Sir Terence English, KBE, DL, MA, BSc, FRCP, FRCS

‘All my life, I’ve taken the view that I was trained as a cardio-thoracic surgeon, and my interests lay in treating my cardiac patients in front of me. I recognized the value of Public Health, but mine was very much a clinician’s attitude’. And yet today, you will find Sir Terence English – past President of the Royal College of Surgeons, past President of the BMA, and Master of a Cambridge college – in Pakistan, helping educate women in midwifery, to address the shocking levels of infant and maternal mortality – inexorably drawn into public health and development work.

Despite his track record, Sir Terence does not seem a man obsessed with ambition. As an engineer-turned-surgeon, he once quit medical school to go prospecting in Canada – but in spite of his best efforts to break away, nine months later he found himself back in England, continuing with his medical studies.

Even his personality seems to shy away from his impressive stature, towering over the room – he sinks into the sofa, perhaps trying to hide his height, legs stuck under the coffee table in front of him. He is quiet and reserved, softly spoken, taking time with every sentence to make sure he does justice to the question asked. Almost invariably he will try to highlight the achievements of others, as though he is always a by-stander – although this is the man who carried out the first successful heart-transplant in the UK. Sir Terence is not someone who has chosen his place in history; fate has chosen him.

Since 2003, Sir Terence has been the patron of the Primary Trauma Care (PTC) Foundation, a small charity dedicated to training doctors in resource-poor settings how to cope with serious traumatic injuries. Recently returned from Iraq, he invited me into his home to talk further about PTC, and the potential for transference of knowledge and skills from the developed to the developing world.

‘In 2003, I went with a colleague, John Beavis, to North West Frontier Province in Pakistan, because he wanted to bring better trauma care there. I knew the country from my son, who had cycled through Pakistan when he was a medical student. He’d cycled up the Karakoram highway, and he’d told me that it was a fabulous country – so, when I’d finished my three years as President of the RCS, I joined a trek largely on the basis of what William had told me. It was wonderful – I love that part of the world: very remote but wonderfully grand. We walked up the Baltoro glacier all the way to the base camp of K2. This was in August 1992.

‘I had actually been to Peshawar [the capital of North West Frontier Province] two years earlier, when the RCS took a visit to Pakistan; we had a meeting first in Karachi and then some of us went to Peshawar, which is where I met the professor of surgery, Mohammad Kabir, and where he and I became good friends. So when John Beavis, in 2002-2003, said he wanted to bring better trauma care to the North West Frontier Province, I wasn’t in any way intending to get involved other than to act as a facilitator through my friendship with Kabir!

‘He proved a great help in getting us to meet the right people in Peshawar – like the governor of the Province and the Minister of Health – and put together the right people to come to the first courses which we held. And then, inevitably, I got involved, because John is a wonderful guy to work with, and we became wonderful friends. He’s got his own charity, IDEALS, and it was his idea to go to Gaza, as well.

‘The need was trauma: there are huge numbers of deaths due to trauma in developing countries. It differs from country to country – for example, in Pakistan, I think John originally wanted to go there (and particularly to the tribal areas) because a lot of children were stepping on land mines left by the Russians. So there were children losing their legs, and there were a lot of road traffic accidents – and gunshot wounds: they all carry rifles up in that part of the world, and when they get excited they fire them off and, sometimes, the bullets come back and go through people.

‘In Gaza the trauma there is largely due to the repetitive invasion by Israel into Gaza. They’ve suffered from bombs, from shelling, from tanks, from rifles, from phosphorous bombs dropped on schools.

‘So where there’s a lot of trauma, how do you deal with these people? There’s a sort of golden hour, if you like, immediately after injury. Often the local doctors may have the knowledge – because they come across trauma in surgery – but they don’t always know how to apply that knowledge in the correct order or form; and so just teaching them this can bring a lot of benefit. I’m absolutely convinced that it can be hugely useful.

‘At that time we didn’t know about PTC. Before we went to Pakistan, John and I both took the Advanced Trauma Life Support (ATLS) course at University College Hospital. There was an interesting experience: there was I, past President of the Royal College of Surgeons, John a retired orthopaedic surgeon, and both of us very frightened at the concept of failing the ATLS exam – and the faculty who were taking the course equally scared about failing us! However, we passed – and we recognized that, having done so, ATLS wasn’t going to be suitable for Pakistan.

‘And then, quite fortuitously, I met Douglas Wilkinson, who’s a consultant anesthetist and intensive care doctor in Oxford, who hails from South Africa. He considered that the ATLS, which was organized by the American College of Surgeons, was not appropriate for delivery to developing countries, because it relied too heavily on sophisticated imaging. But, he also recognized that the principles espoused by ATLS were absolutely the correct ones – the ABCDE of airways, breathing, circulation, and so on.

‘So he adapted this course for use as Primary Trauma Care; and it had been going for some years by 2003, when we went to Peshawar, and so that is what we took with the first team.

‘And it proved to be very successful. There are four medical schools in Peshawar, and through the good offices of my friend Professor Kabir, he had managed to get six of the senior people from each medical school to attend the first course; and following that we selected instructors from those 24 people. They then went back to their medical schools accompanied by a member of our team and held a course, so by the time we left there were 80 doctors trained. Then one group took a PTC course to Delhi in India, which really pleased me because this was the first example of medical collaboration between Pakistan and India for a long time.

