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Med School Minutes
Med School Minutes is where we discuss all things related to medical education. Provided by Saint James School of Medicine, this podcast tries to educate students on selecting and successfully completing a medical school. Our topics are fun and educational, and our hosts are knowledgeable and fun.
Med School Minutes
Med School Minutes-Ep. 57 | How Suriname Eradicated Malaria w/ Dr. Stephen Vreden
Suriname is officially malaria-free 🇸🇷 but the story behind that achievement is even more inspiring. In this episode, Dr. Stephen Vreden shares how a small country used community trust, local health workers, and innovative public health strategies to eliminate a disease that affects millions worldwide.
We also explore how SJSM’s new Tropical Medicine Program gives future physicians hands-on experience in both city hospitals and remote jungle clinics. 🌿
A must-watch for anyone interested in global health, infectious diseases, or real-world medicine beyond the classroom.
Hello, and welcome to another episode of the Med School Minutes Podcast, where we discuss what it takes to attend and successfully complete a medical program. This show is brought to you by St. James School of Medicine. Here is your host, Kashik Gua.
SPEAKER_02:Welcome to another episode of Med School Minutes where we talk about everything MD related with the focus on international studies, specifically students from the Caribbean. Today we are in Sunny Suriname, where in December, incidentally, it is their hot season, and we will be talking to Dr. Stephen Frayden, who is the course director of St. James's Tropical Medicine Program. Dr. Stephen Frayden is a very accomplished physician and has worked in healthcare policy and has uh achieved remarkable things like, for example, eradicating malaria in uh Suriname. So without further ado, let's talk to Dr. Frayden. Thank you so much for joining us on our show. Um, so before we even begin, why don't you give us a little bit about your backups?
SPEAKER_01:Okay, uh I'm Stefan Freden. I am uh born, I was born in the Suriname in Paramaribo. Uh I um lived, I moved as a youth, about 17 years old. I was when I moved to the Netherlands, okay, where I finished my high school. I entered uh the uh medical school of the Rotterdam University. Uh and uh after finishing my uh medical training in the Rotterdam, I moved to the University Hospital of Nijmegen, which is in the east east of uh Holland. Okay, and there I did my residency full five years residency in uh internal medicine. Uh and then I um started mixing up mixing uh a research job with a clinical job. So I was doing 50% uh clinic and 50% research. Okay, I did that for um a couple of years, and that research was primarily in uh malaria. Uh and um in that research period I also went to Tanzania, okay, where I uh worked in the Swiss Tropical Uh uh Institute Field Laboratory in uh Ifakara, which was a wonderful experience, uh working in an excellent laboratory uh in a very remote area and where you could um really uh learn a lot about uh malaria, not only about the parasite on the microscope, but also on what malaria really means in people. And that is for all researchers, it's also important to know not only what you're looking at in a laboratory, but also uh knowing what it means for people, this parasite. So that was a wonderful um uh experience for me. Uh then I went back to Nijmegen uh to continue my research. In fact, this research was all for my uh PhD, and uh what I enjoyed there, they have a wonderful uh insectory at that university. And uh although I'm primarily trained as a physician, a medical doctor attending humans, it was a great experience to work in that lab with uh culturing mosquitoes, okay, uh infecting mosquitoes with malaria, infecting mice and rats with malaria, uh uh in uh slaughtering these poor animals because we needed to see how the malaria was developing in their liver. Right. And uh as a clinician, it's a completely other side of the road to do that, and uh but I learned a lot uh because um I worked a lot in the laboratory, and that that gave me a really far broader view of what what health research means. Okay. So I finished my uh PhD research in the Nijmegen, and then I moved to uh the University Hospital of Leiden because they had a very high-level training in infectious diseases, and uh at that time a training in infectious diseases was not yet included in your internships, so I had to do a full internship in internal medicine, okay, and after completing internal medicine, I had to specifically do a uh uh what we call a fellowship in um infectious diseases, okay, and that was great, especially because I already had a background in infectious diseases, so it was uh really good to be there. Okay. Uh so I spent uh about two years in uh uh Leiden, right, and then I uh got my formal registration as a uh specialist in infectious in internal medicine and infectious diseases. Okay. And that was the time when I thought that I should return to my home country.
