New Medical Writings

Feeling very proud; I have been approached by a Canadian based medical site to submit articles for publication. They are a Pan-Access worldwide collective of experts and non-experts creating a discussion about infection control and prevention using their  online publication forum, http://www.InfectionControl.tips

Check out my profile and my first article cleared for publication (working on the next few)

http://infectioncontrol.tips/author/memmerich/

Managing Infection Control in a Disaster

TECHNOLOGY IN MEDICINE

TECHNOLOGY IN MEDICINE

Past, Present and a Possible Future – Help or Hinder

Published in Sanguine, journal of the ECSSA June 2015

Technology in Medicine, a topic many in EMS chat about, and if we have been in service for 20 years plus, we have then been privileged (or cursed) to see significant changes across the board with regard to equipment, patient care, protocols and drug therapies. Many of us have actively pushed for change and new equipment; be it with regard to fluid therapy, bleeding control, pain management and airway management. As one who has been active in certain areas pushing for change, we sometimes miss the most crucial approach to patient care; neatly summed up by Hippocrates (400-ish BC)

Cure Sometimes. Treat Often. Comfort Always

The classic approach to patient care has always been underpinned by the following:

  • Arrive at a diagnosis by patient consultation and physical hands on examination

  • Confirm ones diagnosis via various diagnostic devices

  • Reaffirm ones diagnosis by means of special investigations

Will technology change this approach for better or the worse?

If we look back at history, we see that not all new technologies have been readily accepted by the medical community. Many were viewed (are viewed) with suspicion. In the 1930’s some doctors doubted an X-ray image of the chest was as reliable as a physical examination. Devices threatened to replace the diagnostic expertise of the traditional doctor. Many doctors have valued their clinical experience over machine-produced information. Other technologies initially failed because doctors or patients found them impractical. The ECG was only useful when it became portable and reliable enough to be used at the patient’s bedside.

We need to also seriously review our progress in Medical Technology with regard to changes that offer only incremental benefits but at much higher patient care cost. The focus must be on evidence-based product development, manufacturers have to be able to show their products and new technologies will add value to their customers. Does new technology automatically translate into better patient care and most importantly improved patient outcomes.Plus we need to ask the question; who is their customer, the patient or the medical practitioner? If we as practitioners treat our patients as customers, they will act like customers, we need to be very careful of venturing into a quagmire such as this.

The entire patient/medical practitioner relationship is also changing, as the patient has access to a wider range of medical information, our patients are possibly smarter (maybe). Patients have access to more medical information, with the end result, that at times, they might be less trusting and prone to ask more questions of their medical practitioner. As practitioners we must be open to this new questioning patient and be willing to answer more questions than we did in the past.

Taking cognisance of all of the above: what is the health care practitioner to do?

There is an acknowledged gap in the “bench to bedside” cycle of medical discovery and its implementation in clinical practice, which can mean a gap of years changing “what we know to what we practice”.Hence the treatment of patients in an emergency setting should not only be concentrated on developing new technologies, but must also involve proper training and skills development; medical talents needs to be honed. New technologies MUST always mandate new skill sets, protocols and procedures.

An area of import in my opinion in medical development is patient information. The more information we have on the patient at hand, will allow us to render more appropriate patient care. Information and knowledge management is critical in helping with the decision making process and thereby improving patient care. Many medical practitioners believe that patients should take an active role in managing their own health information, because it fosters personal responsibility and ownership and enables both the patient and practitioner to track progress outside scheduled appointments and at times of a medical emergency. Patient smart cards is one way to grapple with this issue of information. It will allow patients to upload their health records via a flash drive and carry their information with them in their wallet. Information may be accessed through cloud-based storage and encrypted systems anywhere in the world, or plugged into medical smart readers. Medical practitioners can update to cloud technology in real time and the patients own medical doctor can be alerted to changes in the cloud files.

Another key area where technology can aid us in having more information at our fingertips is via a “differential” diagnosis or problem list, which is accessed via the cloud and links to our patient file and further information we input. After we have reviewed the patient “history” and examination. (e.g. is this appendicitis? a urinary tract infection? constipation? inflammatory bowel disease?) The practitioner must then troll his memory banks and innate knowledge base, or one may need to consult texts/online sources to check up/confirm their thinking. Cloud based technology could aid us and speed up the confirmatory differential diagnosis. As their is no doubt much room for improvement in the current approach, with many practitioners currently relying on their tacit knowledge base at the frontline which, while mostly effective, is subject to human error. Once the differential diagnosis or problem list is drawn up, then a related treatment plan could be formulated, and treatments in the form of procedures and/or prescriptions for medications may be suggested by our cloud database.