‘So I became the Patron at the time. And since then the Pakistanis have taken the course to Iran, and PTC has now been delivered in over 40 countries worldwide. It’s still a small charity – all the instructors are volunteers. When I spoke on a Radio 4 appeal of the week on a Sunday morning I was able to point that, on average, to train a doctor in a developing country in PTC, it costs us about £50. I was hoping that this would act as a stimulus to those who might inclined to give to the charity – and indeed, we got £15,000 from the broadcast, which was a huge surprise and satisfaction.

‘Basically the course itself is designed to help doctors look after seriously injured patients in a very rather rigid way so that they don’t miss out on what really is the priority in each individual. This is delivered not just by lectures, but also demonstrations. In Gaza we had the carcass of a goat on which we could practice insertion of intercostal tubes into the chest, and we were able to remove the larynx and have a very close look at the airway.

‘Usually we have 24 to a course and about five or six instructors – initially from this country, all volunteers – so it breaks up into four groups. There are the so-called scenarios, where one of the members of that group of 6 will pretend to have been injured in a very particular way, whether he’s got a fractured femur or a tension pneumothorax or whatever. One of the members will have been excluded while this has been set up; then that member comes back, he’s told the history, and he has to get on and treat that individual – and does he do the right thing first? Does he put the oxygen mask on first straight away? Does he stabilize the neck appropriately? And the rest of the team are watching his performance all the time – he’s put under quite a lot of pressure to do things in the right way, in the right order. And after a while they love this, because they recognize how fast they’re learning; but initially they can be a bit embarrassed if they get things wrong.

‘Not all of the courses have been successful – for some in Africa, it just hasn’t been taken forward by the locals. It’s very important to get the members of the first course carefully selected, and then form a local committee that will be responsible for picking the instructors to deliver further courses. Sometimes there’s friction between different parts of the country – in Iraq, where I’ve just come back from, we’ve been making an assessment to start the courses there. When we had our preliminary meeting with doctors it was held in Baghdad, but there was strong pressure to try and deliver the first courses in different parts of the country rather than in Baghdad. We felt that what was important was to get a really well trained corps of instructors first and then let them go to the different parts of the country.

‘But the opposition can come from all sorts of different quarters. In Gaza it’s been much more difficult because there have been a lot of different players locally who want to get involved, and how do you bring them all in? You’re not aware of that at the beginning, hence the need for these assessment visits.

‘We approached Medical Aid for Palestine: they were keen, as an NGO, to be seen to be using their money and their influence properly, and for us to go out and do this. But they just wanted us to go in and run a course – they said they’d be able to select the people for the first course, and we said no, we’ve got to go first – John and I had to go, we talked as doctors to the local doctors, and got some sort of feel as to who were going to the main players and who was going to try and resist it.

‘I think that we were lucky in Pakistan because we had the right guy, Kabir. He just took us straight to the Minister of Health, whom he knew intimately. Then he took us to the Governor, who lives in a magnificent palace – he’s an army man, who controls North West Frontier Province. It’s different from the rest of the provinces in Pakistan, and with that sort of authority behind us, everything just happened very smoothly.

‘So it varies from country to country. I have only been to Pakistan, India, Gaza, and Iraq. But there have been 43 countries now, altogether – South-East Asia, Indonesia, Central America, South America, and Africa – the main developing countries which are, in particular, poor nations.

‘It’s also in South Africa. There was a little resistance there first, because I think the white doctors felt that ATLS was the gold standard, but of course it is for the sort of first-world medicine that is practiced in white South Africa – but it ain’t for a lot of rural South Africa.

‘It’s very difficult to actually track the impact in any sort of academic way. We get feedback from the different groups – in Pakistan, for example, there was a bomb attack in the Sind Province last year. Shariq Ali, who was one of the guys who’s been very interested in taking PTC forward was involved in this, and he wrote back to say how effective it had been, in that they were all working from the same hymn sheet. But in terms of actually being able to say so many lives have been saved – it’s nearly impossible.

‘There have been spin-offs: John, as soon as the Pakistani earthquake happened, went out and worked with PTC teams at the site of the earthquake. And he saw that there was this village that had been completed shattered, and so through his charity he bought tents and he put the 200-odd villagers into tents. Initially they were going to rebuild locally, but the landowner, who was getting all the money, wasn’t pushing it down to the villagers. So John decided that the best thing to do was to buy ground about 10 miles away, and build a new village there! There are 36 houses that have been built now, at about two and a half thousand pounds each. So the whole village has moved – they’ve now got the freehold on that ground. And that just came through having got to know Pakistan and love the people.

‘In Pakistan we became aware that there was a very high incidence of maternal and infant mortality – particularly in the tribal areas. There are seven tribal areas, and they’re all self-contained and jealous of each other. There’s a very high illiteracy rate amongst the women, and they have birth attendants but no access to proper maternity care. And so what John did, in conjunction with a local Pakistani NGO in Peshawar, was to identify 15 young women to come out of the Khyber Agency (which is one of the tribal areas), and they’re in Peshawar now on an 18 month course in midwifery. And that’s fantastic because not only will they go back and be midwives, but they’ll be role models for the girls in that tribal area, because they will have come out and seen the world and then, going back, they’re empowered.

‘The future for PTC is in China – and that’s a colossal problem, and I’m not sure that we’re equipped to deal with it. Douglas Wilkinson – who is a medic in the TA; he’s just come back from Afghanistan – found me two days ago to say that it had finally looked as if he had got permission to develop PTC in China. Now, this has taken seven years. He’s had immense difficulties because of the politics of the whole thing. He’s got a large amount of money from somewhere to try and bring this forward, but dealing with the Chinese hierarchy has been extraordinarily hard. He wants me to go out with him in June to sign a ‘memorandum of understanding’ from each country when we’ve done the initial assessment, as to what we’re going to provide and what we expect from them. And that might work – but it will work, as in other places, by going to particular areas and hospitals, getting a core of people really interested in it and sufficiently interested to take it forward in their own country. That’s the strength of it, you see – ATLS is not like that. All ATLS instructors have to be trained by ATLS and only they are allowed to deliver the course; this is the strength of PTC, the way it can be propagated and adapted. It’s flexible.

