Health and wellbeing – How do we get it right? by Catherine Mackereth and Michelle McCoy

Not one of us has had a choice in the life circumstances into which we were born. We are born in a country, with particular parents and with certain advantages and possible disadvantages – and this can have a lifelong impact on our health and wellbeing. We know that some are born with genetic conditions that have a huge effect on their lives; those brought up in poor housing conditions are more likely to suffer from respiratory diseases; children brought up in care may have less resilience to overcome difficulties (which is not to say that many don’t overcome them); and many are not able to make the most of opportunities because of the difficult and challenging circumstances they find themselves in.

Within Public Health, a discipline that has a major focus on seeking to improve health and wellbeing at a population level and reducing inequalities, a model that we often use to describe these situations is the Dahlgren and Whitehead rainbow (below). This, since its publication, has become a frequently used model for describing the underlying causes of ill health in the population and provides a helpful framework on which much of the health improvement work we are involved in is based. It offers a social model, which focuses not just on the individual lifestyle factors that impact on health, but on the wider socio-economic, cultural and environmental conditions, which make a huge difference to our health and wellbeing.

cathmich-1

Underlying these differing life circumstances are inequalities which may be income, education, housing, environment or social conditions. The graph below shows how health and social problems are worse in more unequal countries. These inequalities can be found with regards to child wellbeing, levels of mental illness, drug use, life expectancy, infant mortality, obesity, teenage pregnancy, education, to name just a few.

cathmich-2

These inequalities are not inevitable, and therefore should be tackled in order to ensure people have opportunities to improve their health and wellbeing. It is the role of Public Health and all our other partners to address these issues. It is not an easy task nor can it be undertaken by one agency alone.

Improving health and wellbeing must be supported at all the different levels identified in the rainbow model above. At an individual level, we need to understand why people behave in the way they do. Much of our work in improving the populations’ health and in providing preventive services is about supporting people to make their own positive life choices. However, having the ability to make choices is something not everyone has to the same extent: the very reason why we need to support people. For example, at one level, people have the choice as to whether to smoke or not. But if you are under stress, giving up smoking might be one thing that is too difficult to contemplate: we know that will power is a finite resource, and if you are juggling with a crisis, then all your efforts need to go into solving that crisis. And that is not even considering the physical addiction and the impact of tobacco withdrawal. Remember, very few people actually want to be addicted to cigarettes.

Health and wellbeing also needs to be addressed at a family level. For example, we know that some children are disadvantaged at school entry because they do not have the necessary emotional, social and cognitive skills which enable them to take advantage of the opportunities available from education. Support for parents can provide the self-confidence and self-efficacy to help counteract these difficulties, so that children can have the best start in life. This is extremely important for future life when these children become adults, and affects further wellbeing and subsequent use of health and social care services.

There are many approaches to supporting improved outcomes for population health. For example, at a wider level it is important that environmental issues are addressed. Creating enough green space for children to play or adults to walk and be physically activity can have a major impact on health and wellbeing – as can having nutritious food available locally, or accessible social activities. Having enough money is also a key element of trying to live healthily. In times of job insecurity and rising costs, this can be challenging, so ensuring access to the right kind of advice for claiming benefit, offering support to complete job applications, provide welfare rights information to support people to claim what they are entitled to, providing accessible health services and health information which is easily understood, is vital.

If, as a society, we are to reduce the burden on health and social services, we must work together to prevent and mitigate against the circumstances which act together to limit the ability for communities and individuals to achieve optimum health and wellbeing. There is a lot that can be done to support people’s health and wellbeing, and this must be underpinned by looking at what people themselves really want, not just assuming that we, as health professionals, know what is best for them. We need to listen and understand where people are coming from, and do that with compassion. We all want the freedom and autonomy to do what is best for ourselves, and we need to make sure we support people in achieving that for themselves.

Catherine Mackereth is a Consultant in Public Health and Michele McCoy is a Consultant in Public Health and Interim Director of Public Health at NHS D&G

 

Recreation and Wellbeing by Catherine Mackereth and Michele McCoy

Michelle 1September is well past the holiday season for most people, but we are both just about to go on ours (separately – we see plenty of each other at work!). We both enjoy holidays as it is a chance to relax, a change of scenery, explore new places, try out new things. It’s about recreation. But what do we mean by recreation?

