Archive for Health and Wellness Promotion

Building Resilience Against Depression

Everyone feels down from time to time but depression is more than sadness or feeling ‘blue’. It is a common mental disorder which affects males and females, young and old, rich and poor. It is a treatable health condition that is found across cultures.

Depression can affect the way you think, move and speak. It can affect your physical health. It can also affect your ability to care for yourself, relate to others and enjoy life. Young people with depression can fall behind with schoolwork, miss out on friendships and struggle to find the energy to keep up with sports and leisure activities. In adults of working age, depression can make it difficult to concentrate at work, keep on top of finances, care for children, and maintain homes in order. Older people who are depressed may become socially isolated, forget important appointments and lose interest in work and hobbies. Some people with depression experience severe loss of appetite or thoughts of suicide and self-harm which can occasionally lead to death.

It is important to recognise and treat depression early to reduce suffering and prevent worsening of the illness. Despite advances in depression care, many people cannot or do not access help and they continue to suffer quietly and alone, hoping and praying the depression will one day disappear. Without additional support, some suffer for much longer than is necessary and later look back on their lives with regret over the lost months and years. This should not happen anywhere in the world.

Today we have a holistic understanding of health and this means people with depression can be helped by a combination of: medication, social support, psychological therapy, exercise, nutritional therapy and spiritual care, depending on the severity of depression and the individual’s needs and preferences. These treatment options address the multiple factors which are associated with depression, such as resilience. While being highly resilient does not eliminate all risk of depression, research findings from both higher and lower income countries show that building resilience can help prevent and treat depression.

Depression causes suffering and loss for those who live with it and for their family and friends. Depression can also cause death. With modern, evidence-based approaches to tackle depression, no one should suffer in silence without hope. Depression care can be tailored to the individual who should expect to make a good recovery, build resilience against future episodes of depression, have better physical health and enjoy a fulfilling life.

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Dr Anne Aboaja MPH MRCPsych , University of Edinburgh, Global Health PhD Network

Health in the Eastern Mediterranean Region

The vast complexities of the Middle East and surrounding regions cannot be understood without bringing health into the battleground of analysis. In this context, the Global Health PhD Network organised the event “Health in the Eastern Mediterranean Region” on 28th of October, 2016 with the funding of the University of Edinburgh’s Global Health Academy. The event was framed as a series of four short conferences on diverse topics related to Health in the region, and two networking recesses at the venue’s foyer at 7 Bristo Square, where delicious kenafa was served by the University’s Middle Eastern Society.

The first speaker was Dr Runa MacKay. She studied medicine at the University of Edinburgh at a time where it was not usual for women to go this further in their studies. In 1955 after qualifying in medicine, Dr Mackay arrived at the Edinburgh Medical Missionary Society Hospital in Nazareth, now in Israel, which has served the Arab population there for more than 150 years. Dr Runa Mackay spent around fifty years working across Lebanon, Palestine, and Israel for the betterment of health conditions among the Palestinian population who live within Israel, either in health policy or as a practitioner in war torn Beirut and West Bank. Today, back in Edinburgh, she has written the book “Exile in Israel”, where she tells her personal experience throughout those years which have taken her to state, as she did in the event, that she feels more Palestinian than British.

As the second speaker, Khuloud Alsaba, researcher from the Syrian Center for Policy Research and a final-year PhD candidate in International Public Health Policy talked about part of her research project: “War in Syria: Political Determinants of Health”. In a very critical and insightful way she explained how within the discourse of “The War on Terror” health facilities and health care workers have become a legitimate target. However, turning access to health into a weapon of war has brought unexpected hardships for the population. Khuloud argued that polio, once an eradicated disease, has reappeared in Syria as a consequence of a thrashed and weakened public health system. She concluded by stating that these war tactics are not only militarily and economically inefficient, but also (and most importantly) a violation of the human rights of Syrians.

After a short networking recess, the event carried on with the third talk. Via videoconferencing, Ben Clavey, a young medical student and the co-coordinator at Medact Arms and Militarisation Group, gave a concise explanation about this NGO and its work in the Middle East. Medact is an organisation where health professionals can go beyond the clinic and actively engage with the search for solutions to the most pressing global health issues. Through analysis, lobbying, and education, it aims at having an impact in policy on four main areas: peace and security, climate and ecology, economic justice, and health and human rights. Regarding the Middle East, he added that Medact’s activity in the region has been extensive. It has worked in Iraq and Palestine performing in ground analysis and campaigning for the respect of human rights and adequate health policy for the victims of armed conflict in both countries. Recently, it has worked on warning and lobbying against airstrikes by the British military in Syria and also against UK arms sales to Saudi Arabia, who has been involved in the destruction of Yemen’s health system and the targeting of its hospitals and other healthcare facilities. Finally, Ben invited us to become part of Medact’s effort in taking health as a human right into policy either by donating or joining the organisation. A stand with further information for those interested in participating was set on the venue’s lobby as well.