‘I think it is a model – it illustrates the value of collaboration between communities and countries. In Baghdad, the first course will have two Pakistani instructors, and that’s great. It’s grown using people from one country who are really enthusiastic, to go to a neighbouring country, as in Pakistan and India. It’s the value of people moving into different countries that they’re not familiar with, getting to understand the problems. I had no knowledge about the injustices which the Palestinians deal with until I got involved.

‘We were horrified by what we saw in August. From the moment we left Jerusalem for the border – we had flown into Tel Aviv – there was a demonstration, and we asked our driver to pull over so we could see what it was about. There were two Palestinian homes, and at 6 AM the Israeli eviction police had gone into them, and the women were still in bed. And they had thrown them out, and two hours later, Israeli settlers were in their homes. This sort of behaviour by the Israeli police is appalling.

‘At the border, it was like a bloody great prison. You go through one door, and you have to stop and wait for a green light, and then you go through the next. Then you get to the other side, and the world is totally different, because it’s been totally bombed out – the buildings, the schools, the mosques, the hospitals. You can see it was once a beautiful place, but very little reconstruction has occurred.

‘I used to have the figures – you know, number of hospitals bombed and so on. There were around 1,500 Gazans were killed in the last conflict – it wasn’t a war, just an invasion – at the end of 2008, of which 40% were women and children. When you talk to Gazans, they tell you that the stories of human shields are absolutely untrue.

‘The health consequences are well illustrated by a special Lancet report – but it’s when you go there and you meet normal, decent people trying with families who are trying to make something of their lives and they tell you what they’re up against – these sort of humanitarian, human rights – call them what you will – abuses are going on all the time. Israelis regard Palestinians as just being dirt, they just want them to go away. And this is their whole policy towards Gaza – to drive it into total submission so they don’t want to live there any more. And they won’t win, eventually – they can’t. Twenty, thirty, forty years time, I hope the Palestinians will prevail.

‘I don’t know that there’s a duty for healthcare workers to learn more about these things. I think that they should certainly be encouraged. I think that some will be as I was – very focused on delivering a particular service to a particular group of patients in your area.

‘But I think that particularly young doctors should be encouraged, both during their medical school and during their early post-graduate time, to go to different countries, to go to poorer countries to see what they’re doing. And then some of them will, perhaps, get seized with the idea of what you can learn from them.

‘They’d be better doctors if they do.’

For more information about PTC’s work, go to their website
PTC is a registered charity (UK Charity No. 1116071).

Ben Warner is a third year medical student at Dundee University in the UK
benedict.warner(at)googlemail.com

A system ‘alone’ is unable to produce an explanation of itself, is incomplete and it needs the ‘other’ systems to gain a sufficient level of intelligibility” (1)

Since caregivers are often faced with the suffering of others, especially early in their careers, they may wonder whether enough is being done, and whether they are really taking care of the person in front of them. Inexperience, as well as the fear of failure may lead them to focus more on the disease than on the person.

What can I do to better understand my patients’ suffering?

This is the main question I would like to ask this young anthropologist. Herein are her answers to this and other questions I asked her in an attempt to explore and explain the boundaries where biomedical science and humanistic disciplines meet.

What is cultural anthropology?

Cultural anthropology is a discipline whose origins conventionally date back to the late eighteenth century (when Société des Observateurs de l’homme was founded in Paris) and that, with the publication of the first works by Malinowski and Radcliffe-Brown in the Twenties, saw the blossoming of its “classics”. Its aims are to study the dimensions of human sociality, and especially the variety and the diversity of cultures drawn from communities in different times and places.

What does “culture” mean?

The concept of “culture” is clearly central to this subject: “culture”, which has recently undergone continuous, critical re-elaboration, is described as being very close to the definition of cultural anthropology itself. Currently, we may define culture as “a fluid and shifting boundary set of manifestations and symbolic creative practices, related to social institutions and to interactive relationships that form the social fabric of a given human community”(2).

Can you explain it in other words? How can the society in which a subject lives influence his/her way of looking at the world, especially with regards to suffering?

Since the beginnings of cultural anthropology, its interest turned to how (practically and symbolically) members of human societies organise and confront life experiences, which then led anthropologists to study how different populations, especially those once considered “primitive”, manage the phenomena of disorder and suffering. The study by Evans-Pritchard among the Azande is emblematic, and the resulting publication dated 1937 is now considered the first text in medical anthropology (3).

From cultural to medical anthropology: what do these classifications mean? And what happened when anthropology met bioscience?

Medical anthropology (a particular area of cultural anthropology) initially involved heterogeneous phenomena ranging from the indigenous interpretations of the disorder to the links between culture and psyche, rituals and therapeutic healing; however, the encounter with biomedicine represented a turning point. Until then, in fact, allopathic medicine was not seen as comparable to other medical systems. On the contrary, it was considered a type of knowledge that could provide an empirical description of objective reality and, as such, it seemed to be a useful tool for the interpretation and evaluation of other models. Soon, however, this position was questioned. Kleinman, among others, noted that biomedicine, as well as systems developed elsewhere, provide an interpretation of reality (4).

What is the key point of the different way of looking at this issue?