Recreation is about re-creating, about being creative, in whatever way suits us. It is the key to getting refreshed, revitalised and energised. Creativity is a fundamental part of being human and we should take every opportunity to engage in activities that will promote that side of our lives. It is about looking at the world with fresh eyes, whether looking at a piece of art in a gallery, reading a good book, listening to the birds sing, spending time with friends and family, smelling the new mown grass…or making your surroundings look lovely!

 

Public Health as a function recognises the importance of creativity and its contribution to wellbeing.

Not only do we seek to promote it in other people, we are looking at how we can promote creativity in all our work. One example is around how we engage with communities and the general public. There is lots of talk about community engagement at the moment, but are we any good at it? Of course we are interested in engaging about the health and wellbeing of the population whether that is in regard to; promoting healthy behavior, working with colleagues to develop new services, establish positive environments for people. However, what we need to know is whether or not we are really doing that in an effective way?

The questions we need to ask are:

Will a questionnaire, received by email really prompt the kind of engagement that we are looking for? Will a notice in the local paper help us access the people that we really need to talk to? We all lead busy lives , yet we know that talking and exploring ideas will lead to creativity and finding solutions that we may not have found through simply asking a set of questions via the more obvious channels. This is not to say that these approaches are not applicable, but they must not be the only approach. If this is all we do, people may simply disengage. We need to capture the imagination and passion to achieve the sort of engagement which will help to inform our decisions.

We have been talking about what it would feel like if someone was trying to engage with us. We wondered about venue…maybe a comfortable coffee shop, or a trendy wine bar? What about being offered interesting food to make it worth our while? Or a voucher as a token of thanks for our time? None of these are likely in these times of austerity, but maybe we need to start using our creativity to make the whole process more enjoyable.

We have been developing skills across the region in Participatory Appraisal. This is a way of engaging local people using lots of different techniques, such as focus groups, or fun activities which allow conversations to take place as you do something (one of the most enjoyable was going on a boat trip – a captive audience!). Most people enjoy being asked their views, probably because they feel valued, and most people are clear about what would be best for their health, wellbeing and happiness. Given the time, space and the right environment we all have the ability to be creative about solutions for ourselves and others.

Sharing views, then finding solutions and ways of changing how we work to provide the best results are what true engagement is about. Not just being asked what we want, and information being taken away to have something ‘done’ with it. Real engagement might be a longer route, but it is the way of truly empowering people to be part of the decision making process and ultimately supporting communities to take on responsibilities, using the strengths within those individuals and communities, to improve health and wellbeing.

All too often we are working in situations when we feel the need to be logical, be analytical, instead of being creative. We have both experienced the reaction from colleagues when telling them that we have been engaging with communities and spent time drawing images to symbolise a certain situation, but then when they saw how it added value to the words, or the description they began to understand what we were doing and why. So, we would encourage you to welcome creative ideas, whenever they are expressed. It is amazing to see what solutions can be found when you explore that seemingly wacky idea, and at the very least they will keep us entertained. After all, even if there is no obvious solution, a laugh on the way will help make us all feel better. Those of you reading this short piece who are lucky enough to find they can express their creativity in work should count themselves blessed. For those who aren’t, well, maybe it is about finding those little moments that provide an opportunity to inject a new insight or idea into the workplace when possible. And going out at lunchtime to smell the new mown grass and watch the clouds go by may help.

This is a developing area and we have included the couple of links below which may be of interest

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804629/

https://www.liv.ac.uk/media/livacuk/instituteofpsychology/research-groups/The_Arts_and_Public_Health_Research_Proposal_Final_shortened.pdf

Health and Social Care Integration and the development of the new hospital offer opportunities for being creative in finding solutions to new challenges and ways of working.

We began this blog by stating we were each going off on our respective holidays and whilst these will be different, we will both be making sure that we find every opportunity to be creative and come back to work refreshed.

Michelle 2

Catherine Mackereth and Michele McCoy are Consultants in Public Health at NHS Dumfries and Galloway

Services … but not as we know them…. by Elaine Lamont

Elaine lamont 3“Change is the essential process of all existence…to boldly go… to seek out new life and to explore strange new worlds… “ ( Captain Kirk and the Star Trek crew….)