The fourth and last speaker was Parisa Mansoori, a PhD candidate at the Centre for Global Health Research at The University of Edinburgh, who presented her research project on Iranian health sciences and academic literature production. According to recent data, Iran has had a dramatic increase in the amount of health related academic publications in the past few years. This stands out as a unique situation among the emergent economies, due to the quality of the articles produced in Iran, which have found their way into high impact international journals. Moreover, Parisa pointed out that practically a large proportion of this new literature has been produced by a small group of academics in Tehran University of Medical Sciences and few other Tehran-based institutions. By providing a thorough characterisation of this phenomenon, she expects to lay ground for further progress and development of Iran’s health sciences and their contribution to the global scientific arena.

In conclusion, the event managed to assemble in a couple of hours a wide range of experiences related to health in the Eastern Mediterranean region. Just as this region has been traditionally associated with armed conflict and violent political struggle, health has also been a very pressing issue both then and now, as Dr MacKay and Khuloud Alsaba exemplified. However, as Ben Clavey from Medact and Dr MacKay let us see, there are still spaces for hope and resistance, as well as moments for empathy and sharing. Furthermore, in spite of these difficulties, the region hasn’t stopped creating new knowledge. As Parisa Mansoori portrayed, the region is home for highly qualified and capable academics who contribute to the development of science and knowledge around the world. Lastly, thanks to the networking sessions and kenafa tasting we were reminded that, as in any other place, there are people living everyday lives in this region, where the creation and recreation of very rich cultures has made of it a quite unique and special place.

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Bernardo Moreno-Peniche, MSc Medical Anthropology, University of Edinburgh

 

Images taken by: Clàudia Serra Vinardell

Building our collaboration with Stanford

The event New Perspectives in Compassion held at Stanford University California on 16th March was the first academic collaboration between CCARE and the Global Health Academy (GHA) following the launch of our Compassion Initiative in September in Edinburgh by the Principal. We are very grateful to Dr Monica Worline , deputy director, and Professor Jim Doty director at CCARE for their impeccable organisation. It was attended by just over 200 individuals including Edinburgh and Stanford faculty, students and alumni, and those living in the Bay Area and provided a series of short presentations by Stanford  and Edinburgh academics from a number of disciplines in the sciences and humanities.

New Perspectives in Compassion Panel

New Perspectives in Compassion Panel

 

http://ccare.stanford.edu/events/perspectives-on-compassion-new-thinking-from-stanford-university-and-the-university-of-edinburgh/

It was part of the Edinburgh University’s pop-up week in the Bay area of California, which also included events on big data, veterinary medicine, and history.

We were really fortunate to have the active engagement of the Principal, Sir Timothy O’Shea for the afternoon. After an introduction by Jim Doty and Liz Grant, the first session included a short talk and reading of a poem by John Gillies (written by a Stanford medical graduate) from the second edition of ‘Tools of the Trade’. This is a small volume of poems gifted to all new medical graduates in Scotland for the past two years.

Prof Paul Gilbert, an Edinburgh alumnus, and the psychologist who helped to kickstart research and education in compassion over two decades ago, gave an overview of his developing work including psychological tools to help people with moderate to severe problems of anxiety and self esteem.  Monica Worline introduced the theme of compassion in the workplace, the importance of shifting the balance of efficiency and effective measures from material linear outputs to relational outputs, the satisfaction, the ability to enjoy work, the opportunity to grow and flourish in a work environment. Following Monica was one of CCARE’s research partners, Professor Anne-Birgitta Pessi, a visiting Professor of Church and Social Studies from Finland. She summarised a novel approach based on Ricoeurian theory and using specific training to improve compassionate behaviour in leadership and workforce in large corporations in Finland, based on a novel approach called Co-Passion training -http://blogs.helsinki.fi/copassion/copassion-seminar/

The second session had a recorded contribution from Dr Paul Brennan, Co –Director of the Edinburgh GHA Compassion Initiative on the effects of neurosurgery on compassion in patients. Brian Knutson, associate professor of psychology at Stanford spoke on the neural basis of emotions, and we finished with a fascinating talk by associate professor Firdhaus Dhabhar , a Stanford psychiatrist who spoke about the ill effects of chronic stress on immunity and accelerating ageing, and how these can be mitigated by social support, mindfulness and meditation.

