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 Methods
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Title: Analysis of rural empirical sic practtioners
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Title: Analysis of rural empirical sic practtioners
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Language: English
Creator: Murphy, C. Michael
Publisher: University of Kentucky, College of Medicine, Dept. of Community Medicine
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Table of Contents
    Analysis of rural empirical practitioner
        Page 1
        Page 2
        Page 3
        Page 4
        Page 5
    Methods
        Page 6
    Results
        Page 7
    Discussion
        Page 8
        Page 9
        Page 10
        Page 11
    Sketches of the curers
        Page 12
        Page 13
        Page 14
Full Text

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ANALYSIS OF RURAL EMPIRICAL PRACTITIONERS*

S- By: C. Michael Murphy

One of the most difficult and frustrating problems in the
health field today is how to deliver modern medical care to
large underdeveloped populations. Widespread-poverty and illit-
eracy, lack of trained personnel, and traditional social and
cultural systems that inhibit change have forced designers of
large scale medical aid programs to seek new methods of imple-
menting medical care. -No single approach to this problem will
be effective in all areas of the world. Rather, the best hope
lies in specific types of programs adapted to the needs and
resources of specific population groups. This report describes
an attempt to deliver some medical benefits using indigenous
personnel in the context of private medical practice in a ru-
ral area.
In the early 1960's, a North American physician establish-
ed a self-help program for Guatemalan Indians in a city abont
fifty kilometers from the capital, Guatemala City. This study
bf the medical aspects of that program was carried out by a
third year medical student in the (summer of 1966) under the'
supervision of the University of Kentucky, Department of Com-
munity Medicine. The main objective of the project under study
is not primarily medical in nature, but agricultural. "One
could-treat 300 patients a day here for 100 years and still not
reduce the incidence of disease i n the population. The aver-
age protein level of the people here is so low that they do not
have the antibodies to combat infection. A better diet is the
best solution to health problems in our population", states

* From the Department of Community Medicine, University of Ken-
tucky College of Medicine. This study was supported through
the Milbank Faculty Fellowship.












the physician-founder of the program. To this end, he has
developed an enterprise through which native people from the
surrounding villages have learned to demonstrate and use chem-
ical fertilizers for their crops to experiment with and promote
crop diversification, to recognize and treat some common ill-
nesses in their farm animals, and also to recognize human.symp--
toms and to treat a few diseases common in the population.
Soon after 'the physician arrived in the area, he found that
many of his patients needed prolonged medical therapy yet came
from such a distance that they could not return daily. To solve
this problem, a twelve room house, adjacent to the medical of-
fice, was purchased and furnished With fifty cots for the sick.
Several rooms were set aside as nurses quarters and one graduate
nurse and two practical nurses were hired to operate the "hospi-
tal". Currently, fifty cents per day is charged for use of a
cot and most medicines needed per patients. Thus far, this char-
ge has covered the expenses of the house and its operation, since
food, bedding,.and personal care are provided by the patients and
their families. This project is most remarkable because it was
established and has persisted using only those health resources
locally available to the people of the area.
It was quite obvious, however, that the establishment of
these beds did not do much toward improving the health of the lo-
cal people. The doctor was one of only several in the area with
200,000 people. There were many sick in other villages who either
could not or would not come to the city for medical care. It
would be necessary to employ the resources already existing in the
area in order to take some service to these people in their own
villages.
The physician invited four local Indian girls about 18 years
of age, who showed both an ability to learn about medicine and a
strong desire to help their neighbors, to participate in a pro-
gram of medical training. A private foundation representing U.S.
i *









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citizens interested in supporting overseas rural medical work,
agreed to pay each of these girls ,10.00 per month during their
training-and for their subsequent wbrk in the project. Each
girl spent 20 hours a week at the side of the doctor in his
clinic. As patients were interviewed and treated, the predomi-
nant symptoms and their therapy were explained. In addition,
the doctor lectured to them concerning the theory of diagnosis
and therapy of disease. This training lasted nine months.
Next, the program was field tested. A nearby village of
700 population was chosen as the test site. A door-to-door
survey was made to determine what diseases appeared to be most
prevalent in the village. The doctor and the four girls visit-
ed the village twice a week and the girls were allowed to "diag-
nose" and treat under the guidance of the doctor. At the end
of a year it was thought that the health of the village had im--
proved and the four girls were ready to practice and teach health
care on their own.
The program was then ready for its next phase. A class of
fifteen young married Indian men, fluent in both Spanish and the
local Indiai dialect, were invited to come to the doctor's office
for weekly instructions in medicine and agriculture. The dura-
tion of the course was to be six months. Training in the use of
chemical fertilizers and the diagnosis and treatment of animal
diseases was provided fromally by weekly visits of a representa-
tive from the U.S. Agency for Interanational Development (AID).
A local' Guatemalan, trained by the national government in some
aspects of agriculture and animal care, was employed by the doc-
tor to manage the retailing of chemical fertilizers and animal
medicines. This local man also has served as a resource for dial-
ing with problems of crops and livestock from the surrounding
villages.
During the morning th:e students attended "hospital rounds"
with the doctor where human diseases were discussed as ; they were.