Emergency Medicine must continue its current academic trajectory, to keep pace with the challenges that technology brings to our patient care. If academic training lags behind the technology curve our practitioners and therefore our patients will be the poorer. We must ensure that there is now technology/practitioner gap as we continue to push the boundaries in improving our patient care. The danger of technology, is that it has the ability to make us lazy and self reliant. It has become noticeable in certain areas of emergency medicine how our reliance on technology has allowed us to forget the three cornerstones of good medicine, diagnosis, confirmation and reaffirmation; of which the diagnosis and confirmation are reliant on us having a hands on approach to our patients (which is becoming a dying art). Good solid diagnostic skills will always be an essential tool of medicine, especially emergency medicine, we forget this at our and our patients peril.

MOTOR VEHICLE ACCIDENTS – A GROWING PUBLIC HEALTH BURDEN

My latest Blog post for This Week in Global Health:

http://www.twigh.org/twigh-blog

Road Traffic Crashes do not just happen! They are caused by Fatal Moves (actions) by a driver. The message is simple – DON’T DO FATAL MOVES!” @FatalMoves

1990 to 2010: Deaths from road traffic injuries increased by almost half.

The largest category of fatal events are transport related. In 1990, according to Global Burden figures, these were the 10th leading global killer. By 2013, they were fifth! Ahead of malaria, diabetes, chronic obstructive pulmonary disease, cirrhosis or any kind of cancer. In part, this is because of progress against these diseases. But it also because as incomes have risen worldwide, more people are buying, and crashing, motorbikes and cars.

Most global road traffic deaths occur in low and middle-income countries and are rapidly increasing because of the growth in motorisation. Mortality rates caused by traffic related injuries are increasing in low and middle-income countries and they account for 48 percent of the world’s vehicles but more than 90 percent of the world’s road traffic fatalities. Pedestrians are most often affected, followed by car occupants and motorcyclists. Alcohol plays a key factor in the drivers and pedestrians, notably in South Africa, where as many as 65% of all pedestrians have increased blood alcohol levels. Conversely, traffic deaths are decreasing in high-income countries, Sweden is an excellent case study that we will review further on in this article.

10 countries are responsible for 600,000 road traffic deaths annually (see the MikeBloomberg link in the references below, to see if your country is on the list). Each year, 1.3 million people die in car accidents, so these 10 countries are responsible for nearly half of all road deaths! India tops the list for the highest overall number of road deaths, followed by China and the U.S.

If public health leaders are to catch up on accident prevention, the Global Burden of Disease study (Lancet links below) findings can help them see where and how. “Now that somebody’s done the work and we recognize that there’s a difference we may not have seen before, we can go to work and ask why,” said Dr. Schauben

Besides the rapidly rising fatalities we must also take cognisance of the rising number of injured persons and their cost on the (Global) health burden. Road-traffic crashes were the number one killer of young people and accounted for nearly a third of the world injury burden, a total of 76 million DALYs (Disability Adjusted Life Years) in 2010, up from 57 million in 1990. Most of the victims were young, and many had families that depended on them, who know have to rely on other sources of support, in most instances, the state.

What does the current research then tell us about this rapidly rising burden on global public health; transport injury prevention shows that collective action is as important as individual efforts. Motorcycle helmets, car seatbelts and sober drivers are important, but so are safe vehicles, consistent law enforcement and a reliable infrastructure. Thanks to a combination of insufficient, nonexistent or poorly enforced safety laws, poor infrastructure and a lack of enforcement and corrupt enforcers, the bulk of the countries globally keep aiding and abetting in the deaths of over 1.3 million persons annually! Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all five risk factors (speed, drunk driving, helmets, seat-belts and child restraints). Over a third of road traffic deaths in low and middle-income countries are among pedestrians and cyclists. However, less than 35% of these countries have policies in place to protect their road users.