Biomedical interpretation – as well as interpretations pertaining to other medical systems – is characterised by a particular way of looking at the world and at experiential phenomena, and it is the result of a peculiar historical process. It also uses certain patterns, cuts out certain perspectives and proposes specific value systems by excluding other possible representations of the phenomena that are being investigated.

Pain, suffering, sorrow: how can we enclose them in this model?

The biomedical model provides a specific interpretation of suffering (though hardly exhaustive of the many possibilities of interpretation), and therefore it sometimes contrasts with other models. This different way of seeing life can create communicative and relational barriers, thus leading to situations of non-compliance and to the lack of therapeutic efficacy.

How can I incorporate your message into my daily routine? How can I put it into practice?

This takes on great significance in clinical practice. Indeed, when a person is suffering he/she tries to weave a complex web of different cultural perspectives in an attempt to make sense of his/her suffering. In part, the subject appropriates him/herself of a biomedical prospective, but at the same time, popular representations, familiar conceptions and social experiences will superimpose, thus creating a particular horizon of meaning. The person then orients his practices in relation to this meaning, and either accepts – or does not accept – the solutions proposed by the therapists. This is why an analysis that takes into account the diverse cultural perspectives (among other things, in a social space traversed daily by multicultural trajectories) – will prove to be very useful.

In other words, from your point of view, anyone could live and interpret their disease in their own way by drawing from a web of social and culturally shared representations, is that right?

Yes, by simplifying the concept, we can say so. Consequently, understanding how the sick persons experience their own illness and how they represent it becomes crucial: which etiologies do they attribute the onset of symptoms to? How do they read them, and how do they live them? In other words, in which way are they able to render them intelligible when called to make sense of them?

Try to explain this to me. Why would it be so important?

An analysis of this kind is essential if we consider that symbolic representations are always intrinsically related to the practices enabled by individuals: depending on how a person interprets a phenomenon, we expect that he/she will act in a certain way and not in another. This is of great importance in case of a disorder because the interpretation a person gives to a phenomenon will influence the care that is provided, the health professionals themselves, and the solutions they propose. Therefore, the evolution of the disease itself will also prove to be very different, even compared with apparently similar physiological conditions.

Taking care of the socio-cultural dimension could therefore be very important: one might expect to detect any possible correlations between the clinical condition of the patients, some of the interpretative models they propose, and the ability to share such interpretations with the health care professionals. Mutual exchange of biomedical and non biomedical models – each willing to corrupt their own integrity – could also lead to the co-construction of a shared (and therefore more effective) therapy. Still, for the benefit of the patient, bringing the signs carried in the body into their own personal world view in order to acknowledge them as being more understandable, and therefore acceptable, may be a key point.

How can we collocate the signs (or the symptoms) within this model?

With regards to this concept, the theories regarding embodiment that were proposed in the late eighties in medical anthropology (5) emphasised that the symptoms (or their perpetuation despite treatment) express, through “body language”, a problematic relationship of the subject with the external environment. An environment in which (necessarily) other human beings live, in which they have their own way of relating and interacting i.e., the socio-cultural environment. In order to cure (or to take care of) a disorder, the social relations inscribed in it cannot be ignored: indeed, they might prove to be one of the causes supporting the affliction itself.

It is perhaps worth recalling a precious gift of anthropology, namely the recognition of the inherent “biological incompleteness of the human being” (6): by his own “nature”, man must make use of cultural and symbolic practices, as well as of a network of social relations in order to survive. His instinctual apparatus is not sufficiently defined, he is a “naturally” open entity – just an incomplete one – that society structures. The individual bases his existence on these social frames, and through them he is able to respond to adversity, including disorders and afflictions. The same health apparatus is a socio-cultural construction in itself. A crisis within a similar apparatus, the non-sharing of its operation, immediately makes the effectiveness of such practices problematic.

In conclusion, what is the take home message that an anthropologist may leave a young doctor?

The modeling approach to multifactorial disorders (models created to analyse how the social frame and cultural dynamics interact with the biological and biomedical practices, since they do influence each other) could be extremely useful for proposing a broader understanding of the disease processes and for extending the potential of care within clinical practice.

Savino Sciascia is a medical intern and a TLS Regional Advisor. Ilaria Lesmo is a second year anthropology post-graduate student. They both attend CMID, Interregional Centre of Coordination of Rare Diseases of Piedmont and Aosta Valley, Giovanni Bosco Hospital in Turin, Italy.
sciascia.savino(at)gmail.com

References

1. Remotti F, 2005 “Sull’incompletezza” in Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie. Editions de la Maison des Sciences de l’Homme, Paris).

2. Affergan F., Borutti S., Calame C., Fabietti U., Kilani M., Remotti F., 2005, Figure dell’umano. Le rappresentazioni dell’antropologia, Roma, Meltemi Editore (ed.orig. 2003, Figures de l’humain. Le représentations de l’anthropologie . Editions de la Maison des Sciences de l’Homme, Paris).

3. Evans-Pritchard E., 1937, Witchcraft, Oracles and Magic Among the Azande, Oxford, Oxford University Press.

4. Kleinman A., 1878, “Concepts and a model for the comparison of medical systems as cultural systems” in Social Science and Medicine, vol.12, 85-93.

5. Scheper-Hughes N. and Lock M. 1987, “The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology” in Medical Anthropology Quarterly (1): 6-41.

6. Geertz C., 1973, The Interpretation of Cultures, New York, Basic Books.

1. Injuries and Public Health

Public Health is a major concern of medicine at present. Current outbreaks of disease and the emergence of H1N1 virus (swine flu) make epidemiology and public health hot topics for medical journals. But epidemiology and public health do not only tackle infections. They deal with the prevalence, the risk factors and the preventive measures of all diseases, both physical and mental.

