Shrines dedicated to 33 miners trapped in San Jose, Chile Source BBC

On 5th August 2010, a small mine near San Jose, Chile, collapsed, entrapping 33 miners. It was 17 days later that the rescuers heard echoes and the 33 miners were discovered to be alive. Since then drilling has began to rescue the miners from the collapsed mine.

Interestingly, lessons learnt from space medicine are being used to help the trapped miners as NASA scientists arrive at the site. With their help, today’s media reports that, miners received their first hot meal. Previously, they have been surviving on glucose and high protein milk.

It has been estimated that it will take at least 4 months for the miners to be evacuated, however, with new health concerns, specialised copper mine bore drills are being assembled to speed up the evacuation plan [1]. Living in an isolated environment has been extensively researched by space agencies, preparing their astronauts for long haul trips. Apart from the physiological changes that occur as a result of living in extreme conditions, psychologists argue that the mental attitude of the miners is the key to their survival.

The psychological effects of isolation have been well established in psychology in prisoners and ICU patients. Professor John Cacioppo who specialises in social neuroscience, social isolation and connection at University of Chicago says “If the miners who are trapped can bond and work together to tick off the days they are separated from their families and friends, it would help them survive the ordeal”. [2]

MP3 players, pre-recorded football matches on miniature devices are some of the items being sent to the miners, to keep them entertained. Families are being encouraged to be optimistic in any communication between the trapped miners, to maintain the morale of the miners. However, BBC reports that five miners have shown signs of clinical depression [3]. Telephone lines between the miners and the outside world are being established, and very brief telecommunication has begun; however, a stable telecommunication line is needed so that the trapped miners can stay in contact with their families, and supporters.

The Lancet Student would like to ask, what else can be done to maintain the morale of these unfortunate men?

References

1. http://www.guardian.co.uk/world/2010/aug/29/chilean-miners-rescue-plan
2. http://news.nationalgeographic.com/news/2010/08/100825-chile-miners-psychological-mine-mental-health-science/
3. http://search.bbc.co.uk/search?go=toolbar&q=depressed+miners

By Carlos Fioravanti

State University of Campinas

chfioravanti(a)gmail.com

A versatile new drug candidate called P-Mapa along with a new proposal to fight infectious diseases have emerged in Brazil. They are the result of collaboration among non-academic and academic groups in Brazil, Chile and the US led by the non-profit research network Farmabrasilis.

Figure 1. Crystals (300 x) and nanocrystals (37,000 and 80,000 x) of P-Mapa: an immunomodulator derived from Aspergilus orizae  (Credit: Courtesy Farmabrasilis)

P-Mapa, a proteinaceous aggregate of ammonium and magnesium phospholinoleate-palmitoleate anhydride, is a biotechnological compound derived from Aspergilus orizae [1]. It is an immunomodulator, which can rebuild the organism’s natural defence system against tumours, viruses, bacteria and other disease-causing microbes.

P-Mapa has demonstrated anti-tumor activity, with no relevant signs of toxicity, on studies performed on rodents, non-human primates and on HIV-positive patients-phase I clinical trial [2,3,4]. The compound was shown to induce proliferation of lymphocyte T, increase cytokine production and natural killer cell activity, and stimulate nitric oxide release by macrophages [5,6,7].

Scientists from the Brazil-based Farmabrasilis and the US National Institute of Allergy and Infectious Diseases (NIAID) have confirmed the potential of P-Mapa to treat infectious diseases. In 2009, Farmabrasilis and NIAID teams showed that P-Mapa can protect against Punta Toro Virus (PTV), which produces a fatal hepatic disease in animals and is closely related to the Rift Valley fever virus, endemic in sub-Saharan Africa. In these experiments P-MAPA was compared to the antiviral Ribavirin. Both were able to protect 100% of all infected animals with no signs of hepatic damage, strengthening the possibility of using P-Mapa as adjuvant to treat hepatitis B and C, mainly when the first-choice medicine has limited use or with adverse effects [7,8].

The latest tests carried out by Brazilian and American teams have demonstrated that P-Mapa is active against Mycobacterium tuberculosis in vivo. Wild-type C57BL/6 mice were exposed to an aerosol of M. tuberculosis and later treated with P-Mapa and the antimicrobial Moxifloxacin, used both alone and together. The P-Mapa acted alone to deter the bacterial proliferation in the lung and spleen at levels above the minimum standards required. P-Mapa may have synergized with Moxifloxacin, as the combination of the two drugs provide wider protection than each when used alone [9].