SPEAKER_02:Okay.
SPEAKER_01:So I came back to Suriname in the year 1995. Okay. And uh I started working at the Aquinascent Hospital at the Department of Internal Medicine.
SPEAKER_02:Okay.
SPEAKER_01:Uh and at that time, the the Aquinescent Hospital was related to the medical mission. Uh-huh. In fact, the medical mission was, you could almost say, in the back garden. Or let's say both hospitals were in each back garden because they both had a front street and but no back street. So they were just facing each other. So you could say who's in whose back garden. Okay. But uh, but there was a great interaction between these uh hosp these institutions because Medical Mission, as you know, is uh responsible for the uh health care in the interior of Suriname. Okay. Uh they have more than 50 clinics in the interior where they provide primary health care. And at that time, malaria was a huge problem in Suriname. So many people with severe malaria who came to Paramaribo through medical mission were referred to the academic, to the diagonist hospital where I was working. And so I got quite some malaria patients and uh severe malaria patients, and that is where my expertise in malaria came to use. Um I set up a program together with Medical Mission to work on uh control of uh malaria. So in effect, it started uh with sending students, sometimes foreign students, right, to the medical posts of uh Medical Mission, uh where I specifically asked them to make malaria slides of patients, but also make follow-up slides. So I could see how these patients were doing on uh the medication that we provided. Because at that time, it was the late 90s, early 2000s, uh, the treatment for malaria was not only in Suriname but worldwide, it was quinine with some other drug, right? Maybe quinamycin, uh doxycycline, or uh fancy dar. Uh and by these um results that the students brought back, uh we could see that the uh treatment, quinine and quinamycin, was not efficacious. We could see that people remained having malaria despite this treatment. This could have two could have two reasons. Um I never took quinine myself, but what I heard from people is that it's a terrible drug. Okay. It gives it has very unpleasant side effects. And uh people literally told me that they rather have this the complications of malaria than the side effects of quinine. And that's when we started working on alternatives. Okay. We did formal studies in formally assessing the failing efficacy of quinine, and then we uh did studies with other uh medications, uh and finally ended up with uh artemisinin-based uh drugs, which had a fantastic efficacy and also a very favorable uh side effects profile. So in 2005 we introduced uh this uh drug, this is uh Coartem, and that was really a game changer in malaria. Uh we had uh significantly less cases, and uh we continued doing research just to know what um what was happening with malaria. But one of the most important things in my uh career is that I saw that because in the beginning of this century, if you went to a village in the interior, the village was relatively silent because the children were lying in hammocks with fever, being very pale, having no initiative, not going to school. And as you know, nowadays, if you go to those villages, you hear shouting and playing children, right? And that's really um something that is very satisfying, right? Because you know that the impact of malaria uh on children has we have eliminated that completely. So that is that is if if I achieved something important in my work, that is that is the thing that I would be not necessarily proud, but especially happy with. So um that's um for malaria, as you know, we have continued fighting malaria, yeah, and uh it's a long story, right? But in the next 20 years, yeah, we managed to completely eliminate malaria from the country. Right. And this year, a few months ago, in fact, last month, we were formally certified by WHO as a malaria-free country. Okay, so that's that's um one of the things that uh, of course, not me, but together with the team, because we had a fantastic uh uh malaria, we still have a fantastic malaria team in Suriname, but uh that is my let's say my malaria life. Right.