Unless you’ve been lucky enough to have been hibernating for the past year or so I’m sure you’ll be well aware of the changing landscape and the need for dramatic change in the way we go about our business across the sectors so that the needs of our local population are met. Sadly I have heard so many people talk about the changing demographics and rise in our older population as a’ negative’ or as a ‘problem we face’… but I personally feel this is our opportunity to do things differently….

The facts….

  • people are living for longer
  • people want to live independently in their own homes and communities for as long as possible
  • older people have so much to give in terms of creating vibrant supportive communities
  • we need to think differently in relation to ‘service provision’ and the kinds of support that are key to maintaining good health and well-being

Actively engaging and involving people in identifying what enables them to keep and live well and to feel they are in control so that they can ‘live life to the full’ is absolutely essential and is key to the work being taken forward in Annan by the Health Improvement Team. The ‘Community Engagement, Resilience and Health Service Development Project is supported by the Putting You First Change Fund and is part of Dumfries & Galloways’ response to ‘Reshaping Care for Older People’

Engaging and involving Communities…

There has been some extensive work with older people to try to establish what matters to them and the kind of services and activities they need to enable them to live independently for longer with a good quality of life.

In Annan, for example, we went out into the town to speak to people. We did not organise a public meeting … we went to the Day Centre, visited people in sheltered housing, spoke to people in supermarkets and knocked on doors. We managed to speak to around 600 people.. We asked then to share their thoughts and they were happy to do this. We also found 175 people were in need of some kind of support or information and we were able to signpost or support them immediately (for some it was little things that were making them extremely anxious and for others it was more serious difficulties they were facing. In some cases I think we probably prevented crisis at a later date). Around 120 people gave us their details and said they would be keen to help us plan and develop… A really positive response..

A snapshot of people said…

Elaine Lamont 1Elaine Lamont 2

What do you think would improve your health and well-being?

Recognising our assets… individual and community ..& Strengthening Resilience

Communities and individuals harnessing local resources and expertise to help themselves (Civil Protection Lexicon 2010) In the ‘The Well-Connected Community’, Alison Gilchrist argues the importance and value of building networks within communities that results in individuals, families and the wider community building a ‘resilience’ leading to a sense of wellbeing and greater quality of life.…(SCDC.. Getting to Grips with the language)

We contacted the 120 people who said they wanted to get involved and invited them to work us by coming along to a ‘hands-on’ workshop type session where we spent time identifying local ‘assets’ in and around the town. ..we asked about places, people, services…things that they did or used to keep them well and we asked them to share their stories and experiences..….below are a couple of examples..

the hairdressers on the corner…my Mum has dementia and they are always so good with her.. even when she’s having a bad day..”

“ Skyline Guitars… it’s where I go when I need a bit of respite… I hear people practicing and often just spend quiet time looking at the guitars”

This information was used to populate the ALISS information engine which is a local national search tool that people will be able to use to find things to do or services that they need …

(This is still in development but you can have a look by going to www.aliss.org )

Co-productive approaches to developing ‘support and services’

Co-production essentially describes a relationship between service provider and service user that draws on the knowledge, ability and resources of both to develop solutions to issues that are claimed to be successful, sustainable and cost-effective, changing the balance of power from the professional towards the service user. The approach is used in work with both individuals and communities.” Joint Improvement Team
Having information about how people kept themselves well and things they felt they needed to ‘do more of’ we invited people to come back together with some local Service Providers to start thinking about solutions and ways of meeting needs with the assets available. From these sessions came lots of creative ideas and we are currently working with local people to develop these… Some examples include Knit & Natter group who meet in a local Care Home, Arts & Crafts Groups, Walking groups for people with long term health conditions, creating Dementia Friendly Communities , informal Carer support, Ipad training, Confidence courses, Tea & Tennis… just to name a few. We are also working very closely with local third sector providers to help strengthen their capacity to offer more.

Changing behaviours and mindset..