A plan to fight infectious diseases

Based on these data, the Farmabrasilis team proposed the use of P-Mapa to fight infectious diseases. Launched in 2009 at 3^rd Stop TB Partners Forum, the proposal focuses on the re-establishment of the patients’ natural defenses (immunocompetence) by using P-Mapa as an adjuvant medicine with antiviral and antimicrobial drugs. This approach could help to prevent or treat diseases such as tuberculosis and malaria in patients, including those co-infected with HIV.

The Farmabrasilis proposal includes the possibility of sharing all data and methods of production, free of charge, with governments, institutions or groups interested in using the P-Mapa to treat neglected diseases and disadvantaged populations. In such cases, partners cannot sell the medicines or the technologies associated with them, and must also offer the medicine free of charge to people who most need them, as detailed on the Farmabrasilis website [10].

Broader than other approaches from other Public-Private Partnerships, Farmabrasilis’ call for a collective, open task force against infectious diseases represents a way to reduce the cost of drug development whilst engaging civil society organizations in the search for new models of medicine research and production [11,12].

A collective effort

In its use of non-academic and academic groups, from discovery to the first human trials, the P-Mapa course illustrates innovative ways to produce scientific knowledge. This approach can reduce the time and the money usually required to develop a new drug, as well as to conciliate interests from different groups and help to solve public health needs.

This strategy can be significant especially in developing countries. In Brazil, most drug candidates discovered in research institutes hardly go beyond the publication of papers, and Brazilian pharmaceutical companies only produce drugs derived from plants (used as analgesic or anti-aging agents), me-too compounds (e.g., to treat erectile dysfunction) or generic medicines, rarely addressing the public health needs [13,14].

As part of my doctoral research, I have followed 26 molecules presented over the past 15 years in international scientific journals and in Brazilian newspapers and general magazines as promising medicines. The molecules represented new hope against cancer, tuberculosis, pain, inflammation, arterial hypertension, Alzheimer’s disease, arthritis, epilepsy, mycosis, and ulcers, as well as typically tropical health problems such as Chagas disease and schistosomiasis. The scientists responsible for the research have stated, through the media, that these molecules would be evaluated in humans or be available as medicine in a few years. For various reasons, until 2010 none of the molecules has reached the promised goals.

Figure 2. P-Mapa purified: a medicine in the pipeline (Credit: Courtesy Farmabrasilis)

An unusual story

P-Mapa has had an unusual story. Initially, the physician Odilon da Silva Nunes worked for almost 40 years in a private laboratory, away from formal science research centers, to develop a molecule that could block tumors, according to his own hypothesis about the origin of cancer. The research advanced through collective work by other physicians and both non-academic and academic researchers who evaluated the compound’s properties according to drug development guidelines. In the 1990s, Farmabrasilis teams, led by Dr. Iseu Nunes as CEO and Prof. Nelson Duran as scientific director, scaled up the production and tested the compound on a group of HIV-positive people. Next, unable to forge alliances with pharmaceutical companies in Brazil, the research group reorganized, grew internationally and focused the research on infectious diseases, especially the most common in poor countries, such as AIDS and tuberculosis.

As a science writer and later as a PhD candidate, I have followed the P-Mapa story since 1991. I was privileged to visit the laboratories where P-Mapa was produced and talk to the scientists involved in this research. Their motivation to work voluntarily was “to satisfy idealism or curiosity, seek new challenges, hone skills, build a reputation or enhance careers”, as in other open source researches [15].

In 2007, as a Reuters Institute for the Study of Journalism Fellow at Oxford University, I examined how penicillin emerged in London and was later developed at Oxford. After comparing the course of the English and the Brazilian compounds, I concluded that their development is similar. Briefly, both started in the hands of physicians, moved ahead through a multidisciplinary task force and required overseas aid to be concluded [16]. However, the P-Mapa effect is broader, due to its ability to deter tumours, viruses and bacteria. Unlike penicillin, P-Mapa is a medicine in the pipeline.

References

1. Nunes I et al. United States Patent Application: US20060093628. “Protein aggregate magnesium-ammonium phospholinoleate-palmitoleate anhydride immunomodulator, its production process and formulation”.

