Best care – everywhere in the world

I keep hearing that best care in rich countries is not the best solution for developing countries, but I struggle to figure out what it means. Because I strongly believe that best care is always defined by the patient’s need and the available resources, regardless of where you are.

It was only when I met emergency physicians from Angola that I learned that patients with tetanus can be better off with very little sedation, so that they can take a few breaths themselves if a power cut makes all the ventilators shut down. Many patients would have died had they been subjected to ”best care” in a setting where ventilators have safe backups.

But best care in Sweden is also provider dependent. A patient in cardiac arrest will get intubated if there is an anesthesiologist or an anesthetist nurse around, but ventilated through an LMA if cared for by a prehospital nurse practitioner. A patient with a STEMI will go straight to the cath lab in most parts of the country, but given thrombolytics in others. It is all best care. The problem is when experts familiar with only the university hospital setting, write guidelines to be applied throughout the country.

Modern medicine is about calculating risks, benefits and costs; for the individual patient and for the health care system. The fact that we have good adherence to warfarin treatment in Sweden and readily available PCC, makes me draw the conclusion that many patients with atrial fibrillation should be on warfarin. In a setting where patient compliance is low, NOACs may be a better option. In a setting where it is very difficult to monitor INR and blood products are hard to get, most patients are probably better off with no treatment at all. This is best practice whether you are in a rich country or in a poor country. It is also the reason why knowing your setting is crucial when deciding on your treatment protocols.

It surprises me when some experts from rich countries fail to understand that their practice is not applicable to developing countries, but needs to be adapted. Without clinical experience from other settings it is however understandable. What I can’t comprehend is why providers in developing countries think that outsiders could do their job better than them. That must be a question of confidence. Maybe that is where they have the most to learn from the visiting experts.