Changing practice and ‘hearts and minds’ can be challenging to say the least, particularly in a short-life project or ‘test of change’. This work is part of the Putting You First Pathfinder Plan in Annan and we strive to ensure this ‘person and community focus’ is part of every project undertaken. As part of the work we have introduced the Community Link Worker role which is a resource to both individuals and practitioners. The Link Worker works with people to identify things that really matter to them and supports set personal goals and access what they need to achieve them. Practitioners across the sectors including GPs, Social Workers, District Nurses, Discharge Planners, are now realising the benefits for their client group of this real person centred approach focusing on outcomes rather than outputs and the use of existing assets that they may not have considered before. 

Linking people to these assets and the sources of support is crucial in ensuring good health, independent living and peace of mind as is trying to capture the benefits and outcomes (more about this in a later Blog,,,). The introduction of the Community Link Worker role means that people are introduced to the concept of recognising their potential and setting realistic goals to meet personal outcomes. Sometimes it’s simply about asking the right questions… as more often than not it’s something small, really simple and fairly easy to fix that’s having the biggest impact on peoples’ health and happiness and their ability to feel in control of their lives and health again..

This concept is one we are hoping to take forward as part of the integration of Health & Social Care as it clearly plays a big part of delivering the vision for the future…

Oh.. and the star trek theme… my name before I married was Kirk and I went through my School and University years known as ‘the Captain’.. so, without much choice Star Trek has always been part of my life..

Elaine Lamont is a Public Health Practitioner with Annandale and Eskdale Health Improvement Team.

 

 

Alcohol and Wellbeing by Andrew Carnon

A blog of two parts, first a glimpse into a common public health topic and then something I hope may be a bit different.

A retired doctor friend told me a story. He was invited to be on an interview panel for a consultant appointment in the 1980s. The interviews were held in the new Boardroom at Crichton Royal Hospital. After the candidates had been seen in the morning, a good lunch was provided and then a black-clad waiter with white gloves opened a wood cabinet from which he produced a silver tray with sherry and glasses which were offered around the panel and successful candidate for a celebratory drink. Different times now!

For years alcohol was one of the few causes of death that was increasing in Scotland. Completely opposite to the success stories in heart disease, stroke and cancers through better treatment and prevention, deaths from alcohol seemed to be going through the roof. Looking at the chart, you see that alcohol-specific death rates for females and males have been consistently higher in Scotland than in England & Wales. The female rates are lower than the male rates, and the female rate for Scotland is actually similar to the male rate in England & Wales. And as well as these very specific deaths, there are many more where alcohol is a contributing cause.

Andrew carnon 1

Death of course is the most severe outcome, but alcohol can also lead to a host of other problems impinging on the NHS, from long-term harm to health, falls and injuries, to domestic violence, unsafe sex, unwanted pregnancy, and problems at work or job loss.

Why are alcohol-related deaths so high in Scotland and what can be done about the problems?

Lots of things are tried or proposed, for example:

  • Local or national awareness-raising campaigns
  • Opportunistic advice when patients consult a health professional
  • Brief interventions on alcohol in settings like Accident & Emergency
  • Alcohol and drug treatment service
  • Attempting to restrict availability of alcohol through the licensing system for off-licences (supermarkets, shops selling alcohol) and on-licences (hotels, pubs, clubs)
  • Proposed minimum pricing of units of alcohol.

Do these work? Unfortunately there’s little evidence that campaigns make any more than a whit of difference. I suspect they’re more about salving consciences that something is being done, rather than actually doing it.

By far the most effective public health actions tend to be the big population measures, like tackling availability or price of alcohol, but these invariably run into strong opposition and can become mired down in commercial or contrary interests. The derogatory term ‘nannying’ is often used.

Are the opposite views unbridgeable, depending on whether we give more weight to preventing harm or to protecting individual autonomy for people to harm themselves if they choose? Are there any easy answers at all? At least there’s some comfort that rates seem to be falling in recent years.

Andrew carnon 2Sometimes questions like these seem so difficult that I’m going to segue instead into another public health principle, increasing wellbeing. The Edinburgh book festival (https://www.edbookfest.co.uk/) is one of the highlights of my own year, a real heart-sing event. Last month at the festival my mind was stimulated by (amongst others) philosopher Roger Scruton, journo Jeremy Paxman and Rebecca Mead of the New Yorker magazine.

Rebecca Mead’s theme was that reading classic literature has lifelong benefits. That set me wondering what are possible benefits of reading to busy NHS staff? I’m talking here about reading fiction, rather than the day’s deluge of work emails or NHS D&G’s required reading sent out to all staff, as these are, of course, supposedly non-fiction!