2. Justo GZ, Durán N, Queiroz MLS. Myelopoietic response in tumor-bearing mice by an aggregated polymer isolated from Aspergillus orizae. Eur. J. Phamacol. 1999, 388: 219–226.

3. Farmabrasilis. P-MAPA toxicity and safety. Available from: www.farmabrasilis.org.br/todos conteudos interna.php?idioma=eng&id=217. [Accessed: 22th June 2010]

4. Farmabrasilis. P-MAPA clinical trial phase I. Available from: www.farmabrasilis.org.br/interna relatorios clinicos.php?idioma=eng&id=180 [Accessed: 22th June 2010]

5. Melo A, Justo GZ, Queiroz MLS. Stimulation of myelopoiesis in Listeria monocytogenes-infected mice by an aggregated polymer isolated from Aspergillus oryzae. Human Exp. Toxicol. 2001, 20: 38–45.

6. Justo GZ, Durán N, Queiroz MLS. Natural killer cell activity, lymphocyte proliferation and cytokines profile in tupour-bearing mice treated with MAPA, a magnesium aggregated polymer from Aspergillus orizae. Immunopharmacol. Immunotoxicol. 2003, 25: 305–319.

7. Farmabrasilis. P-Mapa Product Monograph. Available from: http://www.farmabrasilis.org.br/todos_conteudos_interna.php?idioma=eng&id=110 [Accessed: 22th June 2010]

8. Durán N, Gowene BB et al. A biotechnological product and its potential as a new immunomodulator for treatment of animal phlebovirus infection: Punta Toro virus. Antiviral Res. 2009, 83: 143–147.

9. Farmabrasilis. Assessment of the efficacy of the immunomodulator P-MAPA against M. tuberculosis in a standard mouse model. Available from: http://www.farmabrasilis.org.br/todos_conteudos_interna.php?idioma=eng&id=276 [Accessed: 22th June 2010]

10. Farmabrasilis. Infectious diseases proposal. Available from: http://www.farmabrasilis.org.br/pesquisa_desenvolvimento_interna.php?idioma=eng&id=255 [Accessed: 22th June 2010]

11 Rawlins MD. Cutting the cost of drug development? Nat. Rev. Drug Discov. 2004, 3: 360-364

12 Bhan A, Singh JA et al. Grand Challenges in Global Health: Engaging Civil Society Organizations in Biomedical Research in Developing Countries. PLoS Med. 2007, 4(9): e272.

13. Rezaie R, Frew S et al. Brazilian health biotech—fostering crosstalk between public and private sectors. Nat. Biotechnol. 2008, 26: 627-644.

14. Vidotti CC, de Castro LL, Calil SS. New drugs in Brazil: Do they meet Brazilian public health needs? Rev Panam Salud Publica. 2008, 24(1):36-45.

15. Munos B. Can open-source R&D reinvigorate drug research? Nat. Rev. Drug Discov. 2006, 5, 723-729.

16. Fioravanti C. New perspectives on drug development in developing countries: A case study of the Brazilian compound P-Mapa. Reuters Institute for the Study of Journalism 2007. Available from: http://reutersinstitute.politics.ox.ac.uk/fileadmin/documents/Publications/fellows__papers/2006-2007/NEW_PERSPECTIVES_ON_DRUG_DEVELOPMENT_IN_DEVELOPING_COUNTRIES.pdf [Accessed: 22th June 2010]

Also, don’t forget to read this week’s TLS challenge by Muniesh Shanmugam.

Courtsey Dr Karen Au

When I saw the ad for the Future Excellence International Medical School on the TLS website, I knew straight away it was something I wanted to do, particularly when I saw that there would be a cardiology and cardiothoracic Surgery group. In the last few years I had been increasingly thinking of moving to the UK to study medicine as a postgraduate and after some work experience with a cardiothoracic team over the summer, I was convinced of the path I wanted to take. The summer school aims to allow medical students (or those of us who intend to be medical students!) the chance to gain an insight into some of the most competitive surgical and medical specialities, while offering the chance to learn some basic clinical and surgical skills, learn about developing a portfolio and give opportunities for interaction with a wide range of consultants and registrars.