An important field of preventive medicine is injury prevention. Injuries are traditionally considered as random, unavoidable accidents. The term “accidents” implies the factor chance in their occurrence, thus excluding their prevention. But the majority of injury prevention experts claim that injuries, intentional or unintentional, are in their greater part preventable (1,2).

I decided to talk about this topic with an international expert in injury prevention and public health from the medical school of the National and Kapodistrian University of Athens: Professor Eleni Petridou, M.D., M.P.H.

Professor Eleni Petridou

Eleni Petridou is a professor of preventive medicine and epidemiology. She has written over 250 research papers published in international journals and her work is cited more than 2,500 times. She is a board-certified paediatrician and social medicine professional, and Director of the Centre for Research and Prevention of Injuries (CEREPRI). She is also a member of the International Society for Violence and Injury Prevention (ISVIP) and has collaborated with the Harvard Injury Control Research Centre in the development, standardization and implementation of a screening tool and educational package for intimate partner violence in emergency departments and primary health care settings in several European member states (3). She introduced injury prevention principles in the chapter Epidemiology of Injuries in the book by J. Olsen et al. Teaching Epidemiology: A Guide for Teachers in Epidemiology, Public Health and Clinical Medicine (4). She has a large team of PhD candidates, research assistants, and collaborating staff in her department and is supported by a strong administrative staff.

I invited her to give us some ideas on Injuries, Injury Prevention and a new Code she has proposed for Injury Prevention: ECAI.

2. About Injury Prevention

Injury prevention and control requires either “active” (behavioral) strategies or “passive” (structural) strategies. Passive approaches involve changing products or environments to make them safer for everyone, irrespective of the behavior of individuals. Active approaches encourage or require people to take an active role in protecting themselves, despite hazards in their environments (2, 4). Professor Petridou commented on this.

CF: Do you think injuries can be prevented only by passive safety measures or are behavioral changes required as well on behalf of the citizens?

EP: Nowadays, it is well known that injuries constitute the most serious health problem facing children and adults until the age of 34 years. One third of the total number of deaths from birth to age 14 is caused by injuries, while during adolescence and young adulthood the number of deaths caused by injuries rapidly increases to 75% and 90%, respectively. In fact, injury is one of the greatest killers of people and children worldwide; however, a considerable proportion of injuries can be both understood and predicted and eventually prevented. For example, wearing a seat belt in cars reduces by 65% serious or deadly injuries. Nevertheless, in the European Union, and especially in Greece, seat belts are used in an extremely low percentage by car drivers and users (in front seats about 40% put on belts and about 15% in the back seats).

Thus, we can see that effective injury preventive practices do exist. Yet, despite the theoretical effectiveness of these safety measures, their implementation at population level has been significantly hindered under real-life conditions, because citizens on their own seem not to grasp fully their significance. This realization necessitates the implementation of well-articulated prevention programs, aiming not only to raise individuals’ awareness on injury prevention, but also to reduce risk-taking behaviors. As public health specialists, we seek to bridge the gap between research and prevention in society. This definitely requires behavioral changes from citizens in accordance with tailored passive measures for specific groups.

CF: I read in an article of yours (6) that there is a portion of unintentional injuries that could be prevented if there were more preventive measures. Could you tell me more on this please? What actions should be taken?

EP: In the article Unintentional Injury Mortality in the European Union: How Many More Lives Could Be Saved?, which was published a couple of years ago in the Scandinavian Journal of Public Health, we sought to quantify the potential for saving lives in the EU Region were all member states to learn from the experience of countries with advanced injury prevention records, like Sweden or the Netherlands. We estimated that over 73,000 human lives could have been saved in the EU in a single year, notably nearly half (47.4%) fewer unintentional injury deaths could be observed in children, over half in adult (54%), and two-fifths (38%) in the elderly. And, although these calculations were based on a theoretical model, the wide variation of unintentional injury mortality rates across the EU implies that there is both a high potential for prevention and a broad field for public health action.

3. Centre for Research and Prevention of Injuries (CEREPRI) and the European Code Against Injuries (ECAI)

CF: What is the aim of the CEREPRI?

EP: The Centre for Research and Prevention of Injuries (CEREPRI) was created according to the initiative of the Public Health Department of the Greek Ministry of Health, Welfare and Social Securities in December 1991 and operates on the premises of the Department of Hygiene, Epidemiology and Medical Statistics of the Athens University Medical School. Given that injury prevention is a multi-disciplinary field, CEREPRI sought to include in its dynamic individuals with different skills and specialties, such as medical doctors, psychologists, sociologists and biostatisticians, and has achieved in playing a central role in the field of injury prevention in Greece as well as is the main centre representing Greece nationally and internationally regarding injury prevention. It not only conducts epidemiological and statistical programs, but also goes beyond facts and figures to accurately develop prevention strategies in many areas that have not previously been dealt with, such as intimate partner violence and injuries among older people. By collaborating with European and US organizations, CEREPRI aims to contribute towards promoting healthier lifestyles, creating safer environments and ultimately reducing avoidable morbidity and premature mortality.

CEREPRI in numbers

CF: One of your latest projects is the ECAI. Could you please tell me you what this is?