SPEAKER_02:Uh I I do want to uh zero in on a little bit because uh obviously you've spent a lot of time in the Netherlands and you you got your malaria training and you became an infectious disease expert there. What really inspired you to come back, other than the fact that, of course, you were born, but you know, I mean, me included, I was born somewhere else, but I've chosen to stay in a different country. Uh, what what was the reason? What compelled you to come back to Suriname and share your expertise in Suriname as opposed to I'm I'm confident you would have had a fantastic life in staying in the Netherlands as well. What made you come back?
SPEAKER_01:Yes, that is a very interesting question because I would have a very good uh academic career uh while staying in Holland. Right. But uh I frequently visited Suriname and what I saw is that the impact on health that I could have here would be maybe tenfold what I could achieve in the Netherlands, because in the Netherlands everything is already fixed. Right. The changes you can uh implement are subtle. Right. And I saw that um working here would have a better impact not only on the things that I could achieve, but it could have an important impact on uh health in this country. Right. Um at that time when I uh arrived to Sri Lama, there was no treatment available for HIV.
SPEAKER_02:Okay.
SPEAKER_01:So HIV was still a death sentence. And in the late mid-90s, HIV became uh a manageable disease in Europe. Okay, and so I think that if you think of the big gaps that you can close in by being here, and that is something that satisfies me, to satisfies me to do things that have an impact. Right.
SPEAKER_02:So in a nutshell, it sounds like you chose to be in a country that you felt needed you and your expertise the most.
SPEAKER_01:Yes, but to be honest, uh huh, I think I needed the country too. Okay, because uh although there were quite some challenges, um I am well, Suriname is a wonderful country to live in. Absolutely. So it was not a sacrifice for me. That's that let's be clear about that. Okay. I came uh because I knew that I could do a lot of things that would uh make a difference, right? But I'm not a Samaritan. I just came also because I knew that I would enjoy living in this country. Right. Yes.
SPEAKER_02:You know, one thing that is very unique is that obviously um Suriname has had a fantastic malaria program, and now, as you said, it is uh uh officially been certified as a country that has eradicated malaria. If I am not mistaken, Suriname is the first country in the Amazon region to have achieved that. Is that right? That's right, yes. Okay. And uh so I think that that's a huge uh uh it's a very big deal. It is something to be exceptionally proud of. Uh, and obviously it's an incredible achievement. Uh, you know, us at St. James, you've had the luxury of seeing how you've done it um at from a very grassroots level. And we'll get into that really quickly, but I do want to understand you've also done a lot of healthcare policy um around malaria and generally speaking, in in broader terms, as you mentioned for uh various other diseases. But how does one get into that? Like, can any physician, even in their home country, and I believe you also, if you could talk to us a little bit about all the policy that you've done across the globe, not just in one country, but how does a student go from resident, becoming a physician, then eventually get into healthcare policy? How does that work?
SPEAKER_01:Let me give you an example. Uh I also lecture uh infectious diseases and microbiology at the Antotokam University and the medical faculty. And um at one point, uh, because the academic hospital and the medical faculty are in each other's backyard, just like the other example. So I could just walk from the faculty after giving those lectures to the hospital. Right. And one of these days, one of the students who I had just lectured joined me and we started talking. And in fact, that student has since then, and this is already several years ago, never left my site because he was so much interested in infectious diseases, but also in the public health aspects of uh infectious diseases. Now he is the lead of the viral hepatitis elimination program.
SPEAKER_02:Okay.
SPEAKER_01:And he is in his uh he has just finalized his uh medical studies, right? Student uh medical studies. So I think that uh as a student you should look around and see what interests you and don't be afraid to step to the person who is doing it, because uh in fact, uh we are always looking for people who want to continue our work. Okay, so I think this is the way you should just approach the people who are doing things that interest you and just learn from them. Okay, that's actually really good advice.
SPEAKER_02:So um as time has gone on, um obviously you've done a lot of healthcare policy here in Suriname. Can you talk uh talk to us a little bit about your experience doing that, not just for Suriname, but for from other countries that you've done similar things now for?