I didn’t hesitate as I booked flights and accommodation to Manchester and signed up for the cardiothoracic stream. In fact, it was not until I was sitting in student accommodation in Manchester getting my stuff ready for the lectures the following morning, that it occurred to me that I might be a fish out of water. What if I was the only person who wasn’t a medical student? What if I had no idea what they were talking about in lectures? It turned out that I need never have worried. From the lovely group of girls I was fortunate enough to be sharing a flat with to every person I met over the course of the week, people could not have been more welcoming and more encouraging of my plans to study postgraduate medicine. I even met a couple of people who were planning to go the same route or who had arrived in medical school that way!

The first day we were gathered in the University of Manchester for a brief introduction of what to expect from Dr. Richard Taylor and Dr. Stuart Enoch, both of whom worked endlessly during the course of the week to ensure everyone was having a great time and that events ran smoothly, as did the whole of the Summer school team. We were then divided into two main groups, those of us who were interested in a surgical career and those who hoped to pursue a medical career. I quickly made my way into the surgical group where we were to have a day of ‘surgical tasters’. There we would hear from consultants in some of the most competitive specialities about what their average day is like and how to pursue a career in that speciality.

First up was a day in the life of an orthopaedic surgeon. Mr McLauchlan lead an interesting lecture, beginning with a brief history of orthopaedic surgery and the kind of problems and patients he encounters on a daily basis. It was a really enjoyable lecture and made me strongly consider orthopaedics as a possible career path. Mr. Gregory Hall followed next, with a fascinating look at life as a neurosurgeon. Mr Hall offered us a brief insight into the history of neurosurgery and practical advice on becoming a neurosurgeon.

The next talk was my personal highlight of the day. Mr. Jonathan Ferguson, a consultant cardiothoracic surgeon, explained about life as a busy cardiothoracic surgeon. It was a captivating lecture which confirmed for me that cardiothoracics was definitely the route I wanted to go. I enjoyed hearing how advances in interventional cardiology had changed the face of cardiothoracic surgery and what a cardiothoracic surgeon could expect during the average week.

Mr Antonino Morabito, a consultant specialist neonatal and paediatric surgeon followed with a brief look at paediatric surgery. Mr. Morabito gave an interesting lecture, discussing not only life as a surgeon but also about the ethical and moral decisions and responsibilities of any surgeon. Mr. Angus Watson, a consultant general and colorectal surgeon and Mr. Phil Jones, a consultant ENT surgeon followed with interesting lectures about their respective fields. Mr. Richard Napier-Hemy, a consultant urological surgeon gave us a light-hearted look at urological surgery, while Dr. Louise Byrd a consultant in Feto-Maternal medicine looked at a profession which allows doctors to follow their patients from the womb right through their reproductive years. Mr. Donald MacKechnie, a consultant in emergency medicine brought us a chance to learn about life in the emergency department and an insight into what is surely a rewarding career.

We finished the day, with a lecture from committee member Dr. Stuart Enoch, a speciality registrar in Plastic surgery who dispelled any myths that plastic surgery was merely cosmetic surgery. It was a busy and fascinating day and a fantastic way to kick start the week.

Suzanne Martha Murphy
murphs34(a)tcd.ie

1) Why did you decide to study medicine?
From early high school, I have admired the way the living system is organised & the way it functions. I am fascinated by the science underlying pathological condition and how the living system can be aided to restore its homeostasis? Such admiration and profound interest in gaining knowledge about the basic organisation of living being paved way to study medicine.

2) Can you share some things that you wish that someone had told you before you applied to study medicine?
I wish to share one of the invaluable advice provided by one of the Professor who taught me good laboratory practice and various techniques in molecular biology. “Always make a note of the protocol, conditions, incubation timings etc. exactly as you carry out the experiment. It is important to have good record of the work you are doing, so that when the results seem impossible, you can look back and discover where you may have gone wrong”.

3) What profession would you be in if you weren’t in medicine?
I would have been in the field of Aeronautics as I am fascinated by the science of flight. I had an equal passion for Aeronautics, like that of medical science. More realistically I would have been doing Master of Technology in Aeronautics if I weren’t in medical science.

4) What is your biggest motivation?
It is my profound interest in this subject that motivates me. The challenge of science to test the capacity of my brain to deeply understand, analyze and creatively think has kept my enthusiasm towards biology than any other subjects during my high school days.