 

Professor James Doty, Dr Liz Grant, Dr John Gillies

Professor James Doty, Dr Liz Grant, Dr John Gillies

The second half of the afternoon was a distinguished panel, moderated by Jim Doty on The Compassionate Robot: myth, nightmare or solution. We selected this subject because of the rapidly developing technology around robots and their increasing use in healthcare and social settings across the world.  Principal Sir Tim O’Shea suggested that while a non human robot could not provide truly human compassion, it could provide ‘artificial compassion’ where that would be of utilitarian benefit. However, human compassion also had its inauthentic side as well, he suggested. Rev Professor Jane Shaw, Dean of Religious Life at Stanford gave a Humanities based perspective on what it means to be human: having what Adam Smith called ‘fellow-feeling’ or sympathy. In society today this she argued is often characterised by the shared construct we know either as compassion (which is based on a Buddhist model) or grace ( the word that encapsulates compassion emerging within the Christian tradition). Our understanding of compassion in robots can be much enhanced by looking through the lens of arts and humanities.    Alastair Boyle, Global Client partner of Google and head of strategy at the company Essence looked at compassion in advertising, illustrating this with the ‘Dove’ soap campaign which purposefully set out to make women feel better about themselves. He admitted that the strategy used by all companies now of tailoring advertisements though individual’s internet searches could in fact provide inappropriate and unhelpful targeting at times. He also touched on the ‘uncanny valley’ problem of life-like robots making people feel uncomfortable.

Jon Oberlander, professor of Epistemics here at the University of Edinburgh talked about robotic developments which enabled them to perceive and respond to human emotion, also the benefits and problems associated with robotic carers providing ‘care’ but reducing interaction with human carers. Ultimately, he said, ‘robots just don’t care’, in the metaphoric sense, however the responsibility to care lies not with the robot but with the creator.

The afternoon provided both a breadth of disciplinary approaches and, at times, a surprising depth of insight into the rapidly developing area of academic work on compassion. There was a great deal for our Global Health Academy’s Global Compassion Initiative to build on for the future; much more to come!

 


Dr John Gillies,  Senior Adviser Global Health Academy, Co-Director GHA Compassion initiative

Dr Liz Grant, Director, Global Health Academy, Co-Director GHA Compassion Initiative

The Importance of Good Communication Skills

Good communication should never be underestimated at any time, however this is never more important than when communicating with someone in relation to their health. It is impossible to overstate the importance of creating good communication between health professionals and patients in optimising health care.

As a medical oncologist for over 30 years I have seen many examples of both good and bad communication, with a recent example coming to mind. I met an old friend who informed me that he had just been diagnosed with prostate cancer – highly intelligent, well-read but non-medical he told me that the moment he heard the work “cancer” his mind blotted out completely. He remembers nothing of the rest of the consultation and left knowing next to nothing of the proposed management or his future. This is a frequently reported occurrence and for doctors the process of explaining a cancer diagnosis, outlining investigations necessary for staging and possible options for treatment this is ever more challenging.

Over the years I have seen and participated in amazing progresses in the science of cancer and the ever increasing knowledge and understanding regarding individual cancers, not to mention the possibilities for investigation and more and more available treatments. Good medical practice carries with it a responsibility to explain as much as possible to patients, but how and when to do this requires training and expertise. Time is a major pressure with often too much to explain in a single consultation. Patients can only absorb so much information at a time, if any as my friend found.

Sharing explanations between doctors and nurses can help patients digest what matters most to them, and having a relative or close friend with them doubles the hearing/comprehension experience.   Hand-outs are no substitute for face-to-face conversation and doctors really have to work hard to develop the skill of “listening”! Thank goodness the art of medicine has not been totally replaced by science, but communication skills need to be practiced and continuously developed by all of us in helping patients to understand the complexity of a diagnosis of cancer.

 


Professor John F Smyth, Emeritus Professor Medical Oncology, University of Edinburgh

Communicating with Cancer Patients


 

Faith Based Health Care – The Lancet Series

Faith Based Health Care –   The Lancet Series launched at the World Bank as part of the “Religion & Sustainable Development: Building Partnerships to End Extreme Poverty” conference in Washington D.C. July 7th – 9th 2015.

The “new normal” of faith communities engaging in sustainable development was underpinned by the President of the World Bank’s recognition that a new paradigm is necessary within development. Using the framework of liberation theology he posited the importance of building action on a “ preferential option for the poor”. A move to shift development mandates from focusing on developing wealth as a priority to seeing wealth development in the context of a much wider value based paradigm.

