Image Credit: lilivanili

Three new articled published this week in PLoS Medicine, including two magazine pieces on R&D:

Diana Gibb and colleagues investigate the effect of in utero tenofovir exposure by analysing the pregnancy and infant outcomes of HIV-infected women enrolled in the DART trial.

As part of a cluster of articles leading up to the 2012 World Health Report and critically reflecting on the theme of “no health without research,” Suerie Moon and colleagues argue for a global health R&D treaty to improve innovation in new medicines and strengthening affordability, sustainable financing, efficiency in innovation, and equitable health-centered governance.

John-Arne Røttingen and Claudia Chamas, chairs of the the Consultative Expert Working Group on Research and Development (CEWG), summarize their recent report recommending to the World Health Assembly that a global health R&D convention be developed.

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Image Credit: Charles Williams

Three new articles published this week in PLoS Medicine:

A time-series study conducted by Keith Hawton and colleagues reports on the links between withdrawal of the analgesic co-proxamol and subsequent prescribing and deaths associated with analgesic poisoning.

Rajaie Batniji and Eran Bendavid dispute recent suggestions that health aid to developing countries leads to a displacement of government spending and instead argue that current evidence about aid displacement cannot be used to guide policy.

Katherine Todrys and Joseph Amon argue for criminal justice system reforms in sub-Saharan Africa to reduce HIV and TB transmission in prisons and to guarantee detainees’ human rights and health.

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Outhouses in student's tourist tent base in Jawornik, Beskid Niski, Poland. Image by Tomasz Kuran (aka Meteor2017), Wikimedia. CC-BY agreement.

However, that doesn’t have to be the end of it. If you have a garden, you know that cow and horse manures are wonderful soil amendments. But have you ever considered human manure? DIY is very hip right now, and what could be better than DIY compost for your DIY vegetable garden?

If you find this a little repulsive, that’s ok. Most people are not very comfortable with poo, and with good reason – it can and does transmit disease, very efficiently. About 1.5 million children around the world each year get sick or die from diarrheal diseases specifically due to poor sanitation, and improved sanitation can reduce the incidence of diarrheal diseases by more than 35% (Source: US CDC).

But consider this: correctly aged and composted (and there are very feasible, safe, and effective ways to do this), human feces and urine make excellent fertilizer, and many cultures reuse their “waste” for just that purpose. And – bear with me here – this can take care of at least two important problems at one go: waste handling and agriculture. What’s not to love?

Recently a small nonprofit organization called SOIL (Sustainable Organic Integrated Livelihoods) kicked off a series of informal reports on a project they’re doing in Africa (in collaboration with others such as National Geographic Emerging Explorers, SELF, and others) promoting improved sanitation and, specifically, reuse of human waste. For example, they dug up the contents of old, unused latrines to mine the contents for local agriculture. Upon excavating their first latrine – at a grammar school in Benin – they reported, “The pit, once filled with fresh human wastes, was now a chamber of rich black soil, a color and consistency that was in stark contrast to the dry red dust of northern Benin.” They removed the entire contents for a garden they planted with corn. In another wonderful post, they report on their experience promoting a “magic toilet” to the women of a small rural community.

Proof positive that there’s plenty to love about poop.

For more on this topic:

• Community-Led Total Sanitation
• Sustainable Sanitation Alliance
• EcoSan Research

Sustainable models for delivery of both Emergency and Essential surgical care and specialty surgical care are needed to eliminate global disparities in health. The most cost-effective, feasible, and replicable methods to implement the complex systems needed to provide surgery are still debated. However, to quote ophthalmologist and founder of the Himalayan Cataract Project Dr Geoffrey Tabin at the recent Extreme Affordability Conference held by the Center for Global Surgery at the University of Utah, “high quality [surgical] care is the key to sustainability.”  Some would argue that traditional short-term missions, which are often caricatured as a visiting team parachuting into a foreign environment, providing clinical care for a few short days or weeks, and exiting never to be seen again, are a poor return on the investment.  But, can short-term missions be structured in such a way to become components of a high-quality, sustainable plan?

In our experience, they can. Team Heart represents such an effort, with the aim of establishing a self-sustaining cardiac surgical program in Kigali, Rwanda. Since 2007, Team Heart has worked with King Faisal Hospital, a 140-bed referral hospital in Kigali, to provide sophisticated cardiac surgical intervention for critically ill patients suffering from the consequences of advanced rheumatic heart disease. Team Heart encompasses collaborative partnerships with the Rwanda Heart Foundation, the Rwanda Ministry of Health, and a group of committed volunteers from several Harvard-affiliated academic medical centers, many of whom return year after year.