EP: The European Code Against Injuries (ECAI) was developed within the context of the European Commission co-funded project APOLLO (Strategies and Best Practices for the Reduction of Injuries), which lasted three years and was coordinated by CEREPRI. The ECAI epitomizes a courageous attempt to bring together scientific evidence of what works in injury prevention with effective practice. More specifically, it constitutes an effort to “translate” the most effective practices into simple, appealing to the eye and straightforward messages promoting injury prevention to the general population. In total, it comprises of 60 messages divided into 10 prioritized categories (Box 2), each one of them targeting a different type of unintentional injury. ECAI was developed in successive stages, following identification of the top injury priorities in the EU. Along with associates from the Centre for Research and Prevention of Injuries (CEREPRI) in Greece, there were principal collaborators from many countries: UK, Italy, Germany, Spain, Hungary, Norway, and USA; their assistance was in formulating the 60 messages of the Code, integrating all necessary cultural characteristics of each country, and translating the ECAI into 15 European languages. The official launch of ECAI took place during the 2nd European Conference on Injury Prevention and Safety Promotion (Paris, October 9–10, 2008).

The 10 categorised messages of ECAI. Derived from Archives of Hellenic Medicine, 2008, vol. 25, suppl. 1

CF: In a correspondence of yours to the Journal Injury Prevention (5) you mention: “ECAI represents an effort to ‘translate’ effective practices into simple appealing… the main problem though, of implementing injury prevention in every society, remains the translation of evidence into effective practice”. Does this mean that you are somehow uncertain about ECAI’s results to achieve total injury prevention?

EP: No, it does not mean this. It means that the efforts of bringing ECAI to the community are still ongoing. But, if you may allow me to make a prediction: I am optimistic because my team and I have put a great deal of effort in to this project. Hopefully, we’ll make one step further than others in injury prevention, but I believe that we should let the results judge our actions.

4. Conclusion – Advice

Could you suggest an important message that a young doctor should have in mind concerning injury prevention?

Injuries are one of the most prevalent problems in the world and are connected with a significant morbidity and mortality rate. Injuries are predicable and preventable. There are simple preventive measures that do not require cost and time and that will improve our standards of living.

Constantinos Frangos is in his first year studying for a PhD in gastroenterology at University College London in the UK
Constantinos.Frangos.09(at)ucl.ac.uk

Acknowledgements: I would like to thank Professor Petridou’s doctoral student, Evi Germeni, for providing me documentary material on Professor Petridou’s projects.

References

1. Peden M. McGee K, Krug E (Eds). Injury: A leading cause of the global burden of disease, 2000. Geneva: World Health Organization, 2002.

2. Gielen AC, Sleet D. Application of behavior-change theories and methods to injury prevention. Epidemiologic Reviews 2003;25:65-76.

3. Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G, Gruen RL, Koepsell TD, Lecky FE, Lefering RL, Liberman M, Mock CN, Oestern HJ, Petridou E, Schildhauer TA, Waydhas C, Zargar M, Rivara FP. Emergency Medical Service (EMS) systems in developed and developing countries. Injury 2007;38(9):1001-13.

4. Olsen J, Saracci R, Trichopoulos D (eds). Teaching Epidemiology, A Guide for Teachers in Epidemiology, Public Health and Clinical Medicine, 2nd Edition. New York: Oxford University Press, 2001.

5. Petridou ET, Germeni E. The European Code Against Injuries (ECAI): translating evidence into practice. Injury Prevention 2008;14(5):282-3.

6. Petridou ET, Kyllekidis S, Jeffrey S, Chishti P, Dessypris N, Stone DH. Unintentional injury mortality in the European Union: how many more lives could be saved? Scandinavian Journal of Public Health 2007;35(3):278-87.

Nimal Siripala de Silva

The Honourable Nimal Siripala de Silva is the current president of World Health Assembly and was the former chairman of the WHO Executive Board from May 2008 to April 2009. Mr de Silva is also currently serving his 3rd term as the Minister for Healthcare and Nutrition in Sri Lanka. His career in the WHO began in 1997, which started by being elected as a member into the executive committee and has gone on to chair several sub committees within the organisation since then.

How did you come to join the World Health Organisation and tell us some of your earliest achievements at the organisation?

During my first term as the Minister of Healthcare and Nutrition of Sri Lanka, I had the opportunity to represent the South Asian region at the executive board in 1997. Thereafter in 1998 I was elected as one of the vice presidents of the committee, which I served on for a year.

Early on in the organisation I had the opportunity to work closely with Madam Gro Harlem Brundtland, Director General of the WHO, who had very innovative ideas. Some of which included the Framework Convention on Tobacco Control and Rational Use of Medicines. Later on, she invited me to chair several committees, in particular chairing the WHO Interagency Coordinating Body on Health where I remember having discussions with several global institutions, convincing them of the importance of funding global healthcare programs and its necessity for human development.

Currently you are the president of the 62nd World Health Assembly. What are some of your responsibilities?

My primary responsibility was chairing this year’s World Health Assembly for a number of days. I also have to deal with current global health issues and problems, for example an issue of great importance that cropped up this year was the financial crisis and prior to the assembly I chaired a very important meeting regarding this issue.

As a direct result of the crisis, many governments, donor and financial institutions saw a depletion of their funds. The aim of this meeting was to ensure that funding for the health sector was preserved and that healthcare would not adversely be affected by the recession. I explained the importance of maintaining current health budgets and that if cuts need to be made, it should come from other sectors such as defence. Overall the meeting was a success, I noticed a positive response from parties involved to the innovative ideas and solutions that were brought to the table.

What have been your greatest achievements?

On an international level, it was being appointed as the president of the World Health Assembly, this was a great honour for my country and myself. On a domestic scale, it would be the human resource development I embarked upon in Sri Lanka.