What benefits might there be? I can think of:

  1. Learning about how health professionals do their jobs, grapple with ethical questions or deal with lack of resources.
  2. Learning about patients and how diseases or disabilities affect their lives.
  3. Getting information about different lifestyles we might not have experience of ourselves.
  4. Getting inside characters’ heads might help to develop the subtle trait of empathy.
  5. May help improve communication skills (can develop our own vocabulary and range of expression and help us see different communication options and styles).
  6. Possibly (if Rebecca Mead is right) may enhance our own wellbeing, personal growth and development of wisdom throughout life.

I’m sure book lovers amongst you will think of other benefits as well. And the best thing is that all of this learning can be achieved in comfortable home surroundings (with one small glass of favourite tipple if you must), and without having to attend the latest recommended professional development course.

And so, back to the beginning. One thing reading can do is give you wider perspectives and individual insights into alcohol use. Pharmacologist Ronald Siegel thinks it’s a universal human drive to want to get ‘out of one’s head’ with mind altering substances. It seems to be so persistent through history that he equates it with our drives for food, sleep and sex. Could that be right? If so, attempts to control or price alcohol to reduce problems might not work.

Getting out of one’s head to an extreme degree is portrayed by a number of authors. I can’t help drawing attention to a couple of books set in Russia, where protagonists become drawn into a culture of regularly drinking to oblivion – both are fantastic reads quite apart from their alcohol insights: Among the Russians by renowned travel writer Colin Thubron (a previous Edinburgh Book Festival speaker) and Consolations of the Forest by French author Sylvain Tesson.

And just to finish on getting out of one’s head through drugs rather than alcohol, there’s a stunning short story collection: Julia and the Bazooka by Anna Kavan, who was a heroin addict for much of her life. The bazooka is a euphemism that Kavan uses for her syringe which went with her everywhere. The stories give a powerful insight into what life must be like for a dependent opiate user.

Oh and if you’re already a bibliophile or any of this has whetted an interest, the Wigtown book festival is in a week’s time…

http://www.wigtownbookfestival.com/

Andrew Carnon is Joint Interim Director of Public Health at NHS Dumfries and Galloway

 

Whisky with Water by Nigel Calvert

A man dies and goes to Heaven. When he arrives he sees that there is a long line to the Pearly Gates. After some time he hears a commotion behind him and turns to see a man in a long white coat with a stethoscope in the pocket cutting past everone. He strides right through the gates without a pause and past everyone who had been waiting forever. When the man gets to St. Peter he says, “Say, who was that guy who cut past everybody and walked right through?” St. Peter replied, “Oh. That’s God. Sometimes he likes to think he’s a doctor.”(1).

Nigel 2 World-Wide-WebThere was a time when only doctors and nurses had access to the medical information necessary to make a diagnosis and decide on the treatment that was needed. The World Wide Web has changed all of this and now anyone can have access to an almost inconceivable amount of information, both accurate and poor quality. According to the Office for National Statistics, eight out of ten Brits use the web regularly (2). It is interesting to consider the ways that this can impact on health. That, together with a shameless plug for our new Health Protection and Screening website (3) is the subject of today’s blog.

It’s very easy to “Google” a few search terms and come up with a wide range of material, some legitimate and peer-reviewed, some of dubious provenance and quality. With unfettered access to all kinds of health information, we need to help people to make sense of it all. I’m reminded of “J.” the narrator in Jerome K Jerome’s Three Men in a Boat who went to the British Museum one day to read up the treatment for hay fever. In an unthinking moment, he idly turned the pages of the book and discovered that (apart from Housemaid’s Knee) he suffered from every complaint listed (4). The scare stories erroneously linking MMR to autism happened in the early days of the web and certainly before today’s almost universal access, yet various anti-vaccine websites still managed to stir up public opposition to the vaccine despite any credible evidence. How much worse might this be now?