Throughout the Team Heart mission, opportunities for knowledge transfer and skill expansion are abundant. Both Rwandan and American trainees are actively involved in pre- and postoperative patient care, operative management, and team logistics. The trainees work closely with Rwandan faculty members to review complicated cases and collaborate on comprehensive, multi-disciplinary plans for the patients. Daily bedside teaching rounds emphasizing physical exam and diagnosis, opportunities to first-assist in the operating theatre, and hands-on fundamentals of echocardiography are just a few examples of learning opportunities.  One Rwandan trainee, inspired during his involvement in the mission over the several years, is now being sponsored by Team Heart to complete a fellowship in South Africa such that he can return to lead a cardiothoracic program in Rwanda.

Members of Team Heart also remain committed to providing high quality patient care and utilizing proven systems improvement tools, which are nimbly adapted to the available Rwandan resources and infrastructure.  In the debrief session after the last mission, care delivery innovations imported from Boston teaching hospitals such as the Intensive Care Unit record keeping forms and the surgical safety checklist were selected to be incorporated into the daily operations of the host hospital. The mission, by demonstrating the feasibility of specialty surgical service delivery at the host hospital, has both inspired and prepared the local health care administration to undertake building its own cardiac surgery program.  For example, ancillary services including the blood bank and laboratory noted that by participating in the mission, they have acquired insight on how to restructure their departments going forward.  So, indeed, herein lies one example of a surgical mission that is leading to a lasting and safe care delivery system.

Another model of sustainable surgical care delivery is the incorporation of short- term visits of surgeons into longitudinal community-based health care activities.  Operation Smile, an international volunteer organization that performs reconstructive surgery missions around the world, is piloting deployment of its volunteers in overlapping rotations to provide continuous plastic surgery services at Butaro Hospital, a 150-bed rural district hospital in northern Rwanda supported by Partners In Health.  The overall objective of the rotations is to go beyond direct clinical care delivery and provide mentorship and training such that the roles of visitors including operating theatre and ward nurses, surgeons, and anesthesiologists can be effectively transitioned to local staff.  The process of integrating short-term visitors into the hospital’s daily schedule requires patience and flexibility by all parties, but the impact of these missions is anticipated to far exceed the number of surgeries completed.

How to measure the impact of short-term surgical missions was the subject of discussion at a recent Academic Global Surgery journal club session held at the Brigham and Women’s Hospital Center for Surgery and Public Health.  While short-term missions that involve surgical residents have demonstrated positive impact on the core educational and professional competencies of North American trainees, future studies are needed to demonstrate their long-term impact on global surgical care delivery by local and visiting residents. Furthermore, cost-benefit analyses including the clinical effectiveness, skill transfer, and quality improvements resulting from these missions must be conducted. In the meantime, the Team Heart and Operation Smile missions represent invaluable exposure for surgical residents, both Rwandan and American, to mentors committed to training the next generation of global health leaders.

Gita Mody and JaBaris Swain are general surgery residents at the Brigham and Women’s Hospital and Arthur Tracy Cabot Research fellows at the Center for Surgery and Public Health.  They were both recipients of the Team Heart Stanley Rawn Travel Award for the 2012 mission, and Dr Mody serves as a surgical consultant for Partners In Health. Maurice Musoni is a surgical postgraduate at King Faisal Hospital in Kigali, Rwanda and will begin training at the University of Witwatersrand, South Africa, in General and Cardiothoracic Surgery this year.

The BMA's national conference

In Nottingham, medical student representatives from all over the UK attended the BMA Medical Students Conference, commencing with a rousing and thought provoking speech from Clare Gerada, Chair of the Royal College of General Practitioners, on where we go now with the Health and Social Care reforms in the UK.  Although many important and well-considered motions were debated, it was pertinent that, in the same week that the Wellcome Trust announced that all their research would now be Open Access, the Medical Students Conference voted unanimously to support the Student Statement on Open Access as outlined by the Right to Research Coalition. It is really exciting that Medical Students are bringing this issue to the wider profession, and students can, in the coming months, lobby their universities and the government to make research accessible to all.  Any students interested in getting more involved, please do get in touch for information about forthcoming work on Open Access, including a forthcoming conference organized by the Right to Research Coalition in July.