5) What are you most interested in so far and why?
I am interested in molecular biology, and understanding various mechanisms such as physiological signal transduction/signals and their outcome or events which helps to maintain homeostasis. However, I like applying my knowledge of cellular integrity and pathological conditions towards understanding the development of therapeutic strategies devouring molecular biology.
The reason for my desire towards molecular biology is because of the fact, that I had enough exposure to research laboratories employing techniques in molecular biology that address problems in biology both through my course work and internships where I learnt to plan, execute and troubleshoot experiments efficiently.

6) What has been your most difficult module so far and why?
In my view, the most difficult module in my medical studies was to plan and successfully execute “Short term Project” (first independent research experience), for around 3 months that was a mandatory component of my masters curriculum. Department of Biomedical Science, being one of the newly started centers at my university, was equipped only with infrastructure that can sustain few pilot experiments.However with these substructure students of my class were provided a chance to plan on their own project work, yet unique, and complete it within the deadline. This period of my study was more challenging to bring the best in me, both intellectually and physically.

7) What is the most memorable positive moment in your medical studies so far?
Persistent positive moment is the successful completion of “short term Project” (mentioned earlier). This project gave me a strong positive hope that I can satisfy my quest in a systematic way taking research as future career.

8 ) What is the worst horror story in your medical studies to date?
The way I missed the placement for clinical medical studies, after my higher secondary schooling, is the worst horror story. I had just missed it on 3 marks less than the cut-off that had been set during the selection process. And finally I decided to graduate in non-clinical studies though I did not lose momentum being at biomedical science.

9) Where do you see yourself in 10 years time?
a) The wishful thinking version
I would wish to see myself as a Professor guiding more than 10 student in my research in a premier research institute at one corner of the world

b) The perhaps slightly more realistic version
More realistically I will be carrying out my second post-doctoral fellowship, because I feel that at least three post-doctoral stints should be carried out to gain sufficient professional experience to successfully establish a laboratory of my own and guide students very efficiently.

10) Can you share some tips/advice for others
a) wanting to study medicine
I request everyone to feel from within. Studying medical science is not a fantasy or a way to make money, it is as a service to the well being of mankind. Stick to ethical rules when doing research and be more ‘Human’ when dealing with patients.

b) already studying medicine
I request everyone to understand the subjects from the basic principles & concepts to high fidelity concepts and realistically apply your understanding to take a logically worth-full decision, have more patience towards research, and try to convert the failure into a positive troubleshooting energy. And finally don’t forget to enjoy your life and studies.

A common conundrum for medical students is: How can I use the short period of my elective well? So before my elective I thought its important to have some realistic aims and objectives. Firstly, I was given a few points of advise from a friend who completed their elective last year:

* Seven weeks isn’t long enough to save the world
* Having four years of an English medical degree may not be particularly helpful in a lot of clinical situations in other parts of the world
* The limitations of my competencies are the same if I go to another country as they are in the UK (I won’t miraculously be able to work at consultant level)
* I could potentially be helpful
* Its an opportunity to gain experience for potential future careers

An opportunity arose in Colombia that was too good to miss, so that’s where I went. I didn’t really know what Colombia would be like. When planning my elective, every time I mentioned where I was going, the first responses would generally be references to drugs and violence. Though all these were notable components of my elective, they featured in different ways to what had been previously suggested.

Firstly, drugs. The cocaine industry remains strong, producing just under half of the world’s cocaine. However, Colombia has made significant progress in combating the industry, which has plagued their population for far too long (1).

Second was violence. I was told that the 11th commandment is ‘no dar papaya’ which literally means ‘don’t give papaya’, and metaphorically means ‘don’t make yourself vulnerable’. Heeding this wise piece of advice was enough to avoid most violence, and overall I found everyone extremely friendly. I only witnessed a small amount of violence, though the high numbers of armed military police are an indication of recent issues.

For my elective I conducted a pilot study of a holistic needs assessment tool for older people. My study aimed to assess the acceptability of the assessment tool for clinicians and patients in Colombia. The tool is being developed as a standard assessment to maximise clinical efficacy, whilst providing data on public health and healthcare needs. This data can then be used to direct health policy. For me this project was perfect. I wanted to work in academic public health, so having a chance to conduct this study myself was a valuable opportunity, and a great way to spend my elective.