India has the dubious distinction of registering the highest number of road fatalities in the world (250,000), despite the fact that its population is much smaller than neighboring China and there are more vehicles on the roads in the USA than in India. “A large proportion of these deaths can be prevented by simple measures. The most important of these is strict enforcement of traffic rules, which is conspicuous by its absence in our cities as well as on highways,” says the Times of India, and this would be true of the top 10, and also of the country where I reside, South Africa, where 47 persons die each day!

Further compounding the cost of the traffic fatalities is the actual real cost impacting on the affected countries economies; many who cannot afford to have the extra burden on their already strained public health budgets. The economic cost of road collisions to low and middle income countries is at least $100 billion a year! The risk of dying as a result of a road traffic injury is highest in the African Region (24.1 per 100 000 population) It’s such a big problem, in fact, that the U.N. feels it needs an entire decade to fix it. In 2011, the U.N. launched a “Decade of Action” that aims to “stabilize and then reduce” global road traffic fatalities by 2020.

Is there any good news? Sweden is one success story, in 2013 only 264 people died in road crashes, a record low. How have they done this? Planning has played the biggest part in reducing accidents. Roads in Sweden are built with safety prioritised over speed or convenience. Low urban speed-limits, pedestrian zones and barriers that separate cars from bikes and oncoming traffic have helped. Globally we need to reduce human error, or eliminate the opportunity for drivers to make fatal moves; human error can even further be reduced, for instance through cars that warn against drunk drivers via built-in breathalysers and making the implementation of safety systems, such as warning alerts for speeding or unbuckled seatbelts/child-seats, compulsory on all new vehicles, built in any factories across the globe.

Individually we need to be aggressive in safe and sober driving habits and not allow our friends and family to place themselves, their passengers and fellow pedestrians at risk by not looking kindly on their unsafe driving practises. Bad and drunk driving should become as unpopular as using a cellphone while driving.

References:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961682-2/fulltext

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext

http://www.worldlifeexpectancy.com/cause-of-death/road-traffic-accidents/by-country/

http://apps.who.int/gho/data/node.main.A997

http://apps.who.int/gho/data/node.main.A998

http://mikebloomberg.com/Bloomberg_Philanthropies_Leading_the_Worldwide_Movement_to_Improve_Road_Safety.pdf

MANAGING THE GLOBAL BURDEN OF CHRONIC ILLNESSES

An article on an EMS blog caught my eye in the past week:

COPD was the third-leading cause of death in the U.S. in 2011 and is expected to become the third-leading cause of death worldwide by 2020.

Source:

Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep, 2012; 61(6): 1–65.

Lopez AD, Shibuya K. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J, 2006; 27(2): 397.

This caused me to dig up a presentation I did in 2006 at a Fitness Seminar, wherein I was discussing chronic medical conditions, which are caused by poor lifestyle choices and I noted then:

In 1999 CVD contributed to a third of global deaths. In 1999, low and middle income countries contributed to 78% of CVD deaths. By 2010 CVD is estimated to be the leading cause of death in developing countries. Heart disease has no geographic, gender or socio-economic boundaries.

I further stated:

Chronic illness have overtaken communicable disease as a major cause of death and disability worldwide. chronic diseases, including such noncommunicable conditions as cardiovascular disease, cancer, diabetes and respiratory disease, are now the major cause of death and disability, not only in developed countries, but also worldwide. The greatest total numbers of chronic disease deaths and illnesses now occur in developing countries.

I then dug deeper to see how this has changed since 2006, and the outlook has become even more bleak!

More than 75% of all deaths worldwide are due to noncommunicable diseases (NCDs). NCD deaths worldwide now exceed all communicable, maternal and perinatal nutrition-related deaths combined and represent an emerging global health threat. Every year, NCDs kill 9 million people under 60 years of age. The socio-economic impact is staggering. These NCD-related deaths are caused by chronic diseases, injuries, and environmental health factors. Important risk factors for chronic diseases include tobacco, excessive use of alcohol, an unhealthy diet, physical inactivity, and high blood pressure.

The world now suffers from a global epidemic of poor lifestyle choices! Medically we call them chronic illnesses or NCD’s, but the issue at hand is that they can be avoided, reversed and prevented; with smarter lifestyle choices. The why and the how of these lifestyle choices is a debate for another blog, but poor socioeconomic conditions, poverty, malnourishment and diets deficient in basic nutritional building blocks all form part of this dynamic.