He remarked that almost all religions are committed to the poor and vulnerable and have set in place systems to care for the poor, as well as systems to challenge poverty, and the drivers of poverty:

“[True] righteousness is [in] one who believes in God, the Last Day, the Angels, the Book, the Prophets and gives of their wealth, in spite of love for it, to relatives, orphans, the needy, the traveler, those who ask [for help], and for freeing slaves; [and who] establishes Prayer and practices regular charity…” [Quran 2:177]

this is the kind of fasting I want: Free those who are wrongly imprisoned; lighten the burden of those who work for you. Let the oppressed go free, and remove the chains that bind people. Share your food with the hungry, and give shelter to the homeless. Give clothes to those who need them, and do not hide from relatives who need your help. [Isaiah 58:6-7, NLT]

These examples from two of the world’s religions are amplified in other faiths.   But more needs to be done, the shared agenda between the development goal to “ End Poverty in all forms everywhere” and the ethos of Religions to care for the poor should be built upon in new ways.

Goal statements in themselves cannot bring about the transitions required for change.   I believe that there needs to be an investment in the values that underpin development goals as this is where the real and hard work sits and where the biggest differences will be made. Values shape people and belong to people, and as the German Federal Ministry for Economic Cooperation and Development pointed out, “it is the people of faith, the estimated 80%+ of the total world population whose values will determine whether or not the sustainable development goals change the world we live in for good”

As a University what is our responsibility to participate in Sustainable Development Goal One To end poverty in all its forms everywhere?   How and where can the creation, dissemination and curation of knowledge contribute to achieving this goal?     As students, as staff, as alumni and partners of the university we are part of 432 years of knowledge, we are part of a community that spans every country in the world through our alumni presence, both past and current, we are part of a deep and rich hub of information management and sharing capabilities.   We all have the responsibility of taking our University mission of creation, dissemination and curation of knowledge and of applying this knowledge, ours is the responsibility of implementation. And in this implementation we can work together. Knowledge by its very nature is a catalyst for change, and each of us carries this capacity.

In looking through the lens of “preferential options for the poor” the Global Health Academy is seeking to raise scholarships for those who cannot afford the fees for the many innovative online distance learning MSc programmes that we have developed and which target critical global health challenges. We recognize that brilliant minds living in resource poor countries hold the key to bring about change both within their country, and globally. Recognising especially in healthcare the impact and extent of faith community contribution to rural health services we have recently partnered with faith communities to help train doctors for rural family medicine in the new MSc in Family Medcine

This is just one example, the opportunities and the needs are vast and there is always more that could and should be done – we welcome your ideas, stories of knowledge in action and thoughts on what, where and how next.


 

mgrant1  photo

Dr Liz Grant, Director of The Global Health Academy and member of the working group for the Lancet Series- Faith Based Health Care


 

 

www.globalhealthacademy.ed.ac.uk ;http://twitter.com/@GlobalHealthEdi ;

www.youtube.com/user/GlobalHealthAcademy ; www.ed.ac.uk/global-health/blog

Membership of the Global Health Academy is open to everyone with a passion for engaging in global health.

Keeping women’s and reproductive health on the agenda for sustainable development

Maternal and child health has been in the limelight for at least two decades and was prioritised by the Millennium Development Goals (MDGs). We have seen great progress. Maternal mortality fell by 45% and 17,000 fewer children die each day, than in 1990. The focus has, however, been narrow but thankfully worldwide priorities are now changing to much broader more inclusive framework of sexual and reproductive health and the concept of women’s health. In September 2015, at the UN New York summit, the proposed 17 Sustainable Development Goals (SDGs) and their 169 targets will be finalised.

The current draft goals include: achieve gender equality and empower all women and girls; ensure inclusive and equitable quality education and promote lifelong learning opportunities for all; ensure healthy lives and promote wellbeing for all at all ages; and reduce inequality within and among countries. The focus for the next 15 years will be on sustainability. This month has seen a particular focus on women’s health and sustainable development with a Lancet issue devoted to it. See http://www.thelancet.com/commissions/women-health-2015 for a range of articles. Dr Ana Langer from the Women and Health Initiative at Harvard T H Chan School of Public Health writes “Sustainable development needs women’s social, economic, and environmental contributions, which will increase when women are healthy, valued, enabled, and empowered to reach their full potential in all aspects of their lives, including in their roles as providers of health care.”