I was pretty daunted by the prospect of conducting a study independently, especially with Spanish as my sketchy second language. I was able to get going with data collection relatively quickly after arriving because I had been in contact with a professor and some doctors who helped me source participants. Aware that my limited Spanish could affect the study, I organised for a modern languages student from the university to work as a translator, which was good experience for both of us.

I conducted the interviews with elderly people and clinicians in a couple of different hospitals. It was both a challenging and rewarding experience. Having good support from the doctors with whom I was working was vital for the success of the project, as logistically it would have been really difficult to sort out without them. I will now be writing up my research both independently and in combination with other students who conducted similar studies in various countries around the world. I intend to continue working on the assessment tools and with the team developing them in the future.

During my elective, I also had the opportunity to sit in on clinical consultations and participate in ward rounds. This was really interesting, giving me an insight into Colombian health care provision and the conditions that they treat. It was a great opportunity to contrast the situation with the UK, where I am training.

The high level of economic growth being experienced by Colombia is causing an epidemiological transition. This refers to how as a country and its health services develop the disease burden changes, from predominantly infectious diseases to chronic diseases related to modern western lifestyles. However, at the moment Colombia is moving through this progression, and is experiencing a ‘double burden’ of the diseases related to poverty and those relating to affluence. For example, it was not uncommon to see infected insect bites, malaria and dengue fever in the morning; and angina, COPD (Coronary Obstructive Pulmonary Disease) and stroke in the afternoon.

As well as the medical work I also spent a lot of time with a group of young artists. They had just finished the first issue of ‘Periodico Viva Vos’ (You Live Newspaper). It is a monthly publication of politically charged articles, creating a voice for those in society who aren’t being heard. It was great to see how they are pushing for social change with a drive and optimism that is inspirational. I painted a few murals with them including one during a hip-hop jam pictured below.

Overall I had an informative, productive and highly enjoyable time on my elective in Colombia. I would definitely recommend it to other medical students, though Spanish is a must if you want to get the most out of your time there.

Reference

(1) http://www.businessweek.com/news/2010-06-22/colombia-cocaine-output-fell-below-half-of-world-total-in-2009.html

This week in TLS News

Waters of calamity

In this blog medical student Maria Siddiqui writes about the devastation of Pakistan floods upon her country.

Abbreviations in a medical conversation

In this blog, medical student Matthew Rinaldi writes about how doctor-patient relationships are affected by medical abbreviations and acronyms.

Journey to Liberia: Carter Center staffer reflects on country’s mental health needs, new initiative

In this blog, Jane Bigham writes about her experiences from Liberia and the mental health needs of people affected by trauma.

Niger: 5 years and still waiting

In this blog, TLS student editor, Versha Prakash writes about the unmet needs of people in ‘double disaster’ struck Niger.

Editorial – Medical school admissions: time to rethink?

In this blog, TLS student editor, Joanna Hunter questions the logic behind medical school selection criteria.

This week’s Elective Report

Womens health in Nepal

Sian Cooper from Barts and London Medical School, shares her experiences from her elective in Nepal.

This week’s 10-point Medical Student Questionnaire

Chun’s TLS Ten Question Challenge

Chun Yat, third year medical student from University of Cape Town has accepted this week’s TLS ten question challenge.

This week’s Articles

What should you expect when you graduate?

In this article, Kevin Gillmann writes about the realities of life after you graduate from a medical school.

Harm reduction schemes in Malaysia and their impact on HIV transmission

In this article, Elliot Davies from King’s College discusses the impact of harm reduction schemes upon HIV transmission.

News and Events

Scapel Undergraduate Surgical Conference

On Oct0ber 9th, Scapel, the University of Manchester Surgical society present its second annual conference. The aim of this will be to give students a fantastic opportunity to gain experince in presenting research, case reports of interest or audits to their peers and senior surgeons on a national level. There will be the opportunity to deliver both oral and poster presentations, with prizes given for the best presentations as judged by a select panel of senior surgeons.The conference is open both to medical students who wish to present and those who simply wish to attend. There will be plenty to do throughout the day.

Key Conference Dates:

• Abstract submission closes: 1st September 2010 @ 6pm
• Abstract selection announcement: 8th September 2010

For more information visit the website on http://conference.scalpelmanchester.com/ where you’ll find more registration and programme information.