These poor lifestyle choices and the death, illness, and disability they cause will soon dominate health care costs and should be causing public health officials, governments and multinational institutions to rethink how they approach this growing global challenge. To exacerbate the matter; the deaths, illnesses and disability are spiralling at even faster rates in the developing world, where the infrastructure is even weaker than in the developed world.

causeofdeathdevelopingcountries

It is estimated that by 2020 the number of people who die from ischemic heart disease will increase by approximately 50% in countries with established market economies and formerly socialist economies, and by over 100% in low- and middle-income countries. Similar increases will also be found in cerebrovascular disease (Stroke) by 2020!

This is indeed a frightening prospect; NCDs are expected to account for 7 of every 10 deaths in the world! The overextended healthcare systems in Africa and Asia will battle to cope with these spiralling patient numbers.

A (positive) point to ponder as we consider this bleak outlook; the principal known causes of premature death from NCDs are tobacco use, poor diet, physical inactivity, and harmful alcohol consumption – all of these are preventable and manageable; as they relate to personal choices. Therefore we need to focus on creating a environment where these same individuals can make the correct choices which will have a positive impact on their lives. This is where governments, aid agencies and multi-nationals should focus their energies, and the approach should be more carrot than stick, which is not the case at present.

Reference’s:

http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng.pdf

CORPORATE RESPONSIBILITY AND DUTY OF CARE – HEALTH INSURANCE AND ASSISTANCE

“Between one in two and one in three expatriates has no international health insurance”
International Private Medical Insurance Magazine from the report: International And Expatriate Healthcare And Insurance 2014

I believe this to be a very accurate statement notably, with regard to the African continent (where I spend most of my time), this figure might even be flattering to some companies employing expat staff in Africa.

The globally mobile population has grown dramatically. There are over 50 million expatriates, and by 2020 this will be 60 million. 232 million people now live away from their country of birth.
Between one in two and one in three expatriates has no international health insurance, although a minority is covered by domestic health insurance. Several countries seek to get expatriates and migrants to pay for healthcare or have compulsory health insurance.

This is a disturbing issue, as too many companies are happy to send their staff abroad, or to remote work sites, without any or inadequate medical cover; be it insurance or assistance. This shows very poor duty of care. In discussions with some of these companies, when trying to assist them with advice on even basic assistance packages or client managed services, their responses are troubling; when viewed against the light of corporate responsibility and duty of care. To defer the responsibility to the employee and abdicate corporate responsibility, should be cause for concern.

The duty of care of the employer, is a term that is often thrown about and The UN Global Compact, is one way that companies are being encouraged to show a greater duty of care, although some would cynically say that Corporate Social Responsibility is a box-ticking exercise, companies are just paying lip service, but do no more than is necessary to avoid affecting the bottom line. The UN Global Compact, is engaging over 8,000 companies in more than 145 countries on human rights, labour standards, environment and anti-corruption, hopefully at the same time pushing to commit to a sustainable workforce, via duty of care and corporate social responsibility.

The level of care offered by companies, will depend where the company is registered, as to what laws could be enforceable, hence most companies register an off-shore shell for hiring, staffing and contracts. (this is in itself a topic for another day – relating to contracts, taxes etc.)

Possibly other avenues should be explored, with respect to medical assistance/insurance; by pushing that investors use their muscle, ensuring that their investment capital is being well managed. Staff that cannot be properly cared for (ex-pat and local), via medical cover that is in place, place a further drain on company resources, shifting capital away from its intended purpose. A well managed corporate health care plan, ensures ongoing confidence in the company.

Till now I have only been speaking about expat staff, but the issue of medical care for local staff would also need to be addressed, in fact poor care for expat staff, could be viewed as an indicator of poor care for local staff. The ever growing impact of business on society means that staff, investors and consumers expect corporate power to be exerted responsibly, the corporate community will have to step up its game and build greater trust with respect to duty of care. Business are being expected to do more in areas that used to be the exclusive domain of the public sector – ranging from health, education and to community investment.

Having insurance/assistance programs from reputable companies, linked to well managed onsite managed health care programs, which is in place for ALL staff, makes good business sense. This then empowers staff to work safely in environments that might be deemed risky, allowing them to work with confidence and be fully focussed on their daily tasks.