Many issues remain which should now be tackled. Although gender equality has been achieved in primary school education, a large proportion of girls do not complete secondary school which means their choices for their future lives are severely limited. Bangladesh has one of the highest rates of child marriage in the world. Around 20% of girls become wives before their 15th birthday, even though 18 is the minimum age allowed by law. Child marriage can have a damaging impact on young girls, and allowing them to continue their education is a way to avoid the future potential of sexual exploitation, dependency, domestic abuse and adolescent pregnancy. Adolescent bodies are not ready for childbirth and complications in pregnancy and childbirth are the leading cause of death in girls aged 15-19 in low- and middle-income countries.

Despite admirable efforts, female genital mutilation continues in its various forms. In seven countries the national prevalence is almost universal (more than 85%) whilst in four countries there is high prevalence (60–85%) and medium prevalence (30–40%) is found in seven countries. National averages, however, often mask marked variation in prevalence in different regions of countries.

Source: MICS, DHS and other national surveys, 1997-2006. Map developed by UNICEF, 2007

http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/

Finally, a somewhat forgotten issue is that of maternal morbidity. For every woman who dies of pregnancy-related causes, an estimated 20 women experience acute or chronic morbidity. Maternal morbidity adversely affects families, communities and societies. There are multiple causes, with varying duration and severity ranging from transient to permanent. Diagnosis and treatment options, as well as rehabilitation approaches, exist but in low- and middle-income countries these are rarely freely available. Ladeisha Lombard, Rosemary Geddes and Liz Grant from Edinburgh University and colleagues recently published a review (http://www.ncbi.nlm.nih.gov/pubmed/25640771) on rehabilitation experiences after obstetric fistula repair. There is a paucity of research in this area but it was found that for women resuming social roles as wives and mothers is a positive rehabilitation experience, whilst concerns and fears about longer-term emotional, economic and physical consequences cause negative experiences of rehabilitation. There is a real need for community health education and counselling services post-repair for women and their families, in order to reintegrate and restore the dignity of these women in society.


Dr Rosemary Geddes, Programme Coordinator Global Health Challenges, University of Edinburgh


 

 

Calling for a stronger climate and health nexus within the UNFCCC

From 1-11th June I was part of the International Federation of Medical Students Association’s (IFMSA) delegation at the UNFCCC intersessional’s in Bonn. The IFMSA has been engaging diligently in the UNFCCC process for over 5 years working to reinforce the climate and health nexus within the negotiating text. Our efforts have been greatly appreciated by delegates and the global climate policy community, as there is a relatively small health community engaging with the UNFCCC, despite the recognition that climate change is the “greatest threat to global health of the 21st century” (1). Last December, our work was rewarded in the Lima Call for Action where health was placed firmly in the preamble of the text (2). We entered these intersessionals with positive spirits, due to recent successes of the World Health Assembly, which took place in Geneva the previous week. This resulted in a resolution on the public health dangers of air pollution and the need to phase out fossil fuels in order to both tackle ill-health from pollution and reap co-health benefits of climate change mitigation (3). However, as we head towards COP21 in Paris, which aims to produce a legally binding global agreement, there is concern that the need to dramatically shorten the text will force certain issues into the side-lines. Our aim from now until Paris is to use the contacts we have made at these intersessionals and previous COPs to coordinate a larger coalition of countries that will provide a strong position on health in the new global agreement.

This was my first experience as a delegate at the UNFCCC, and despite not having particularly high expectations, I must admit that the pace of the talks was even slower than I had expected. Negotiations hardly got further than discussing commas and brackets and how these could be used to shorten the text from its former 96 pages to something more manageable. However, after day 6 they had only managed to cut this down to 86 pages, and nothing of the substance of the text had even begun to be discussed. This was frustrating for many of the organisations who had come to lobby delegates on a breadth of issues which need to be included within the text such as human rights, intergenerational equity, gender and health. Being part of the youth constituency, I found there were many barriers to prevent our voices being fully considered. From informing us of interventions less than hour before, not providing adequate translation services, giving us interventions only at the end of sessions and forcing our creative actions to be within strict rules and regulations; our opportunity to represent young people, who are going to be most impacted by the decisions, was severely restricted. The lack of representation of the Global South also made me question the legitimacy of the process. How are we supposed to go about constructing effective policy solutions when those suffering the most from climate change are not represented? Of course, this is not an issue unique to climate change policy, but to witness this stark injustice in reality was a powerful reminder of the need for change.

After spending the past year being involved with local and national action on climate change and health, the pace and level of engagement at these high level negotiations was at best disheartening. It is clear we cannot wait upon the UN to ensure effective solutions to the impending and already tangible impacts of climate change. Whilst the IFMSA and others will continue to be at the forefront of ensuring a legally binding and successful agreement that will protect and promote global health, we rely upon a forward thinking global health community to implement solutions in their own communities. This needs to go beyond acknowledging the intersections between ecology and health towards being part of the structural change needed to ensure a sustainable and healthy future.

