Tropical Medicine: A Clinical Text, 8th Edition, Revised and Expanded

Introduction

Introduction Knowledge of clinical tropical medicine is essential for every modern physician. The diseases of warm climates are no longer restricted by geographic boundaries because the scope and speed of air travel and flows of ideas and people have destroyed the barriers of time and space, and the massive increase in international migration in the past half century makes us all part of a global community. The detection of tropical illnesses is utterly dependent on an awareness of their very existence, and on understanding their pathogenesis, signs, and symptoms. These fundamental facts are rarely taught in any depth in Western medical schools, and the diseases considered in this book—the greatest cripplers and killers of the world—rate only passing attention in most academic curricula in temperate climates. In some European nations, though, there has been a traditional interest in the diseases of the tropics, an interest developed during the colonial period. In these countries there are still major schools (and hospitals) specializing in tropical medicine. Financial support for these institutions has, however, waned in recent decades as the pressures to treat and investigate domestic ailments steadily escalate. In the United States, an appreciation of tropical medicine has always been far less than in Europe. There are no American schools or hospitals specializing in this discipline , and only a minuscule percentage of our national research budget is allocated to these major albeit neglected diseases. The economic realities of prolonged postgraduate training in the tropics, and the patterns of insurance payments make it difficult to sustain a cadre of experts in tropical medicine. Almost all those whom I have trained, for example, gravitated toward gastroenterology, where colonoscopies and endoscopies are procedures reimbursed at levels far in excess of what is provided to tropicalists. PAGE 1 ................. 18086$ $CH1 07-15-11 13:49:00 PS 2 introduction The quality of laboratory diagnosis in developed countries has also fallen over recent decades. For example, the approach of using wet mount analysis to detect intestinal protozoa is an almost lost art; no longer is the characteristic motility of an ameba able to be detected in specimens sent in preservatives to unknown technicians in distant laboratories. A 2010 study in New York City checked known specimens submitted to a major university hospital laboratory and to the largest commercial medical laboratory in the area. The hospital missed 50%, and the commercial diagnostic inaccuracy rate was 70%. Learning tropical medicine should not consist of merely memorizing parasitological and microbiological details. A clinical discipline depends on observations, experience, and judgment. My approach in this text is based on the realization that most medical students wish to become practitioners, and that most graduate physicians want the necessary basic information that will allow them to properly care for patients. In tropical medicine, as in other specialties, clinical tools must be learned and constantly refined. I hope that the excitement, wonder, and satisfaction that I have found in the diagnostic and therapeutic challenges of tropical medicine are reflected in these pages, for that surely is my intention. Based on centuries of clinical contributions, The Royal College of Surgeons of Ireland (RCSI) holds a distinguished position in the history of modern medicine. Today, it is the most international medical school in the Western world. Undergraduate medical students from 35 nations mix with hundreds of graduate doctors who also come from around the world to seek specialty training and certification. The RCSI now has branch medical schools in Malaysia and Bahrain. During my 36-year tenure as Chairman of the Department of Tropical Medicine at RCSI, I taught more than 4,000 medical students using earlier editions of this textbook. The text is also a product of The Tropical Disease Center of Lenox Hill Hospital. This Center, part of the North Shore–LIJ Medical System , has served thousands of ill and indigent patients, missionaries of all denominations, and United Nations personnel. Finally, the book reflects the efforts of The Center for International Humanitarian Cooperation (CIHC) to alleviate suffering, particularly in war-torn areas, where the breakdown of health services, and the resultant spread of PAGE 2 ................. 18086$ $CH1 07-15-11 13:49:00 PS introduction 3 epidemic diseases, usually cause greater morbidity and mortality than gunfire. The CIHC’s academic arm for the training of humanitarian workers is the Institute of International Humanitarian Affairs at Fordham University in New York. PAGE 3 ................. 18086$ $CH1...