Nigel 3 google-300x168But what about the positive ways in which the web can affect health? Using the web as a means of interacting, and even as a tool for delivering healthcare has exciting possibilities. Peer support forums, often run as self help groups – with or without the support of charities – are common. These are perhaps most beneficial for stigmatising or embarrassing conditions where the relative anonymity of the internet can be an advantage. People with rare conditions can also benefit from the global reach of the web. Online consultations with GPs now take place using email, and increasingly with Skype/FaceTime etc. In a rural area, telemedicine can help an isolated GP to get a quick dermatological opinion about an unusual rash. In Scotland we have many national Managed Clinical Networks and teleconferencing over the web can sometimes save hours of travelling for some more productive use of the time.

The web has enabled a shift in the balance of power between health professionals and the public. More than a decade ago, there were reports (5) of patients bringing printouts of websites into their consultations with health professionals and today this is commonplace. Interestingly in that survey, the patients reported far more benefit in bringing in material from the web than did the health professionals.

Nigle 4bridgeThe wider public health can also be affected by the web. An internet-enabled society means that more of us can “home work”. Whilst this may reduce traffic pollution, congestion and potentially accidents, it can also lead to isolation and perhaps a reduction in physical exercise. When whole communities come together on the web it can build social capital. Inevitably when talking about public health, we must consider inequity. The term “digital divide” has been coined to describe the gap in web access that exists between the “have nets and the have nots”. As we grapple with ever decreasing budgets and more printed health information is replaced with web pages (with all the benefits that this brings) we may, paradoxically, be making it much harder for the very people we are trying to reach to actually get access to information about breast screening, immunisation and how to stop smoking.

As healthcare professionals we have to adapt our practice to embrace the world wide web. It provides exciting opportunities to improve quality of care and access to services, particularly in a rural area such as ours. It is true that not everyone has access to a computer, and that in some remote areas internet speeds are still very slow, but in time that will improve.

Nigel 1By its nature, the health related material on the web can’t be controlled so we have to provide easy access to high quality health information. Many charities such Marie Curie, Meningitis UK and Diabetes UK do a great job. The NHS too has some websites of which it can be justifiably proud – NHS Inform is a good example. Now for my shameless plug. Just before Christmas we launched our new Health Protection and Screening website. It provides some original content, such as our policies and newsletters, but much of it consists of links to other material on the web – there’s some great stuff out there if you know where to find it. So far, we’ve had about two and a half thousand hits – a reasonable start. Please have a look – just remember Gavin and Stacey’s Uncle Bryn’s (6) sage advice to put w-w-w (whisky with water) in front of absolutely everything – www.dghps.org.

References

  1. http://jokes.cc.com/funny-god-jokes/fg98b0/heal-the-world
  2. http://www.ons.gov.uk/ons/rel/rdit2/internet-access-quarterly-update/q3-2013/stb-ia-q3-2013.html
  3. http://www.dghps.org
  4. http://www.gutenberg.org/ebooks/308
  5. http://www.ncbi.nlm.nih.gov/pubmed/11956037/
  6. http://www.imdb.com/character/ch0122304/quotes

Nigel Calvert is a Consultant in Public Health Medicine at NHS Dumfries and Galloway

 

Global Surgery, Public Health and MDGs by @fanusdreyer

@fanusdreyer chairs the International Development Committee of ASGBI, is a member of Edinburgh University’s Global Health Academy and of the WHO’s Global Initiative on Essential and Emergency Surgery.

african-child
What is the primary care of obstructed labour, or a cleft lip, an imperforate anus or other birth defect? In the mid-1980s I worked in a small mission hospital at Nkhoma, Malawi as a medical officer. One day a boy was born with imperforate anus. It was the rainy season and there was no way he could be sent to the city. So I looked in the book how to do a defunctioning colostomy in a newborn, gave him ketamine and did the operation. Afterwards he stopped breathing every few minutes but started again when we flicked the soles of his feet. Our few incubators were all in use, each with three prem babies inside. So, over lunchtime and while the nurses kept our baby breathing, I built a wooden incubator, with plastic sheeting as a transparent top. That way we could give him oxygen, put two warm water bottles next to him and keep watch. I sat with our boy through the night, stroking him and flicking his soles so he would breathe, until the ketamine had worn off by the early hours of the next morning. He left hospital a few days later, ready to wait for the Canadian paediatric surgeon who was visiting a few months later. And I learnt that surgery can be primary care …

The declaration of Alma Ata (1978), which is a cornerstone of WHO healthcare states in section VII.3 that primary health care “includes at least: education concerning prevailing health problems,…maternal and child health care, …appropriate treatment of common diseases and injuries.” What place then for surgical conditions within “prevailing health problems”?