This is a critical year for climate action and the implications of inaction on our health and our future is unprecedented. I hope to continue to work within the UNFCCC, but also to bridge the gap between this process and community action which is a key part to building climate resilience. Through attending several side events during the conference I also found that public health provided an important and coherent narrative in which to address a wide range of climate change issues from food and water scarcity, air pollution, occupational and community health surround fossil fuel extraction, transitions towards sustainable active transport and rising infectious diseases in crops, livestock and people. It was clear that health is a powerful tool to provide an anchor of agreement in the UNFCCC, as well as provide a lens to engage a breadth of people with climate change. I look forward to tracking the progress of the UNFCCC and hope that an agreement in Paris will be reached that will mobilise the diverse and collaborative movement needed to save human and ecological life on this planet.


References

Costello (2009) Managing the health effects of climate change. The Lancet [pdf] https://www.ucl.ac.uk/global-health/project-pages/lancet1/ucl-lancet-climate-change.pdf

Lima Call for Action: http://unfccc.int/files/meetings/lima_dec_2014/application/pdf/auv_cop20_lima_call_for_climate_action.pdf

World Health Organisation (2015) World Health Assembly closes, passing resolutions on air pollution and epilepsy [online] Available at: http://www.who.int/mediacentre/news/releases/2015/wha-26-may-2015/en/


ADP2.9: Last Updates from the IFMSA Delegation

ADP2.9: Updates from the ADP 2.9 United Nations Climate Change Conference

ADP2.9 – Meet the IFMSA Delegation!


 

Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.

http://www.healthyplanetuk.org/

 

Rewarding research: Social Science and Health Research in Zambia

Rewarding research: Using my ‘self’, psychotherapeutic perspectives and reflection in social science and health research in Zambia

Following a long career in the NHS in Scotland as an Art Psychotherapist and leading several projects training mental health staff in Ghana and Zambia, I embarked on an MSc in Africa and International development at the University of Edinburgh.

My MSc incorporated a work-based placement at ZAMBART[1] in Zambia where I conducted a secondary analysis of case studies of households caring for patients with TB /HIV – from a mental health perspective. This gave me the opportunity to include my ‘self’ and my professional knowledge and stance as elements which worked in dialogue with each other as to inform and shape my dissertation. .

This was no mean task and required both reflection and personal challenge – an acceptance of painful self-realisations – in order to expose the normalised assumptions endemic in my attitudes. I judged men as ‘bad men’ – when their risk taking behaviours impacted on their families. Recognising this and then understanding these behaviours from a non-judgmental psychotherapeutic stance enabled the complex systemic relationships around men’s mental health in rural Zambia to no longer be hidden in a blind spot – beginning their exposure to greater understanding and analysis.

Such fruitful discoveries from such a self-reflective approach and a psychotherapeutic stance point add to the enhanced value of practitioners engaging in research and the blending of psychotherapeutic stances with research objectives.

More detail on this aspect of my work-based placement is given in  Who Cares about Mr Mubanga

 


Lesley Hill, MSc Africa and International Development (2014)

 

References

[1] ZAMBART – a non-for profit research organisation based within the University of Zambia that is also a research collaborating centre for the London School of Hygiene and Tropical Medicine

 

Nkhoma Hospital Cervical Cancer Screening Programme: a Scottish–Nkhoma partnership

In Malawi, cervical cancer is the most frequent cancer among women of reproductive and economically important age (45.4% of female cancers) and an 80% mortality. Numbers are projected to increase over the next 2 decades as improvements in other areas of health (eg treatment for HIV) increase length of life. There is no national programme for cervical cancer prevention through immunisation or screening and many women now survive childbirth only to die later of preventable cervical cancer. Inadequate access to treatment, ostracisation of women with severe symptoms of cervical cancer, and limited palliative care services are additional features.

We received funding from the Scottish Government International Development Fund for Malawi (2013-2016) to set up a sustainable programme of cervical cancer reduction in Nkhoma Hospital and 10 surrounding health centres. The project is jointly led by Professor Heather Cubie, Consultant Clinical Scientist in NHS Lothian until recently / Honorary Professor, Global Health Academy, University of Edinburgh and by Dr Christine Campbell, Senior Research Fellow, Centre for Population Health Sciences, University of Edinburgh. The principal clinicians are Sr. Hilary Brown and Dr Graeme Walker from NHS Lothian who participated in ALSO courses (Advanced Life-Saving in Obstetrics) in Malawi a few years back and others from round Scotland have helped / are helping for short periods through sabbatical or unpaid leave.