SPEAKER_01:Well, I have not necessarily done it for other countries. Uh I have cooperated with several countries. Okay. Uh in Suriname, I've been involved in um HIV AIDS care. Uh I have been in and am still involved in uh uh Chagas uh epidemiology and um two probably other things that I cannot uh uh recall now, but together with uh French Guyana, our neighboring country and Brazil, I have worked on projects uh with um border malaria.
SPEAKER_02:Okay.
SPEAKER_01:We have done several uh research projects uh together and uh also made kind of protocols together, right? So that is that is uh with regards to my uh international policy. I have also uh worked in uh health projects for mobile and migrant populations uh uh in the interior, and we have some uh studies published are published on that. Um during uh COVID, we've been working also on a project in um diagnosing COVID in mobile and migrant uh populations. That was also a very uh very uh interesting uh thing. So these are the things that I'm uh uh involved with. And with pol with regards to policy making, I um I used to be the chair of the the ethical board of the uh ministry of health. Uh and the ethical board uh specifically aimed at uh evaluating um research proposals. Uh uh that's something that I've been doing for some time. And also this year I have just uh stopped working as the chair of the specialist uh registration board. Uh that is a kind of a council of the um VMS, uh, which um sets the guidelines for uh specialization in the country, and also that has a register, the only national register for um medical specialists. So I've been doing that work for about 15 years. Okay, and I just uh uh handed it over to uh someone else this year. Okay.
SPEAKER_02:Wow, that's really impressive. So um obviously you have a passion, and as you mentioned, you really are looking for people to carry on some of the work that you've done. Uh, you're working with St. James, obviously, to create a tropical medicine program that imparts some of the knowledge that you've gained over the years. Um, can you tell us what exactly? So, why is this important to you and what is your goal for having a tropical medicine program?
SPEAKER_01:Well, I think that um tropical medicine, if we look at what is tropical medicine, um tropical medicine is more than the infectious diseases that are typical to the tropics. Tropical medicine is uh about what are typical health challenges in tropical countries, and uh these challenges can be related to uh just climate, uh, they can be related to environment because there are typical conditions that are related to the forest, and but not all tropical countries are forested areas, uh, but they can also be related to the socioeconomic situation of the country, right? And I think that if you're talking about tropical medicine, you should address all these points, okay. Not just uh a disease, not just a pathogen, uh not just a forest or an animal, but because many of these tropical diseases are zoonosis, that will that means they are related. There are there are animals, uh forest animals related in the cycle of this disease. So it's uh it's it's a complex, and you need to be aware of all these things and also um knowing what to do in uh especially resource-limited settings, because um knowing tropical medicine means also knowing uh what to do when not everything is available and still uh deliver adequate health care. Right. So this is this is what tropical medicine means for me. And I think that why it is important that at least there should be doctors everywhere who know what to do when not everything is available. Because even in a highly developed country, there may be a day when there is no electricity, for instance. But then you still need to provide health care. So I think that there should always be in every uh health institution doctors who know what to do when not everything is available. For instance, no electricity, no internet, uh, no CT scans, right? Uh and then still because if you're then empty-handed, I don't think I don't think that every doctor needs to do tropical medicine. Right. But I think that you always need to have doctors in your institutions who know what to do when there is no CT scan and no MRI, and you just have to work with your hands and your eyes, and most of all, with your brain.
SPEAKER_02:So, this course that you're designing um with us, how does this uh train the physicians that are coming to this particular course to do that?