represented by the patients. These morning sessions were follow-
ed by lectures on agriculture and animal diseases by the AID work-
er. The doctor's office nurse (RN).,completed the day by instruct-
ing the students on dosage of drugs, sterile technique, methods of
giving injections,.etc. Emphasis was put on keeping everything as
simple as possible. Diseases not common in the local population
(coronary artery disease, cancer, diabetes, etc.) were not discus-
sed.
Five members of the group were selected to receive special
attention. Each day, Monday through Friday, two of the previous-
ly trained girls traveled to the home of one of the five selected
students to set up a "medical clinic". The student was present at
the clinic to show his affiliation withthe doctor's group. The
\girl and the new student worked together on all patients who came
to this weekly clinic. In addition, each week the doctor visited
the \home of one of the students and held a clinic. Again the stu-
dent was present and assisted the doctor. These visits lasted for
one year, until a new class of students was to enter training.
A second group of 15 men begin training in April, 1965. Their
ages ranged from 28 to 55 years. Some were accepted on the recom-
mendation of friends of the doctor in the villages; others had
heards of the program and came to see what it would be like. By
this time the doctor was becoming well-known to the villagers of
the department (state). Some came with a desire to help the sick
of their villages. One was a repeater from the original group
'who desired more training; others came in search of a new source
of income for their families. One was already a "village medicine
man" and came to improve his cure rate. Variety as well as intel-
ligence were evident in the group.
Training was more intense in that these students came two
days a week to classes. The lectures on agriculture and animal
diseases were reorganized. The indications for giving medicine
were simplified as shown in Table lI









-5-


'-4^


TABIE I
1%


Symptoms Elicited

1. High Fever, headache

2. Mild diarrhea, no fever


3. Mild diarrhea, fever


Severe diarrhea

Sore or swollen mouth

Skin abscess

Skin rash

C9ugh for one month
\
RUQ pain

Convulsions

Measles (by appearance)

Conjunctivitis


Cough and high fever

Joint pain

Nausea

Vaginal bleeding


.2


1

1

1

1


4.

5.

6.

7.

8.


9.

10.

11.

12.


13.

14.

15.

16.


Medicine to be Given

1. Chloramphenicol

2. Solutation of sulfaguanidine,
Kaolin, Pectin, and atropine

3. Solution of sulfadimidine,
Kaolin, dihydro-streptomycin,
Al trisilicate and Mg
trisilicate

4. #2 plus paragoric

5. Penicillin

6. Penicillin

7. Benadryl

8. Sent to doctor for cheat
X-ray

9. Phenobarbital and belladona

.0. Dilanting and/or phenobarbital

.1. Penicillin and sulfadiazine

.2. Opthalmic drops containing
chloramphenicol

.3. Penicillin and sulfadiazine

4. Asprin

5. Atropine

.6. Erogtrate









-6-


Two other general rules were established out of a desire to
satisfy local expectations of what a curerr" should do: 1) every
patient must receive an injection; if no injection is indicated
by the symptoms, and injection of Vitamin B complex is given; 2)
if a patient has chest or abdominal complaints, a stethescope must
be put to the affected area. (No physical examination as such is
generally employed). Lastly, fees were to be charged to the pa-
tients only for medicines given, not for services rendered. Thus,
if the curerr" had no drug therapy to offer his patient, no charge
was to be made. They were also told that it was allowable to set
different prices for different people. The poor must be cared for
and medicines could be sold to them as reduced prices.
The objective of the study reported here was to describe the
work of these people in eliciting symptoms and dispensing medi-
cines. It would have been desirable to determine whether the vil-
lagers were better off because of these "curers" than they had
been before these men began to practice, but such a determination
was beyond the scope of the work done by the medical student in
his two months in the area. No attempt was made to investigate
the agi-i"atural and veterinary aspects of this program.