Reference’s:

http://www.researchandmarkets.com/reports/2788557/international_and_expatriate_healthcare_and

https://www.unglobalcompact.org/abouttheGC/thetenprinciples/index.html

HEALTH ISSUES ON THE AFRICAN HORIZON FOR 2015

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

1. Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent’s development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverage and is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

2. Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW’s.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW’s numbers have been reduced as a result of war, poor political will and Ebola.

3. Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW’s have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett’s latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

4. Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW’s.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc…

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

5. Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.

THE NEED TO KEEP EBOLA ON THE FRONT PAGES

I had already started to pen this weeks article when a few headlines/comments/articles caught my eye, forcing me to push it onto the back burner, as I feel this issue is more pertinent and pressing.

A tweet from Laurie Garrett had me concerned. She tweeted; Google News no longer ranks #Ebola in top 20 search items, and even within the health category, only in the Italian and USA news-feeds. This was then followed by a press release from the UN (United Nations’ Ebola Emergency Response Mission – UNMEER) stating that they will miss their December the 1st containment target, due to escalating numbers of cases in Sierra Leone.

The kicker, that then really got me switching my thought train was a press release from the the nonprofit ONE.org (http://www.one.org/us/ebola-tracker/). The Ebola Response Tracker follows the money and shows us the money; i.e.: how much that has been pledged, has made it onto the ground in West Africa to fight the good fight. While the Office for the Coordination of Humanitarian Affairs (OCHA), the UN, and the World Bank have data on the dollar figures associated with each pledge, no one had taken the time to figure out how much of those resources have actually made it to the ground in West Africa.

Erin Hohlfelder, global health policy director at ONE and the brains behind the tracker, says the tracker shows the importance in transparency (and the follow through on ones commitment). “It’s one thing to make a great pledge and commit to doing that, but in the meantime, every day that goes by without these resources is a missed opportunity.”

While progress has been made in the months since these pledges, there is still much work to be done. The USA leads the pack with the highest pledge and disbursement; $572 million of which 72% has made it to the ground in West Africa. Here is a sampling of a few other countries, foundations and institutions: (in no particular order)

Google/Larry Page Family Foundation pledged $25 million – none disbursed yet

Bill & Melinda Gates Foundation $50 million – 27% disbursed

African Development Bank $220 million – 20% disbursed

Paul G. Allen Family Foundation – $100 million 3% disbursed

Silicon Valley Community Foundation $25 million – none disbursed yet

EU $468 million – 17.5% disbursed

China $123 million – 8% disbursed

Australia $36 million – 38% disbursed

Visit their website to check out other countries and follow them on twitter and facebook.

At a press conference last week, Liberian President Ellen Johnson Sirleaf said that the progress her country has made may be damaging. “Our government remains concerned that progress in this battle will lead to complacency on the part of the international community. We must not interpret gains as an outright victory—nothing could be more dangerous.” Complacency must not be allowed to seep in, we need to keep the issues on the front pages. Margaret Chan, director of the World Health Organization, agrees on the complacency front; “We must not forget—Ebola virus is a formidable enemy. Yes, we are seeing some early signals of hope. Cases are stabilizing, we are also seeing some new areas where they are reporting new cases. We must maintain our vigilance. Complacency would be our enemy. And in order to get it to zero, we have been successful in bending the curve a bit, but we need to continue to do more to get to zero.”

The fight is still in the early stages, we must aggressively push to keep Ebola in the news and for more action on the ground. The international response is being outpaced by this epidemic, If more help doesn’t arrive soon, the worst may not be over. Ebola hasn’t simply overwhelmed these health-care systems, it has decimated them. Women in need of support for childbirth have been turned away, leading to an increase in infant morality rates in a region with the some of the highest numbers in the world. Children suffering from malaria or extreme diarrhea are now too often left without medical care, leading to an increase in deaths from dehydration. Life-saving vaccines for those illnesses and others are lying unused in clinics and warehouses, as there are not enough (or any) medical workers to disburse them. Crops are not being planted, food is not making it to the market places!

UNMEER was set up to provide coordination, policy and logistics rather than to treat patients. It needs more resources to halt Ebola as quickly as possible, at present the emphasis is on allocating existing resources in the smartest way, possibly because they are still waiting for more resources/pledges/manpower to make it to the ground in West Africa.

