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.

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.