METHODS
The survey was conducted as follows: three days and one night
were spent with each "graduate" of the program. A total of eight
practitioners were observed by accompanying each on his visits
with'every patient seen during this three-day period. Some histo-
ry taking and physical examination were done by the investigator
on about 60% of the patients seen by the curer. Data recorded on
each patient seen (Figure I) were analyzed to indicate how the
symptoms observed by the curer related to the treatments given in
regard to the established rules and teachings of the program. The
observed could understand Spanish but not the local Indian language,
so most symptoms were relayed by the curer in Spanish.









-7-


RESULTS
R SThe characteristics 'of the patient group seen were a good
reflection of the population residing in the area serviced by these
"curers"; 90% of the patients were Indians, the other 10% being of
mixed Spanish and Indian descent. Thirty-five percent of the pa-
tients seen were under 10 years of age.
The three leading "chief complaints" were: fever, 23% (of to-
tal "chief complaints"); cough, 18% and diarrhea, 10%. The other
most commonly elicited symptoms (excluding all "chief complaints")
were: fever, 16%; cough, 14%; diarrhea, 8%; headaches, 8%; anore-
xia, 8%; and vomiting; 66%. The curers' most common "diagnosis"
were: pneumonia, 27%; malnutrition, 16%; TB, 12%.
A further description of the treatment of the total 230 pa-
tients seen by the eight curers is contained in the accompanying
tables. Medicine most commonly used (Table II), evaluation of
indicate -o? for each drug (Table III), dosages of individual pres-
--cripdions (Table IV), amount of profit made by the curer per pa-
tient (Table V), evaluation of total therapy per patient (Table
VI) are all tabulated. The number of patients seen by each curer
during the observation period varied widely. One curer treated on-
ly one patient during the observation period, while another curer
saw 60 patients in an equal period of time.
The treatment given for several of the most common "diagnosis"
was selected for further study. Forty cases suggestive of pneumo-
nia were identified by the curers, and 35 received penicillin.
Of ,these 35, 51 appeared to be indicated by the symptoms and 28 of
the injections were of appropriate dosage. It was not possible
to determine if subsequent injections would be continued to achieve
adequate treatment for a possible infection.
Of the 24 patients thought to have tuberculous by the medical
student, 14 received streptomycine injections, but only 8 in ap-
propriate dosage. Eight received I.N.H.', all in appropriate dos-
age,













- 8 -


DISCUSSION
The concept that sub-professional health personnel must be
employed as part of any realistic attempts to solve the medical
problems of large underdeveloped population is now well-establish-
ed.
There is, however, no such universal agreement regarding the
details of the recruitment, training and employment of such work-
ers. Many markedly differing programs of training of subprofes-
sional health personnel have been described. Our present report
has its-Value in that the program it describes is in several ways
unique.
The concept of training health personnel for only semisuper-
vised "private practice" has not been widely advocated. Further-
more, the training of these men in several areas of medicine
(systematic medicine, agriculture, and veterinary medicine) em-
bodies well the basic principle of the holistic concept of com-
munity health. Lastly, the degree of supervision under which the
health workers.operate is far less than that existing in most
other programs.
The value of this report, then, lies in its implications for
future programs designed to meet the needs of people living under
similar circumstances. (The degree of reliability with which
.these health workers have carried out instructions is impressive.)
Factors such as lack of resources, sparcity of equipment, and
lack of formal schooling need not be insurmountable handicaps to
the establishment of better health care for underdeveloped popu-
lations.









-9-


FIGURE I


Sample Data Sheet on a Home Visit


AGE 24 SEX M RACE I

TO BE SEEN IN 1 DAYS


FIRST VISIT REVISIT X

REFERRED TO DOCTOR: Yes No


CHIEF COMPLAINT Cough

OTHER SYMPTOMS Sputum production, anorexia, hemoptysis, night sweats,

fever

"DIAGNOSIS" OF GRADUATE TB

"DIAGNOSIS" OF MEDICAL STUDENT TB, malnutrition


Rx

1. Streptomycin

2. INH

3. Ferrotron


Amount

1 gm

21 tablets

4 oz.


Cost

25 cents

-gratis

50 cents












- 10 -


TABLE II


TABIE III


TABLE IV


Most Frequent Medicines Dispensed
Penicillin 21%

Vitamin B injection 12%

Expectorant 7%

Streptomycin 6%

Antidiarrhetic 4%


Indication for Each Drug

1. Appropriate for symptoms
*according to instructions

2. Not indicated by symptoms
but harmless

3. Not indicated by symptoms
and may be harmless

4. Routine shot

5. Indeterminate

INDIVIDUAL DOSE FOR EACH DRUG


70%o

8.4%


9.6%


9.4%

2.4%


too little -
appropriate

too much


- J


11%
89%

0%.


