The Scottish and Nkhoma teams, October 2013

The Scottish and Nkhoma teams, October 2013

In the first two years of the project, our Malawian colleagues have provided information on the value of cervical screening to 4 Traditional Authorities and 84 Group Village Headmen and obtained their permission to speak to around 30,000 people in the region. In addition, a potential 120,000 (50% of the population) has been reached by local radio broadcasts. Twenty-four Malawian healthcare professionals (mainly midwives and clinical officers) have been trained to provide cervical screening using a procedure called VIA (visual inspection with acetic acid) and treatment of early lesions using cold coagulation. Case load is audited and competency of each provider is assessed by Scottish clinicians using similar standards to the UK.

Talk to women to explain what would happen in VIA clinic, Nkhoma Hospital

October 2013

October 2013

In the new outside classroom, October 2014

In the new outside classroom, October 2014

 

 

 

 

 

 

 

 

Over 7000 women have had their first-ever cervical screen. Those with early signs of abnormality have been offered treatment and 75% received it the same day. At the start of the project, a number of women said they would need to ask permission from their husbands to receive treatment but this is no longer a big issue. Hopefully this is because the information messages have reached the whole population, men and women, giving women a sense of empowerment. Two-thirds have returned for follow-up visits, despite this being considered difficult to achieve.

Sadly, the VIA clinics still see too many women with cancers which are too advanced for immediate treatment. There is little Malawi can offer in terms of chemo- or radiotherapy, but the project does ensure that these women have their diagnosis fully explained and are offered surgery or palliative care where appropriate.

The project now has daily clinics in Nkhoma Hospital and weekly clinics in 5 surrounding health centres, some Government and some CHAM. Year 3 of the project will extend to weekly clinics in 5 more health centres and consolidate training to allow sustained service. We are currently looking for further funding to extend the ‘hub and spokes’ model to additional hospitals and their health centres.

 

Sustainable Programme of Cervical Cancer Screening

 


Professor Heather A Cubie  (Global Health Academy)  and Dr Christine Campbell (Centre for Population Health Sciences), University of Edinburgh

 


 

Global Health Academy

 

 

 

The Lancet Commission On Global Surgery

Surgeons have long felt that the importance of surgery has been lost in past efforts to impact on global health issues. The Lancet Commission on Global Surgery seeks to address deficiencies in surgical and anaesthetic care, provide evidence and solutions for achieving health, as well as welfare and economic development through the strengthening of surgical health systems in Low and Middle income Countries (LMIC).

Twenty five commissioners have worked for almost 2 years consulting extensively in over 100 countries in 6 continents. Their report may not please all but is a significant achievement. Surveys, epidemiological studies, estimates, audits and mapping programmes helped to provide evidence and to highlight further disparities in surgical care through 5 key messages at their recent London and Boston launches:

  • 5 billion people lack access to safe affordable surgical services when needed. Nine of ten people in low-income and lower-middle-income countries cannot access basic surgical care.
  • 143 million additional surgical procedures are needed each year to save lives and prevent disability. Only 6% of 313 million procedures that are undertaken worldwide annually, are performed in the poorest countries.
  • 33 million individuals face catastrophic health expenditure to pay for surgical services.
  • Investment in surgical and anaesthetic services saves lives, is affordable and promotes economic growth.
  • Surgery is an indispensible part of health care and should be an integral component of a national health system in countries at all levels of development.

map image web

The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

The Commission’s stated targets for 2030 are daunting:

  • A minimum of 80% coverage of essential surgical and anaesthesia services per country.
  • 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians, per 100,000 population.
  • 100% of countries tracking surgical volume, a minimum of 5000 procedures per 100,000 population.
  • 100% of countries tracking perioperative mortality.
  • 100% protection against impoverishment from out of pocket payments for surgical care.
  • 100% protection against catastrophic expenditure from out of pocket payments for surgical care.

Some might see these as challenging for some developed countries so how can these objectives be met in developing countries where increasing funding of health care still results in disparities.

We know that targeting specific health care issues through philanthropic support in the developing world has brought about mixed success. Numerous philanthropists and charities have stumbled in attempting to deliver sustainable solutions when investing in facility or service. Outreach programmes from well intended overseas surgical teams may actually impact adversely on the very environment that they hope to support. Essential emergency provision of surgical care may be compromised when, for example, limited facility is set aside for the orchestrated elective missionary surgery. The conditions or surgical pathology targeted or technology being shared may seem entirely appropriate to the visiting team but may be largely irrelevant to the needs of the local population.