SPEAKER_01:Well, what we do on day one is to give them an overview of the course and also an overview of the country that they're in, right, especially with regards to uh geography and also uh health provision systems. Uh and then we proceed with some uh lectures about diseases, tropical diseases, uh in the context of the environment where they're in. Uh, we also think that it's very important for them that they know the basics of diagnosis of uh the most important tropical diseases. Uh so they uh get some specific training in the laboratory, so they learn about malaria diagnosis, for instance, they learn about how to uh investigate stools for uh infections, uh, so those things, and they see slides about several other uh parasites and tropical diseases. So uh that's how the course starts, but we also think that they should get a taste of um health in remote regions. Okay, so we take them to a clinic of medical mission in the interior where uh there are where there is no big hospital, uh where there are not many doctors, maybe one or two, but where we still have a relatively adequate health uh system providing primary health care to those uh the people living there. And also they learn what to do in emergency cases and what to do in severe cases, how this system is uh a part of the national uh uh health system. Uh so I think that is that is important because it's typical uh an aspect of could be a typical aspect of tropical medicine. Uh in Suriname, we also have another uh population, which is the mobile and migrant populations, and um they are mobile, they're migrant, which almost implies that they do not have a stable health provision system. And what we want to uh demonstrate to these students is that is how you can at least provide minimal basic health care to these mobile and migrant populations. Because as a government, you're responsible for health provision for everyone who is on your territory, regardless if the person is a migrant, but you need to have systems in place. And sometimes it's very challenging, right? But we try to demonstrate what basic health care access we can provide for the mobile and migrant populations. Okay, so um that is something uh that we that we also try to uh demonstrate to these uh these uh students. Um one of the aspects is also that they should um participate in multidisciplinary communications. Because uh in Paramaribo all severe cases of uh infectious diseases are being uh attended, but um sometimes it takes more than one discipline, more than one specialist to make a good decision. It can be an infectious disease specialist with an orthopedic surgeon or with a thoracic surgeon or with uh um ENT doctor, because we have uh infectious diseases can occur in every part of the body. And um we ask these uh we allow these students to participate uh once weekly in a meeting where uh several uh specialists are present, and these meetings, easy cases, are not being discussed because that is it can be solved. The the difficult cases, the complicated cases are discussed, and then they see how together with inputs of expertise from different sites, you can come to a good plan for a working plan for uh patient care. I think that is also uh instructive for doctors to see that you're you shouldn't try to do fix everything uh just on your own. Right.
SPEAKER_02:So uh I know when we were uh designing this course and talking about the various components, um we had St. James said that we should keep it to the city hospitals and stuff like that, and you're very insistent on sending them to the interior. So it this is a a good explanation of why that is important. Um when we've spoken about uh the migrant populations and the migrant and mobile populations that Suriname has, you've spoken um a lot about trust between authorities and this mobile population. Could you talk a little bit about that? Because I think that that is such a strong cornerstone of any physician for any patient, not just the migrant population. But I think personally, from what I've seen in Suriname, generally speaking, I think that that aspect is emphasized a lot more than in, say, the healthcare system in the United States, for example. Um, can you talk a little bit about why do you think that that is so important for you?
SPEAKER_01:Well, um, if you work with mobile and migrant populations, you see that quite a proportion of these uh may not have a legal status.
SPEAKER_02:Okay.
SPEAKER_01:And um and then something that is already that should be obvious for doctors becomes more obvious in such a situation because you know, you may know, that you are providing healthcare for someone to someone who is uh illegal, uh sometimes even someone who might be arrested if uh the legal authorities were there. But it's very important that as a physician you focus on your oath, okay, providing health care regardless of who is sitting in front of you, and respecting the fact that you have sworn to keep the information that you get from this person confidential. Uh it's um not something that you have to work with every day, but it must be on your mind continuously if you work with people, especially if you work with people from a community where there is a relatively high uh uh proportion of illegality.
SPEAKER_03:Okay.