Profit per Patient


0 *

1-25 cents

26-50 cents

51-75 cents

76 cents $1.00

Indeterminate


TABLE VI


Total Therapy per Patient


Appropriate, but incomplete

(Appropriate and complete

Wrong, correct drug not used

Wrong, correct drug not available

Unnecessary extras added

No treatment

Indeterminate

Total patients seen (230)


3.0%

6.0%

16%

30%o
12%

4.0%


14%

43%

9%

5%
19%

4%
6%

100%


TABLE V'










12 -

Sketches of the Curers:

#1. A successful farmer with a second grade education, he was
recommended to'be trained f6i the program by the.local priest. He
is one of the members of a new cooperative store. He lives in a
town of 12,000 with a very poor unchlorinated water supply which
is contaminated all year. The town has two pharmacies run by
former practical nurses. The public health center is staffed by
one practical or auxiliary nurse, with whom he has made friends.,
They often work together. (35 patients seen during study).
#2. He was the "village, curer" for three years before study-
ing in this program. He is in the business strictly for the money
and freely uses such tricks as saying not to go to the doctor be-
cause he costs so much, treating the disease after it is cured,
and treating people without proper indication. He says he was
the first one in his village to use chemical fertilizer, and be-
longs to a Peace Corps operated rabbit co-operative. His practice
is big and promoted by going through the streets looking for sick
people and asking people if anyone in their home is sick today.
It appears as though a lot of his practice consists of treating
elderly widows in his town of 1,000 population without a drug store.
(62 patients seen during study)

#3. He was formerly a barber, and still cuts hair. He studied
in the program to earn more money for his family since he is very
poor. A member of "Alcholics Anonymous", he was recently elected
head of the Peace Corps credit co-op project. He is very consci-
entious, but not aggressive. For this reason, curer #8 has taken
away all his business. He lives in a town of 15,000 people which
is geographically isolated from the world. There are three phar-
macies in town and two physicians spend a total of three days a
week there. The town also has another empirical practitioner
trained by a local physician some years ago. (4 patients seen dur-
ing study).









-13 -


#4. This 55 year old intelligent man is losing his eyesight.
He is one of the leaders of the church. A very tense individual,
he wants his son to take over his practice in their town of 500
people at the base of the great volcano, Acatenango. He belongs
to the rabbit co-op also. (31 patients seen during study).
#5. This man lives in the same town as #4. He is young, un-
married, and a former officer's candidate school student who quit
the army during the last revolution. He, like #2, goes to the
adjacent towns and seeks out the sick, but does not enjoy his prac-
tice. Apparently an opportunistic and very intelligent fellow,
he enjoys being a curerr", but does not enjoy "curing". (24 pa-
tients seen during study).
#6. This man .is most impressive. He.is very concerned over
the welfare of the people in his village. He tried once before
to l.sarn a little medicine from another M.D., but was turned down.
He also has learned some English. He is a leader of the younger
generation in his town, having led the fight to establish a sepa-
rate church for the young people, with more progressive ideas.
He preaches in the. church on Sunday and teaches the young children
catechism on Sunday afternoons.. He belongs to the Peace Corps
cooperative farm, the rabbit co-op, and is a leader of local Al-
coholics Anonymous. His "TB" patients are well-controlled and are
getting chest X-rays regularly. He has taught his wife how to
give streptomycin injections to them. There is one pharmacy in
the town, which is located at.the end of a 12 Km. dirt road. A
doctor has a clinic there one-day per week. (28 patients seen
during study).
#7. He is the only member of the original group still practic-
ing. He has a big fertilizer business and is assistant mayor of
his village. He has a back injury that prevents him from doing.
heavy work. Recently, he has started in the egg producing busi-
ness. (1 patient seen during study).


















14 -

#8. He is a self-made man of humble origin, still ouite"poor,
but medicine has made him rich enough so that he plans to build a
new house of his own. He has.taught himself English and has be-
come one of his nation's well-known artists by teaching himself
how to paint. One of his pictures hangs in the U.S. Embassy in
the capital. He is in medicine only for the money and has an ac-
tive practice. He lives in the same town as #3 and has taken all
of #3's business away.' (45 patients seen during study).


,' ,'.*-




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