I have increased the number of consultants, increased the number of nurses by 15,000 over 4-5 year period, increased the number of paramedics to 4,000 and other posts such as physiotherapists. Thus I have managed to fill in shortages that the Sri Lankan health service has faced for a long time. However we still have shortages of consultants in pathology, radiology and anaesthesiology if it wasn’t for the migration of doctors we should have had enough specialists in the country. I am fighting hard to produce more doctors and to retain them in Sri Lanka.

What would you like to have achieved by the end of your presidency at the WHA?

I am focusing my efforts towards the idea of universal primary healthcare that is preventative measures, which in my opinion is of equal or more importance to secondary healthcare. It should be mentioned that curative treatment is essential, whereby if a person falls sick adequate facilities should be available in the country to treat the condition, however the more cost-effective option is prevention. I hope that by the end of my presidency, this idea is strongly absorbed by our member countries and necessary primary healthcare programs implemented.

Your honour, could you tell me your stand on the issue of migration of health workers from developing countries?

My view has been very strong on this issue, I have always been an advocate against migration. At the WHO I have supported the idea of forming an international convention on migration of health workers, which currently is in progress. I have also taken part in many consultative meetings and I have pushed forward the idea that developed countries should at least pay compensation to developing countries when they recruit health professionals of such background.

Could you tell me what role you played in bringing the concept of “Social Determinants of Health” to the attention of the WHO?

Initially the WHO did not know of the concept of “social determinants of Health”. I was involved in several meetings where the importance of social factors and its relevance to health was discussed. I am happy that after discussion at the Executive board, a Commission on Social Determinants of Health was formed.

I had the opportunity to give evidence regarding this issue before the commission. Their report concluded that health should not be considered as an isolated entity within a society but other factors such as nutrition, safe water, sanitation, economic factors, gender equality, housing and especially education, need to be considered in order to achieve good health indicators.

In Sri Lanka, how has the concept of “Social Determinants of Health” been practically implemented?

We have managed to focus our efforts in the education sector effectively, thus achieving a high literacy rate. We have also managed to address other issues such as women’s empowerment, providing safe water, and sanitation. We have also strived in the field of providing housing, for example Sri Lanka has the lowest number of slums when compared to other countries in the South Asian region. All these changes has been effective in achieving good health indicators, for example Sri Lanka has achieved both its Millennium Development Goals with regard to reducing child mortality and improving maternal health.

What advice would you like to give to medical students?

Medical students are brilliant but what needs to be understood is that brilliance alone will not make the perfect medical student. They should have a good heart, good mannerisms towards patients and not go after money. In my experience, I have seen many doctors who are in the profession for personal financial gain. I believe that medical students should hold the idea of serving people above all else.

Wazim Izzath is a final year medical student at the University of Glasgow.
0500214i@student.gla.ac.uk

Guppi Bola is a campaign coordinator at both Oxfam and the UK Youth Climate Coalition (UKYCC). She has completed a degree in Biomedicine at the University of Leeds and is about to begin a Masters in Global Health at Oxford University. She chats to Erica Pool about the importance of student activism.

Guppi doing the Green Finger action showing one of the things she wants to protect from climate change, photo courtesy of the author.

Guppi started campaigning somewhat by accident, when at the tender age of 16 she painted “fair trade” onto her chest in an attempt to attract the attention of Coldplay frontman Chris Martin during a music festival. An unusually sunny day saw Guppi completely sunburnt apart from the words “fair trade”, now boldly emblazoned in white on her otherwise toasty brown skin. Having the slogan so prominently displayed forced Guppi to swot up about the problems associated with international trade in order to answer the questions of friends and the odd passer by. The issue of trade recurred on her second day at university when a member of Medsin – a UK based organisation of students with an interest in global health – approached her. They started chatting about the Make Trade Fair campaign and Guppi, now something of an expert on such issues, was hooked. Just a year later she was Medsin President at the University of Leeds which that autumn hosted the Medsin National Conference.

When asked what motivates her, Guppi responds that it is “knowledge. But knowledge is not enough. You have to communicate what you know” – the essence of campaigning. She believes that those who are privileged to receive an education and have awareness of the issues have a responsibility to impart that knowledge. Doctors, medical students and other health workers have particular responsibility and should engage in the issues, she thinks. Trusted by the general population and respected by politicians, medics are in a somewhat unique position of potential influence. They should use that position to advocate for those people and issues which are less able to garner such support.

The inseparability of science from social and political factors was emphasised during Guppi’s undergraduate dissertation. The topic was microbicides; compounds that can be applied to the internal surfaces of the vagina or rectum to prevent against sexually transmitted diseases. Rather unusually for a student of biomedicine Guppi’s study took a holistic approach to the subject, including a strong focus on the social factors affecting microbicide use. It seemed incomplete to her to address the topic of microbicides without doing so – this could lead to the development of a microbicide which might be biologically excellent, but socially unacceptable, resulting in under use. Female control of contraception was also a focus as some consider that for a contraceptive method to be successful women must be in control of its usage, sometimes without their partner’s knowledge – making issues such as the smell and texture of the microbicide compound very important.