According to October estimates from the World Bank, the epidemic could cost the West African countries affected upward of $32 billion in the next 24 months. What are we waiting for! Every day spent without pledges being delivered on, manpower to hit the ground and the process of rebuilding shattered healthcare services and networks; more people die. Containing Ebola is a constant battle and already we are seeing it cropping up in Mali, where to next?

I will let Anthony Banbury from UNMEER end this weeks blog:

Containing the epidemic still calls for a tremendous increase in resources on the ground. We are far, far away from ending this crisis, there is a long battle ahead of us.

MEDICAL RESEARCH – AN EVIDENCE BASED APPROACH TO GLOBAL HEALTH

A question posed by Jessica Taaffe on twitter, who is a TWIGH panelist, is my inspiration for this weeks blog. The question posed was: If you were to list three major research gaps for access to medicines what would they be? I posted 2 comments to that statement, the 140 characters per tweet, was not enough to fully weigh into the matter, so I am using this weeks post as a soapbox to expand further.

Firstly you might be asking what does this have to do with global health? In a nutshell, it has a huge impact, access to medicines, is dependent on the research that underpins it, it is the foundation on which medicine that we use stands. How firmly it stands depends on the strength of the research. If the road travelled to arrive at the end product is not evidence based (we will discuss the vagaries of this shortly), we then run the risk of having a flawed product, or even in some cases a product that never sees the light of day, (see my blog on Politics and Medicine).

The two comments I posted to twitter stated that evidence based medicine must be driven by independent clinicians, scientists and medical policy makers. Furthermore I stated that Levels of Evidence A (LOE – A) must be the benchmark. We cannot just be led by the large multinationals (Pharma and Medical Device Industries), they can most certainly push money into research, but the parameters of that research must be in the hands of independent clinicians, shared decision making can and must play a key role. This is a huge challenge but must be addressed, we need to claim back the labs and work alongside the drug and medical device industries

So what is evidence based medicine , why is it important and why do I say the we need to adhere to LOE -A?

Evidence based medicine grew out of critical appraisal, when Gordon Guyatt took over as the director of the internal medicine registry programme at McMaster University. He wanted to change the program so that physicians managed patients based not on what authorities told them to do but on what the evidence showed worked. It then appeared in an article in “The Rational Clinical Examination” series in Journal of the American Medical Association (JAMA) in 1992.

The strength of evidence is assessed by a specific grading system which, in fact, is quite simple. It combines a description of the existence and types of studies supporting a certain recommendation.

-Level of evidence A: recommendation based on evidence from multiple randomized trials or meta-analyses

-Level of evidence B: recommendation based on evidence from a single randomized trial or non-randomized studies

-Level of evidence C: recommendation based on expert opinion, case studies, or standards of care.

So the highest standard to attain is LOE – A, is this always the case? In 2009, a very interesting paper was published in JAMA, assessing the strength of evidence underlying the American College of Cardiology (ACC) and the American Heart Association (AHA) practice guidelines. They were reviewing recommendations to see if they were based on strong levels of evidence (LOE – A) and how much is based on “expert” opinion.

In only 11% of the guidelines published was LOE – A the benchmark, and most of the current guidelines included more than 50% of LOE – C as the standard! The authors correctly concluded that “expert opinion remains a dominant driver of clinical practice, particularly in certain topic areas, highlighting the need for clinical research in these fields”. I am sure if we had to review other areas of medical research we will be in a similar ballpark.

I can cite numerous examples from my own area of speciality where we have used certain drugs for years, with no studies definitely stating that they were beneficial to the patient, but there use was continued because of expert opinion, what drove that expert opinion is open to debate.

The Internet has also allowed incredible access to masses of data and information. However, we must be careful with an overabundance of “unfiltered” data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.

This is where the Cochrane Review stands the test of time, as it enable the practice of evidence-based health care, where health care decisions can be made based on the best available research, which is systematically assessed and summarised in a Cochrane Review. Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognised as the highest standard in evidence-based health care.