Investment in infrastructure may seem to produce a tangible legacy for the donor but it is challenging to maintain such quality facilities when these are seen by some as a source of material to be plundered to support their families in desperate financial need. Furthermore, some initiatives have been been criticized for focusing too narrowly on the capacity of science and in neglecting the importance of economic, social, and political factors. Such surgical initiatives require significant funding and need to be considered in parallel with improvements in public health, education and the health system. Pressurised surgical services dealing with trauma in the developing world might rather welcome greater health and safety regulation, improvements in street lighting, better maintained roads and greater driver regulation.

So where to start? Records often do not exist so reliable surgical audits or death rate statistics for surgery do not exist in LMIC. Investment in information technology is limited in most developing countries but finance is required to obtain key information that would identify clearly the needs of surgical services in the LMIC. GlobalSurg is a collaboration supported by Clinical Surgery at the University of Edinburgh (http://globalsurg.org/get-involved/). The group is currently using an international network of training and qualified surgeons to study variation in outcome of emergency intra-abdominal surgery across various clinical settings. It will determine whether globally relevant quality improvement strategies are needed within acute surgical units. This project would serve to provide much needed information in an area of acute surgical care and will allow development of regional, national and international surgical networks. The group recently published on the benefits of these networks in the Lancet. There is no reason why the group cannot establish key global studies, including the opportunity for randomised trials.

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The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

Humanitarian and global surgical outreach programmes have been supported by surgical colleagues in Edinburgh at considerable personal social and psychological sacrifice. Such direct support has undoubtedly had significant impact on the lives of those affected by conditions including those arising from complications of obstructed labour. The social stigmata attached to this condition are considerable and the repair transforms the patient’s existence. And yet, the procedure to correct a vesicovaginal fistula is categorized as a ‘can do’ rather than a ‘must do’ surgical procedure. Where should the priorities lie when the challenge is so immense? How can such outreach programmes deliver a legacy in a developing country?

The target set by the Commission that 100% of countries should have at least 20 surgical, anaesthetic, and obstetric physicians per 100,000 population is formidable. We have experience supporting surgical training in Malawi which produces some 100 medical graduates per year. However, for a population of 17 million people, there are currently only some 15 trained surgeons in practice since many move overseas when they are exposed to the opportunities that exist for well-trained doctors in the developed world. The Lancet Commission requirement by 2030 is projected at 60 specialists per 100,000 population. It is difficult to imagine where the additional 10,000 or so specialists will emerge for Malawi without substantial investment.

Scotland has a strong tradition of investing in education on Africa. Gordon Brown as UN Special Envoy for Global Education, and through the Office of Gordon and Sarah Brown, has promoted and initiated education programmes in Africa. Edinburgh University has invested strongly in postgraduate educational initiatives that have benefited LMIC. The huge success of our own surgical distance learning programmes has allowed us to support more trainees from these countries.

Our surgical Masters programmes currently have over 450 students enrolled in 40 different countries. In 2009, the Scottish Government and J&J/Ethicon supported the University of Edinburgh and the Royal College of Surgeons of Edinburgh to deliver free postgraduate educational support to training surgeons in Malawi. Since then, the first three students have graduated from the three-year distance learning course which supports the educational and professional needs of the young training surgeon. Six more Malawian trainees are currently in the programme. Surgical trainees have been supported without the need to remove them from the area of greatest need. The programme content adds value to their in-the-workplace training and allows the young surgeon to attend to local service needs. We are also aware that educational resource has been extended to medical assistant practitioners who are a vital link in the surgical care chain.

The Lancet Global Commission has ensured that surgery can no longer be overlooked as a health need for the world’s poorest people. The Commission has set itself ambitious targets but no one initiative will address the current unmet need. Better global surgical and anaesthesia care will only be realised through increased investment in human and physical resources. Early and urgent domestic and external investment in surgical and anaesthesia care is needed to realise these returns. Our group sees itself as being in a strong position to invest in the postgraduate education of the surgical workforce in these countries.

Similarly, research, monitoring, and assessment will have to play an increasing and crucial part in the future of global surgical and anaesthesia care. There is a paucity of scientific rigor around implementation science, and an absence of globally accepted surgical metrics which have contributed to past neglect of surgical and anaesthesia care within global health. A commitment to better understand the problems and solutions should be a priority for those dedicated to improvement of surgical and anaesthesia care worldwide. We will continue to invest primarily in the training surgeons in these LMIC through postgraduate education. In this way, we should empower the very body that can engineer change locally so that we might yet see some practical light at the end of a very long tunnel.


Professor O James Garden, Regius Professor of Clinical Surgery and Honorary Consultant Surgeon, University of Edinburgh