There are so many issues in global health today that it can sometimes feel overwhelming, where do you start? Guppi doesn’t believe you have to choose one area or issue, although it sometimes is useful! She does warn that “trying to remain highly engaged in lots of issues can turn your brain into scrambled egg!” As a solution to the scrambled egg problem she found that concentrating on over-arching themes in global health helped her to direct her interests and research. Her area of choice is climate change. It was in fact Guppi’s mum who alerted her to the centrality of climate change to the other issues she worked on. Late one night when Guppi, supposed to be revising for her university exams, was found painting canvases for a Make Poverty History art exhibition, her mother exclaimed “there’s no point making poverty history if global warming messes up the planet first!” Guppi and a friend soon decided to found the Medsin climate change campaign – Healthy Planet – whilst chilling out on an organic farm in France. Healthy Planet’s inception was the result of conversations following their attendance at a conference which saw significant amounts of waste and unnecessary disposable freebies. The two friends decided that if Medsin was serious about it’s commitment to global health it couldn’t continue in this way. The campaign also benefits from being able to utilise the health student members amongst its ranks to highlight the carbon footprint of the NHS, as well as the now well appreciated links between climate change and health. Guppi cites her attendance at a campaigns training course with Oxfam; CHANGE, as equipping her with the ability to run the campaign. At the course she learnt the skills needed to organise, mobilise and communicate her issue. This focus has now taken Guppi to the UKYCC, a coalition led by young people for young people. Its aim is to help UK youth take meaningful actions to influence decision makers on climate change. UKYCC campaigns, training, projects and communications are all about being positive whilst aiming to engage member organisations into the coalition. Guppi tells me “Martin Luther King didn’t say ‘I have a complaint’ or ‘I have a strategic plan’ he simply said ‘I have a dream’.” This statement characterises the energetic and unifying approach that the UKYCC take in order to inspire, empower, unite and mobilise youth from around the UK.

The next six months will be all about activism for Guppi and will be dominated by the build up to the UN climate talks in Copenhagen this December, where world leaders will agree on a new global deal on climate change. As “Captain Coalition” for the UKYCC, her job is to bring together the diverse members of youth organisations under the coalition and begin mobilising for December. The journey begins with ‘Power Shift’ – the UK’s biggest ever youth summit on climate change – taking place on the 9th-12th October 2009 in London. Power Shift hopes to create up to a 1000 effective youth climate leaders through providing innovative training from the designers of the Obama community organising strategy, as well as four days of performances, prominent speakers and a mass day of action. She continues to work building the coalition, and supporting the youth delegation who are travelling to Copenhagen to join thousands of other international youth to campaign within the conference centre itself. Alongside all of this – she plans to complete her post-graduate degree at Oxford!

This year’s Lancet lecture at UCL was given by Professor Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Professor Kazatchkine has spent the past 25 years working in the field of HIV/AIDS as a physician, researcher and policy maker. He has held many posts in both academic and policy-making organisations and was elected executive director of the Global Fund in 2007.

The lecture, entitled “Equity, Global Health and the Fight against Disease”, looked at the ways in which the fight against AIDS, tuberculosis and malaria highlights the importance of health in the development agenda, and shows how disease targeted programs can help bridge inequities between the global north and south. The presentation focused on the specific experience of the Global Fund to Fight AIDS, TB and Malaria as an innovative and inclusive model in health and development which offers strong incentives for improving efficiency and productivity in health systems, national ownership of programs and accountability for results.

Rachel Scott talked to Professor Kazatchkine about the Global Fund and the need for a more partnership based approach in tackling global health issues.  (more…)

 Dr. Kamran Abbasi is editor of the Journal of the Royal Society of Medicine and is CEO of OnMedica, an online publication for healthcare professionals. He has been acting editor of the BMJ, editor of the Bulletin of the WHO, and writes a cricket blog for cricinfo.com. He is also a patron of the South Asian Health Foundation. Kamran has been a journalist for many years, and says of his work: ‘My journalistic approach often upset people but I believe it’s good to be provocative and controversial if you need to be’. Here, he talks to fourth year student Sarah Ghulam-Mustfah about journalism, the solution to world poverty and his burning plans for the future. (more…)

 photo source NHS: http://www.chelwest.nhs.uk/hiv-sexual-health/sexual-health-information.html

2008 marks the sobering 25^th anniversary of the discovery of the Human Immunodeficiency Virus (HIV). From the outset, Professor Brian Gazzard has been on the frontline.  Over the years his career has seen him as the founding chairman of the British HIV Association (BHIVA) and chairman of the Expert Advisory Group on Aids (EAGA) to the government. Alexander Hills and Kapil Sugand caught up with him at the St. Stephen’s Clinic (Chelsea and Westminster Hospital, London) to ask him about his journey in HIV medicine so far and the challenges that lie ahead. (more…)

 Dewayne Neptune with the crew in Haiti

Dewayne Neptune is a 3rd year medical student on the 4 year (graduate entry) programme at St George’s, University of London. Like many on such courses his path to medical school has not been direct but his experiences en route from Trinidad to Tooting have shown him the direction he plans to take in his future career and confirmed his devotion to the cause of providing healthcare where it’s needed most. (more…)

Have you ever wondered if NHS waiting lists will be a thing of the past?  John Petri may well have the answer as Florence Hogg explainsJohn Petri dislikes waste – waste of time, waste of resources, waste of talent and waste of opportunities. Efficiency personified, the consultant orthopaedic surgeon at the James Paget Hospital is now somewhat of a celebrity, one could even say an NHS pin up. In 2005 he received a Medical Futures Service Award in recognition of his innovation. Following on from this accolade he has been a topic of debate at Prime Ministers Questions, has met and advised Tony Blair and has even appeared on the popular Uk TV show, Richard and Judy. The reason behind the hype isn’t the typical dinky gadget that one may expect from the more innovative breed of orthopod. His innovation is painfully simple, highly effective and not at all lucrative: it is a system of surgical practice with the potential to transform all NHS waiting lists, a scheme he calls ‘dual operating.’ (more…)