses that you may complete in order to sit for the CTropMed. The CTropMed may be more suited for individuals who already have prior tropical medicine training or do not have the time to complete a full DTMH diploma course. Of the tropical medicine courses that satisfies the requirements for the CTropMed, two of the most well-known are the programs at Tulane University and the University of Minnesota. Upon completion, individuals will be eligible to sit for the CTropMed.
See table below for information on some of the previously mentioned courses.

Gorgas Memorial Institute of Tropical & Preventive Medicine 

Liverpool School of Tropical Medicine

London School of Hygiene and Tropical Medicine

Tulane University

University of Minnesota / CDC

Wrap-up 

For individuals desiring to work in global health, a basic understanding of tropical medicine is needed. As we have illustrated, the depth and type of training will depend on your goals and where you will work. Depending on your self-assessment, there are many available options to obtain this knowledge and training. Remember, the goal is to provide you with the needed skills to provide high quality care both here and abroad.