SPEAKER_01:Especially if you're just working in a hospital with urban people who are all legal, everything is okay. But sometimes you need to be reminded that in fact I have sworn that I will respect the privacy of my patients and that I will keep his information confidential. So that is something that that comes out, and it is not only because of your oath, it is also especially in communicable diseases. We would have never been able to eliminate malaria if we didn't had the trust of the population. Because for malaria to address it uh properly, I need to ask you about your whereabouts in the past month. Right. Because I need to know if the malaria that I diagnosed with you, if it has been acquired in this area, because then I have to go and search this area, or if it was in another area, because then I have to search that area, or notice my neighboring countries that they have a malaria problem over there and there. This is very sensitive information that someone may not give you if he doesn't trust that this information is safe with you. So even from the public health point of view, you need to have the trust of people just to be able to address communicable diseases. So it's the so the oath is important, but also the public health is important. I recently said in a meeting in Washington that law enforcement and health proficient cannot go through the same door, at least not at the same time. Right. They really need to be separated.
SPEAKER_02:So so that's a very interesting, and I think generally speaking, um the world would be a better place if there were more physicians with your mindset. Um but I wanted to take a step back and talk a little bit about the uh malaria uh eradication programs, just generally speaking. And um I know you've gotten uh clinics or in the mission, there are a lot of mission clinics across uh Suriname, and a lot of these are very, very remote areas. Like as you were telling us, you have to fly there and then take a boat. Um how do you distribute or provide health care in such a remote area when and and just like any other country in the world? I mean, I think the profession with the most significant um uh uh or short supply of uh physicians, uh this is a common trait across every country in the world. There aren't enough physicians for the populations that they have. Suriname is really no different, am I right? I mean, Suriname has the same issue that every other country in the world has. But at the same time, Suriname is still providing basic healthcare in the most remote corner uh to various indigenous tribes that typically shy away from uh modern amenities. How is Suriname doing that?
SPEAKER_01:Well, um we are doing that uh first by involving the communities. Okay uh because a community uh needs to trust you in order to leave its own uh traditional medicine. Practices and accept yours. So you can only achieve this by including people from the community in the work that you're doing and training them so that they can provide the care to their community members. This is something that the medical mission has uh done consistently, and therefore, on many um clinics in the interior, you will see that healthcare workers are from the community that they work in. And um it's not a superficial training, it's a four-year training uh to allow these people to provide health care. So they're not medical doctors, we call them medical assistance. Uh but what they are learning is to work according to protocol, and they always have access to doctors to communicate about what they found and what they need to do. Uh this system, it's not unique to Suriname. There are other uh areas where this system uh has been implemented. It um allows you to have indeed uh a healthcare profession, access to health in uh all regions, and we are convinced that you need seven times 24 hours, you need health care in such a remote region. Right. Because sometimes you cannot even have a flight at night. So there should be someone who can provide health care, and that is the system of meta commission. We have the medical mission has 58 clinics dispersed through the country where there are always uh health assistance available to provide primary care. In previous years they were communicated communicating through radio, but now uh internet is so strong. So uh WhatsApp is uh uh uh or or uh zooming is is uh is much more uh available. So the communication is uh it's um is more accurate now. So that is the way uh healthcare is being covered in the stable communities in the interior. Okay. In the unstable communities, which are the mobile and migrant workers, they are mainly involved in gold mining. Uh, it is not possible to have this system uh because it's a community, but it's not a community. Uh, this is not uh a group that has been together for decades, but it's just people who come there to work and they may not even know each other too well, although they may be working together in the same region for some years. Um at the same time, it is not very safe to deploy uh healthcare workers from the government or from the hospital in those areas because there's absolutely no law enforcement. It's a kind of uh free-for-all there. Uh and there are things happening that uh you wouldn't uh like your staff to be uh in between. Um so what we did is from those communities, we recruited people uh primarily for malaria services, but they have been expanded later, um who would who were prepared to be trained in doing malaria diagnosis and providing malaria treatments. And we call these people, their name is malaria service deliverers, it's MSD. Nowadays it's not only malaria services that they are delivering, but the name state uh MSD. Uh so and these people, they have uh done a tremendous job in those mobile and migrant populations. Because imagine if there is malaria in these populations, who would be able to control it? Right. So with people from the communities, uh they were uh screening for malaria, they were diagnosing malaria for malaria, and they were also reporting to us anytime they have a case. Uh and if necessary, if it proves that there was somewhere an outbreak, then we would go there and try to end this outbreak. Uh for example, in the year 90, in the year 2023, about 35% of all the imported cases of malaria and Surinama were diagnosed among the mobile and migrant populations in the interior. Okay. And we always say that if we had no MSDs there, we would have never reached malaria elimination. Right. Because these cases would only have been detected after they had locally spread. But now they were detected in time and we could prevent local spreading. So it's um it's very important to have these uh malaria service deliverers. In general, it's very important that wherever you have people living, uh you should involve the community in providing basic healthcare.