BMA co-chairs and Medsin National Coordinators L-R Elly Pilavachi (BMA), Dan Knights (Medsin), Marion Matheson (BMA), Felicity Jones (Medsin)

A bit further south at King’s College London, Medsin’s CONFLICTED conference was also a vibrant and exciting weekend.  From the moment Dr Robin Coupland launched into his opening speech, it was clear CONFLICTED was going to pose some challenging issues, and that these were issues that the Medsin network were not only prepared to grapple with, but also take beyond the conference, and take action on. The weekend provided ample opportunity for engagement, focused as it was around the themes of conflict, health, and humanitarian aid, and the four plenaries set their complex interaction in sharp relief.  Newcomers and experienced Medsin-ers alike were fully engaged with the issues discussed, as evidenced by the quality and quantity of questions both during and between plenary sessions and workshops.

Medsin’s CONFLICTED conference

And Medsin not only engaged, but also took action. Hundreds of attendees signed postcards against the arms trade, and petitions and letters to their MPs on multiple related issues, and a large group headed to the Millennium bridge to put their Hands Up for Healthcare Workers, as part of Merlin’s campaign on the issue. 

Many signed up to one of Medsin’s amazing activities; topic-specific groups, such as Student Stop Aids, or Healthy Planet (working on climate change).

All-in-all the weekend provided delegates with insight into many aspects of global health inequity, and the opportunity to take forward specific issues such as the Hands Up for Healthcare Workers campaign, which has now been officially launched within Medsin. The next conference, focusing on Maternal & Child Health, will take place on the 20-21st October in Warwick.

All of the plenary sessions and the keynote address were professionally filmed by Kwatsi and are available online here!

It is clear that at both conferences, making contact with students from all over the UK was as important as the topics themselves. The issues can seem insurmountable, and one can feel unsure where to start.  Learning how to work on these issues together, like a jigsaw puzzle, will serve us well in tackling the inequalities we seek to address, as well as in our careers as doctors.

Links:

www.medsin.org/blogs

www.bma.org.uk

Felicity Jones

Karin Purshouse

Felicity Jones is a fourth year medical student at King’s College London. She is currently Joint National Coordinator of Medsin-UK, along with Dan Knights. Follow her on twitter: @faejones.

Karin Purshouse is a final year medical student at Newcastle University and was Chair of the British Medical Association’s Medical Students Committee (BMA MSC) 2010-11.  She has been involved with Sexpression and Medsin since 2006, and was part of the Medsin-UK delegation to the International Federation of Medical Student Associations (IFMSA) August Meeting 2011.

Image Credit: Melvin “Buddy” Baker

Two new articles published this week in PLoS Medicine:

A Mendelian randomization analysis conducted by Børge G. Nordestgaard and colleagues using data from observational studies supports a causal relationship between body mass index and risk for ischemic heart disease.

Seye Abimbola and colleagues describe and evaluate their program in Nigeria of recruiting midwives to rural areas to provide skilled attendance at birth, which is much poorer than in urban areas.

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Image Credit: Adam Selwood

I read an interesting book about sugar recently (Sugar: A Bittersweet History by Elizabeth Abbott), which has forced me to evaluate my attitudes towards it. I wonder whether it could be considered an example of a Paracelsian poison (where the dose of a substance determines whether it is a toxin or a medicine). In the past, sugar was considered a medicinal agent, known for altering ‘the humours’ and for its soothing properties. I remain somewhat unconvinced of the medicinal benefits of sugar, but certainly it has a role in treating hypoglycaemia, and is used widely to make medicines palatable, especially for children.

The toxic value of sugar is now well established, as a major cause of dental caries, insulin resistance and type 2 diabetes mellitus. However, it has taken many centuries of sugar consumption for society to begin to acknowledge its dangers. Although sugar was available in small quantities in Europe from the 13^th century, consumption began in earnest in the 15^th and 16^th centuries. This followed the discovery and cultivation of sugar cane (Saccharum officinarum) in the New World by European explorers such as Christopher Columbus. At home, affluent Europeans developed a taste for this luxury import and soon lucrative trade routes were established between Europe and the Caribbean sugar islands. In time, much of the agricultural land in the new territories was used for growing sugar cane alone. This crop was demanding on soil nutrients and the harvesting of the sugar was tedious, painful and often dangerous. Slavery was introduced, providing the labour source to supply Europe’s greed for sugar, but it also fractured societies and families, causing incalculable hardship and innumerable loss of life.  North American populations also developed a love of sugar and began to import and cultivate ‘the noble cane’.