Of the global disease burden 11% needs surgery, mainly due to injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%) and peri-natal conditions (4%). Only 3.5% of 234 million annual surgical procedures worldwide are performed on the poorest 33% of people, but 80% of surgical deaths occur in low and middle income countries (LMICs). About 800 women die every day due to complications of pregnancy and childbirth e.g. obstructed labour, haemorrhage, sepsis, uncontrolled high blood pressure and unsafe abortion, i.e. mostly conditions that can be managed surgically. A significant complication for mothers who survive obstructed labour is obstetric fistula, which means that they are continually wet, smell badly and are ostracised by families and communities. With appropriate training fistulae can be repaired by non-doctors.

 

Girl's hands holding globe --- Image by © Royalty-Free/Corbis
In non-communicable diseases (NCDs), the diseases of “rich countries” e.g. diabetes, vascular disease, hypertension and cancer, the highest incidences and mortality are in LMICs. The WHO expects 16million cancer deaths by 2020; 70% of these will occur in LMICs. Worldwide 5.8 million people die yearly from injuries, which is 32% more than from malaria, TB and HIV/AIDS combined. That means that 2300 children die daily from injuries. Road traffic crashes are responsible for 23% of all injury deaths, with 20 injured patients per fatality, reaching epidemic proportions in sub-Saharan Africa (50/100000 vehicles compared with 1.7/100000 in high income countries).

Household surveys in Rwanda and Sierra Leone have shown that the immediate surgical need is higher than the HIV rate, that 15-25% of respondents had a surgical need in the previous year that affected their ability to earn a living or their quality of life significantly, and that 25% of household deaths in the preceding year were due to surgical conditions.

 

millenium-development-goals
The Millennium Development Goals (MDGs) have to report in 2015. At present there is a worldwide review of what global goals should replace the MDGs, with the WHO, the Gates Foundation and other philanthropic institutions all recently asking for submissions. The problem is that only MDG 1 (eradicating extreme poverty and hunger by >50%) is expected to be achieved worldwide by 2015. There has been some progress with MDGs 4, 5 (Child and Maternal Health) e.g. in Ethiopia through the work of community health workers, but in sub-Saharan Africa it might be that Rwanda is the only country to achieve all targets. The question can rightly be asked “Did the MDGs fail because these were drawn up in a room by rich countries for poor countries?”. For development to be real and sustainable it needs to be based on indigenous knowledge and solutions, not donor-led philanthropy.

What role then for global surgery after 2015? I have no doubt that the provision of safe and effective surgery should form part of the post-2015 development goals, and surgeons have a responsibility to contribute to this global debate. How can this be achieved? When we started our critical care teaching programme in Africa, now under the name of Alba CC Course Design, we first went to Hawassa in rural Ethiopia to teach health officers (non-doctors) who were doing an MSc course in emergency surgery. With funding from the Clinton-foundation they are taught to do 12 operations well and look after these patients; this covers 85-90% of surgical emergencies in rural Ethiopia e.g. Caesarean section, ectopic pregnancy, incarcerated hernia, debridement of open fracture. When I asked the first intake of students in Hawassa “Why are you doing this course?”, 6 of 8 answered “Because I have seen women in obstructed labour die”. When we went back for a second visit 18 months later, one of those same students had already done 70 Caesarean sections, under spinal, alone in theatre except for a midwife and a scrub nurse. Now that is public health worth fighting for.

Cost studies in surgery provision in Bangladesh and Sierra Leone have shown that the cost per disability life-year (DALY) averted is equivalent to the costs of a measles vaccination programme. Providing essential and emergency surgery saves more than it costs.

With various other groups we are proposing a programme called “15-by-15”, which will aim to teach 15 essential and emergency operations to the same minimum standard worldwide by 2015, to decrease the physical, psychological, social and economic burdens of untreated surgical disease in even the poorest communities. Everyone has “the right to heal” (http://vimeo.com/59388957).

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(References available on request).

Next weeks blog will be by Penny Halliday, Non-Executive Director of NHS Dumfries and Galloway and is titled “Woman Interrupted”