In closing then, to come back to the original question; what three major research gaps for access to medicines:

  1. Research must be evidence based with LOE-A as the gold standard

  2. Research must be driven by independent clinicians, scientists and medical policy makers

  3. Research needs to be taken back to the labs and institutions who will research what is needed globally.

We would need large NGO’s such as the WHO and the European Research Council (amongst others) to monitor and guide where research needs to be focussed. We need to thank all scientists, inventors, and researchers who are motivated by the need to know, the thrill of discovery,and the desire to make a positive contribution to mankind as a whole and acknowledge the right of people to the common ownership of medicines/vaccines etc. which are basic to their common and individual well being, as to life itself.

As the cognitive linguist George Lakoff puts it, “Empathy is at the heart of real rationality, because it goes to the heart of our values, which are the basis of our sense of justice. Empathy is the reason we have the principles of freedom and fairness, which are necessary components of justice.”

MALNOURISHMENT – A GROWING CONCERN – Food as a Weapon

The number of hungry people has fallen by over 200-million since 1992, so says the 2014 Hunger Map and a report titled “The State of Food Insecurity in the World: Strengthening the Enabling Environment for Food Security and Nutrition” jointly prepared by World Food Programme (WFP), the Food and Agriculture Organisation (FAO) and the International Fund for Agricultural Development (IFAD).

They go on to say that 805 million people, or one in nine of the world’s population, go to bed hungry each night. But in Sub-Saharan Africa, this is even worse, with one in four people suffering from undernourishment. The report says that sub-Saharan Africa faces the most severe challenges in securing its food; mainly due to sluggish income growth, high poverty rates and poor infrastructure, which hampers physical and distributional access.

It states: “In general, in Africa, there has been insufficient progress towards international hunger targets, especially in the sub-Saharan region,”

The report also says limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities, while the region continues to face challenges in improving dietary quality and diversity, particularly for the poor. I did some work in the Southern DRC (based out of Lubumbashi in 2006) and we noted then that dehydration, was the leading cause of death in children under the age of 5. Dehydration as the result of diarrhoea, caused by unsanitary drinking water. For those who survive they are then in turn faced with stunted growth, which is made worse by poor food nourishment.

This report just published confirms that the situation has not changed in the past 8 years, limited progress had been made in improving access to safe drinking-water and providing adequate sanitation facilities. In fact the report notes, that progress has been so poor, that the WFP target of halving the number of undernourished people by 2015, will not be realised.

The report highlights the following to move forward:

1. Sustained political commitment at the highest level
2. Placing food security and nutrition at the top of the political agenda
3. Creating an enabling environment for improving food security and nutrition through adequate investments
4. Better policies, legal frameworks and stakeholder participation
5. Institutional reforms are also needed to promote and sustain progress.

Plus an integrated plan focussing on:

1. Public and private investments to raise agricultural productivity
2. Better access to inputs, land, services, technologies and markets
3. Measures to promote rural development
4. Social protection for the most vulnerable (persons and countries)
5. Including strengthening their resilience to conflicts and natural disasters
6. Specific nutrition programmes, especially to address micro-nutrient deficiencies in mothers and children under five.
As reports go it is a very good piece of work tackling many complex issues and outlining clear broad action plans. As with most reports though, I take issue with their expected outcomes, to broad, not specific and in my opinion, to broad. Its like position papers from government departments or even aid agencies. It does not tackle the problem head stating what is at fault and what needs to be done in clear action plans; to do that will require stepping on toes or worse – maybe even naming names!

Regional conflicts, greedy power hungry warlords all demanding access to food, how it is priced and distributed. This can affect when and if crops are planted, and who gets the produce, and they who sells it. Food can be and is used as a weapon, to control people or even to get votes, Zimbabwe and South Africa are cases in point.

The cost of food is then another key factor, Lester Brown wrote in 2011’s “Food Issue” of the Foreign Policy magazine:

Americans generally spend less than 10% of their income on food, but there are 2 billion people who live in poverty around the globe who spend 50 to 70 percent of their income on food.

A slight increase in the cost of food for these persons could be life or death, and the costs when they do escalate, are beyond the control of the consumer, at times manipulated by external forces, for their own (political or economic) gain.

On a sad and macabre note, Saudi Arabia, South Korea and China ventured beyond their borders in 2008 to grow grain in cheaper regions, such as Ethiopia and Sudan, where, of course, people where starving and did not get any of the planted grain.

So where to from here; I think if we cast our eyes to Burkina Faso, we might see a way out, People Power. The people need to speak and speak loudly in the only way the politicians and regional leaders will listen.