In Europe, sugar consumption was initially restricted to the rich.

Image Credit: Kevin Jones

Indeed, Queen Elizabeth I reputedly had poor dentition due to her love of sugar. Over time however, prices fell and the normal working classes also had some access to sugar.  At this time, the health consequences of sugar were hotly debated. A few voices raised concerns about the risks of sugar over-consumption, but these voices were often silenced by others who had strong financial interests in maintaining the demand for sugar. Slavery also became a topic of dispute and gradually public opinion turned against it, culminating in the abolition of slavery in England in 1833, and throughout the British Empire in 1834.

Now, most European populations source sugar from locally-grown sugar beet, with fewer adverse consequences on the agricultural, ecological and societal aspects of our world. However, the cost of ignoring health concerns due to financial gain is a lesson which holds true for every generation. Despite the evidence of the dangers of excessive sugar, we give sweets and chocolates to children and enjoy them ourselves as adults. Perhaps we need to develop a more sober attitude to this, the most tempting of toxins.

Recommended reading:

Abbott E. Sugar: a bittersweet history. Duckworth & Overlook, 2009. This is a fascinating book.

An Anopheles stephensi mosquito obtains a blood meal from a human host. Source: CDC/wikimedia

There are many reasons to feel encouraged. Globally the number of malaria deaths is dropping, thanks to progress on several fronts over the past decade: better prevention strategies, including widespread distribution of insecticide-treated bed nets; rapid, easy-to-use diagnostics; and more effective treatments at more affordable prices. Malaria is higher on the global health agenda, with more funds for developing new tools and testing new strategies.

But WHO estimates that current funding covers only 25% of needs for malaria control. Every day we see the consequences of this shortfall on the ground, where reality is sometimes far removed from all these advances.

I recently returned from a field visit to Katanga province in the Democratic Republic of Congo (DRC), which is in the midst of a widespread malaria emergency—on top of the country’s chronic instability, longstanding shortages in everything from medicines, doctors and nurses to paved roads, and one of the world’s lowest per-capita health budgets.

Two months earlier, I had worked with colleagues from Doctors Without Borders/Médecins Sans Frontières (MSF) and Epicentre to analyze the latest information from the DRC Ministry of Health and MSF’s established in-country projects. Despite some gaps in the data we pieced together an overall picture: a 250% increase in confirmed cases compared to already-high 2009 levels, exceeding the WHO epidemic threshhold, and a proportional increase of severe cases being admitted to our hospitals. Based on this analysis and those from other regions, MSF quickly set up emergency interventions in four highly-affected provinces—remote places reachable only by plane or long, arduous drives along dirt roads.

During my trip I visited three new sites and one longstanding project. All faced enormous gaps in medicines, diagnostics and malaria control activities. In some areas the last bed net distribution was 3 years ago, and no indoor residual spraying had been done in over a year. Although a few areas were overstocked with rapid diagnostic tests, many had none; most had no artemisinin combination therapy (ACTs, the first line treatment) or pediatric ACT formulations. Oral and parenteral quinine was generally available, but not parenteral artemisinins, and there were few transfusion materials to treat people with severe malaria-related anemia. These disparities sometimes existed within the same administrative zone.

Our main emergency response was set up in Kabalo, in the North of Katanga, where the number of cases jumped from 11,141 in 2010 to 22,798 in 2011, and malaria-attributed deaths increased four-fold (from 95 to 421). The 28-bed malaria unit we opened in the hospital’s pediatric ward soon had 2 children per bed, and a 6-bed Intensive Surveillance Unit sometimes accommodated as many as 18 patients, with 7 or 8 concomitantly undergoing transfusions. The week I was there we had 113 admissions and 77 transfusions, and we diagnosed and treated almost 500 cases of uncomplicated malaria.

Initial mortality rates were high, mainly due to patients arriving with already-advanced disease. Some parents had carried a sick child up to 80 km on foot, often after seeking local treatment by private healthcare providers or traditional healers. Some of these children had been transfused—mostly with untested blood given under questionable sanitary conditions.