SPEAKER_02:Right. What other services are the MSCs providing? You said it's expanded now.
SPEAKER_01:Yes, we have slowly expanded these services because um malaria was one thing, but when malaria decreased, we thought that we have now a system of people in the field that we need to keep working for us. So we said there are communicable diseases, but also non-communicable diseases. So we trained them in doing blood glucose measurements, we trained them in doing blood pressure measurements, they are doing several other uh rapid tests like uh phytohepatitis, like uh HIV. But also, as you know, in the forest uh in South America you have uh cutaneous leishmaniasis, that is uh an infection that causes big ulcers in the skin. And um this is treatable and it's also diagnosable. So we train these people to make smears from the wound. They don't have to read them, they need to, they just have to fix them and send them to Paramaribo. Okay, and then we can provide treatment in the interior. Okay, and uh these treatments are injections. Okay. So some of the health, those MSDs have already been formally trained in Paramaribo to give injections for the treatment of flesh peniacin. Okay.
SPEAKER_02:So uh Dr. Faden, if you can tell us what qualifications do you need from the community members to become MSDs? Do they need to have a bachelor's, a high school diploma? I mean, what do you need?
SPEAKER_01:You don't need any education. Okay. Well, yes, you need education. You need to be able to read and write. Okay. Uh in those mobile and migrant populations, normally you don't have people with bachelor's and pastor's diplomas. Okay. Uh most of them don't even have high school diplomas. Okay. There are most of them are kind of marginalized people because living in the as a mobile and migrant worker, uh, it's not by choice. It's because other opportunities were not available. Right. But still, these people can be quite smart. Right. And they have ambitions. Right. So we just ask them, can you read, can you write? And we have a communication to see whether they can um they they they are adequate.
SPEAKER_03:Okay.
SPEAKER_01:And um then we train them most of the time first in the field, in do you have the guts to prick someone's finger? Because even that is a minimum requirement. You need to uh do that. And so because some people, if the ones uh if they see blood, they already faint. So that is so that is a requirement. Uh but um after that we just train you and we explain you uh several steps on how to uh continue. And um if we see that you can you pick it up quite well, we can continue with you. Okay. And what we do is first they just do a blood slide. They also must be trained in okay, what medication, how many pills are you going to give to someone? This is very it's relatively simple. It's still uh a lot of information because the slide that they did they they we ask them to make a rapid test, and the rapid test can give two or three different answers. Is it the P vifex malaria? Is it the P Velcipra malaria? Is it the mixed infection? So that it really takes some training for them to understand. And once they've understood that, then you must give them, explain to them what medication are you going to give for what kind of malaria. So, yes, it can take half a day before such uh on a one-on-one training, someone understands that well. Okay. Uh and then there is also a training in how do you going to do the registration of everything you've been doing. Okay. So it's it is uh so the people they don't have a very high education, but they but they certainly need a certain level of um what do you call it? Acumen? Acumen, yes. So uh and there's there are a lot of people, lots of them there. One of the things that we that really struck me is that because at some point we have groups of these uh MSDs come to Paramaribo for uh a refreshment training, and we decided to give them at the end of the training a certificate as a certified malaria service deliverer, right? And uh we didn't realize how much it would we mean for these people, right? Because for most of them, it was the first certificate, right, the first proof of of uh adequacy that they got in their life.
