This week and next, I have a change of pace from “work as usual.” I have the privilege to be teaching in a Family Medicine program in Rwanda, and though I’ve traveled and worked in Africa before, I’m reminded once again of the things that are strangely familiar in the midst of remarkable differences…

•     Mobile phones are ubiquitous, though diagnostics such as ECGs or Blood Gas analysis are hard or impossible to come by. It is just plain odd, to me, to be in an African hospital ward, many beds to a room, yet with nearly every patient having a mobile phone tucked carefully in by the pillow or stored nearby with belongings.

•     Despite the tendency to think of “all those odd tropical diseases” that they get “over there” (at least that’s what folks at home seem to think), the most common diagnoses this week are the same as bread-and-butter diagnoses at home – pneumonia, pelvic prolapse, hypertension, heard disease and the like.

•     On the non-medical front, while folks at home were concerned about what we’d have that was safe to eat, in actuality here we’ve had outstanding meals each night at local restaurants – definitely good enough to write home about – and I have!

•     I’ve gotten back into the routine of my usual morning run (which is much nicer here at about 65 F than the 30F temperatures back home!), and while I’m used to being accompanied at times in the morning, it’s not usually by workers pushing their ware-laden bikes UP the local hill!

•     Most of all, I’m struck (as each time I come to Africa) how with much less than we have in the “developed” USA, it is possible to practice good medicine and provide great care despite much less technology and much simpler surroundings. Sure, there are times that having more labs, and more testing options would be nice, but when you have much less, you make it work – and the results may well be just as good!

Far from home, things can seem very different, but underneath, there is often much that is the same – and most of all what is the same, is the importance of providing the best care possible, one life at a time.

A BMJ article on aortic aneurysms jogged my memory of a conference workshop where a well known local researcher described a square shaped age mortality curve that is developing as people live longer and are more likely to be taken by the grim reaper of unavoidable disease. Square shape rather than a regular drop off of say 2% of the population per year of aging as happened in past decades and centuries. One where everyone gets to live to say 90 and then drop off like flies, dying not of conditions like infection, premature CVD and cancers, but being claimed by degenerative diseases especially neurological and complex interactions of multiple co-morbidities and polypharmacy.

Even the way accidents claim lives is changing especially in affluent nations. Improved motor vehicle, industrial and sports safety have greatly reduced individuals' chance of injury and death, even for the adrenalin junkies who persist in trying to leap from high buildings, swim with sharks, kayak down raging torrents and climbing into backyard balloons. In the 50s only Superman indulged in these sorts of activities, except the last. Nowadays every mother's son (and daughter) seems to be into some form of extreme sport and despite this, there has not been a large growth industry in accident fatalities in the first world. Maybe it’s the risk adverse behaviour indoctrinated into modern generations by baby boomer one and two child parental anxiety.

Actually the baby boomers aren't only a problem as parents. They are failing to follow their parents example of growing old gracefully. According to accident insurance data they're still out there falling off their bikes, skis, motorcycles and even taking up new sports when they should be sitting back sipping their tea and eating their scones. Is it the butter in scones, the poison left after you have taken everything good out of the milk. But have you ever made scones with olive oil? * 

This square curve, besides being an oxymoron, now poses family physicians with a need to consider a new realm of social and ethical issues when it comes to interventions in the multiply co-morbid elderly. Is it worthwhile replacing this 80 year old's arthritic knee when he has CHF, prostatic cancer and moderate renal failure? How realistic is the patient's expectations?  How realistic is societies? Does it equate with those of his cultural group? What if he was a fit health 90, no pills, no diseases (other than the ubiquitous NSAID) but with a 50% chance of dying in the next 2 years?   

Fortunately the curve still had a round corner to it, but how long before an Orwellian system develops a polypill with a timed euthanasia component?

Anyway I'm taking up kite surfing when the weather warms up and it’s too hot to have tea and scones. It is safe they tell me.

*Scone: a peculiarly English cake, often served with cream of some type.