Today, the number of cases is decreasing in Kabalo and other areas of Katanga where we collect information. Countrywide, MSF has treated 85,000 cases of malaria in the first three months of 2012, although this number may represent just the tip of the iceberg. Looking forward, we are working to identify the cause of this malaria spike—information that can help tailor the control strategy.

So as we acknowledge significant progress in many countries on this World Malaria Day, we also need to acknowledge regions where efforts are inadequate, and failing—countries like DRC that are afflicted by conflict, instability and/or simply mired at the bottom of the development scale. It will take better tools and strategies, a better allocation of scarce resources, and far more commitment to ensure that these regions share equally in progress to be recognized on future World Malaria Days.

Estrella Lasry is a physician working as Tropical Medicine Advisor for MSF-France.

Image Credit: Clockwise from top left: Centers for Disease Control, Centers for Disease Control, Dr. Banchob Sripa (Khon Kaen University, Thailand), Dr. Héctor H. García (Universidad Peruana Cayetano Heredia, Lima, Peru), WHO/TDR/OCP, Dr. Mark L. Eberhard (CDC/CGH/DPDM, Atlanta, USA)

More than half of the world’s population is at risk of helminthiases (parasitic worms), and hundreds of millions of people are currently infected with one or more helminth species. Consequences of chronic infection include suffering, stigmatization, subtle and gross morbidity, and premature death. These infections are associated with low work productivity, poor cognitive performance, and slow socioeconomic development, thereby contributing to accentuate poverty and inequality.

The April 2012 issue of PLoS Neglected Tropical Diseases features the launch of a new collection, “A research agenda for the control and elimination of human helminthiases.” The collection includes a series of eight reviews from the Disease Reference Group on Helminth Infections (DRG4) that, taken together, outline a research and development (R&D) agenda for the control and elimination of helminth diseases of humans. Emphasis is placed on six major helminth diseases: soil-transmitted helminthiasis; schistosomiasis; lymphatic filariasis; onchocerciasis; food-borne trematodiasis; and cysticercosis/taeniasis. Additionally, an Editorial from Jürg Utzinger provides an overview to all eight reviews and emphasizes the importance of continued research on these six diseases, which together have an enormous global health impact.

Controlling and eventually eradicating major human helminthiases will take commitment at all levels – from local communities to politicians, philanthropic organisations, and civil societies. Although some of the necessary policies outlined in the collection have been implemented by various bodies, additional implementation and coordination is necessary. The series aims to move beyond providing a reference for researchers on existing and known issues in the field and instead plots a course for policymakers, researchers, and funding bodies in key areas to target in the ongoing campaign to eliminate helminthiases.

DRG4, chaired by Sara Lustigman and co-chaired by Boakye A. Boatin, was given the mandate to undertake a comprehensive review of recent advances in helminthiases research, identify research gaps, and rank priorities for an R&D agenda for the control and elimination of these infections.  The 14 members of DRG4 are academic or public health leaders at world-class research institutions, international bodies, and public health and governmental organizations. This group of eight reviews on helminth infections was developed out of analyses and deliberations by the group members conducted during 2010 and 2011.

DRG4 is part of an independent “think tank” of international experts, established and funded by the Special Programme for Research and Training in Tropical Diseases (TDR), to identify key research priorities through the review of research evidence and input from stakeholder consultations. TDR is a programme based at and executed by the World Health Organization (WHO), and co-sponsored by the United Nations Children’s Fund, the United Nations Development Programme, the World Bank, and the WHO. For more information on the TDR Think Tank and the resulting reports, please visit: http://www.who.int/tdr/stewardship/research-think-tank/en/.

Image Credit: US National Archives

Closing out our April publishing month, PLoS Medicine publishes three new articles, including the monthly editorial which revisits conflicts of interest policies.

The PLoS Medicine Editors discuss financial conflicts of interest at the American Psychiatric Association, and raise concerns about new evidence from the social sciences that suggests conflict of interest disclosures worsen rather than ameliorate bias.

In a randomized controlled trial David van der Ham and colleagues investigate induction of labor versus expectant management for women with preterm prelabor rupture of membranes.

As part of a cluster of articles leading up to the 2012 World Health Report and critically reflecting on the theme of “no health without research,” Martin McKee and colleagues examine the question of what to do to build capacity in the many countries around the world where health research is virtually non-existent.

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