SPEAKER_02:Wow.
SPEAKER_01:So they were really proud of it, and they were they instead of us thanking them for their work, they thanked us for giving this opportunity. Wow. And uh so that is that is something that you uh didn't expect or didn't think of, but you see that it's for both parties, it can be very important because they see that people that they are recognized that they can do something.
SPEAKER_02:Right. So the summarizer almost sounds like in order to eradicate a disease as uh ubiquitous as malaria, which is pretty much in most tropical countries with evolve, your big pillars were uh trust with the community and um lowering the barriers of entry to provide uh this service. Like, for example, you know, in the United States, you have to have a high school diploma, a bachelor's degree, this and that to be doing some of the things that you're actually uh describing. So essentially lowering the barriers of entry so that somebody can become an MSD and trust with the community are the two primary pillars that have enabled Surinam to eradicate malaria. Would you say that that's correct?
SPEAKER_01:Yes, uh yes. Um I must also say that the malaria program has also distributed insecticide-treated bed nets in the interior. Okay. Thousands of them. So that is the protective measure, the individual per personal protective measure has also been uh distributed. Okay, and with regards to lowering the barriers, you know, there are um several locations in countries around us where health proficient is provided. But the laws of these countries do not allow lay people to provide basic diagnostic care. At the same time, the countries are not able to guarantee that there will be someone at those posts to provide health care. So they make if there is the choice between no care or care in the hands of lay people, of instructed lay people, they make the choice for no care. Okay. And I think that for malaria, that is not the good choice. Okay.
SPEAKER_02:That's very interesting. I mean, generally speaking, I mean, I've uh seen healthcare systems in a couple of different countries, obviously, not as many as you have, uh, but it really seems that Suriname in particular is unique. And like we're very uh appreciative and thankful for uh you partnering with St. James to provide this exposure to not just our students, but to really anybody, and especially uh this is a program that is uh really geared towards physicians for them to see this. I think this will be uh make a world of difference and hopefully we'll have an impact in the American healthcare system as well. But what is your uh aspiration for this particular course, and what do you want the students to kind of take away from this?
SPEAKER_01:So, my aspiration is that I think it is wonderful, it would be wonderful for Srinama to have a uh well attended and a well appreciated tropical medicine course in place, uh, together with uh St. James Medical School, of course. Um so we are happy to be part of it because I think that we are trying to put our health system on the map, uh especially with regards to tropical medicine. So I hope that um because I'm kind of trying to retire, I hope that this uh if this would be the last thing that I could achieve to have a uh the well-running uh tropical medicine course uh ongoing in Suriname, that would make me very happy. Okay, but I think it's also good for the country and for the students. I think that many of the aspects that I mentioned in this interview are important. Is um medicine is not just a clinic, medicine is much more, medicine is about people's health, right? It's about people's social life, it's especially about people's uh travels. And since currently people are really traveling across the world, I would always say like mad. But uh it's true. So you really need to have a kind of a broader perspective about uh uh health than just uh the the consultation room. Okay. So that is something that I think that this course will certainly help to achieve. Um and I think that apart from the traveling history, you should be aware of social, socioeconomic determinants of health. And that is also something that we want to add. And uh I was trained primarily as a very clinical physician out of university into a university hospital, and you have a very limited view of the world at that time. I must say that I have even after finishing my internal medicine specialization, I really became aware of what health and health proficient should look like. And I think that it would be good if that was more included in the curriculum of uh medical doctors, because uh as I said, it's uh there is more to uh decision than a consultation room, much more.
SPEAKER_02:Right. Well, that's awesome, and we're excited to be able to present this uh course to uh as many students who are interested. But again, thank you so much for your time, Dr. Frieden, and uh we are very confident that this course will be uh fantastic for the students.
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