Hands Up for Health Workers – Public Stunt

Merlin’s Hands Up For Health Workers campaign is looking for volunteers to help with a public stunt they are carrying out in London on Peace Day on 21 Sep. Please join us in our campaign for change! If you are interested or want more details please contact lotte@merlin.org.uk.

This week’s Lancet Seminar

Pre-eclampsia

Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity. It is a pregnancy-specific disease characterised by de-novo development of concurrent hypertension and proteinuria, sometimes progressing into a multiorgan cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Predisposing cardiovascular or metabolic risks for endothelial dysfunction, as part of an exaggerated systemic inflammatory response, might dominate in the origins of late onset pre-eclampsia. Because the multifactorial pathogenesis of different pre-eclampsia phenotypes has not been fully elucidated, prevention and prediction are still not possible, and symptomatic clinical management should be mainly directed to prevent maternal morbidity (eg, eclampsia) and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery—the only definitive cure. Pre-eclampsia foretells raised rates of cardiovascular and metabolic disease in later life, which could be reason for subsequent lifestyle education and intervention.

Have a great weekend and please get in touch,

The Lancet Student Editorial Team

The articles analysed the effect of naltrexone and bupropion on weight loss, the pentavalent rotavirus vaccine in sub-Saharan Africa and in Asia, and the effect of pre-conception exposure to radiation on stillbirths and neonatal deaths.

These articles were accompanied by comments on cardiometabolic risk and weight-loss drugs, the potential of a rotavirus vaccine, the survivors of childhood cancer, the suspension of the HPV vaccine in India, advanced renal carcinoma, the epidemiology of mine accidents in China, and  the availability of homepathic treatment on the NHS.

The world reports discussed the Niger hunger crisis and the appointment of Donald Berwick as US centers for Medicare and Medicaid Services (CMS) Administrator.

One in five, or 17% of children are malnourished in Niger (Source: BBC)

A prolonged drought had hit Niger in 2005 leading to a widespread famine. The devastation caused widespread starvation, malnutrition in children and a huge loss of livestock. Located in western Africa, Niger is among the world’s poorest nations and is currently facing another hunger crisis or ‘as yet undeclared’ famine this year.

It’s already lean season in Niger but the grain banks are still empty. Now, the conditions are so extreme that people are left with very little or no food at all. According to this week’s Lancet world report, “[i]n villages scattered throughout the provinces of Zinder, Maradi, Diffa, and Tahoua, people have been reduced to eating leaves and lizards as their granaries run empty.” The UN’s World Food Programme (WFP) says that one in five children is malnourished and 7.3 million people are in desperate need of food. These figures far exceed those normally used to declare a state of national emergency.

Despite all this, the initial demand for funding is so far unmet and aid companies are merely mending the situations temporarily. Even in 2005, the emergency was foreseen as early as this year but it appears that the international community comprehends the gravity only when they see pictures of children actually dying due to starvation. And, with what little funding they have received so far, aid agencies are merely plastering the situations temporarily. It’s just not the food that needs to be delivered, improving the overall hygiene and sanitation is equally relevant in order to reduce the many health risks faced by people, especially young children.

The failed crops over years have pushed people far below the poverty lines and thus incapable of buying what’s available in the market. Moreover, with the recent torrential rains posing a logistical barrier to relief aids, people are left homeless and starving. Had there been an earlier response to the pleas of aid agencies and charities, Niger would not now be facing such a catastrophe. Let’s hope the waiting for aid does come to an end and a better response is implemented in the future.

7% of children, or one in five, are acutely malnourished.

Continue reading the main story

Related stories

• Niger’s hungry ‘fleeing south’
• Niger ‘faces total crop failure’

The figure – based on national surveys in May and June – is well above the WFP’s normal 15% threshold for declaring an emergency.

It is appealing for $213m (£136m) in aid, but is still 40% short of its target, a spokesman said.

‘Famine situation’The charity Helen Keller International (HKI) has accused the international community of failing to respond effectively to repeated appeals for help for Niger.

HKI’s Africa director, Shawn Baker, told the BBC that tens of thousands of children would die unless more aid is pledged.

Map of Niger

“Famine is a very loaded word,” he said, “but I think if you look in terms of the number of children affected, the way the livestock have been decimated, and the population movements that were seen earlier in the year, you certainly could consider a famine situation.”

He said the government of Niger was doing all it could.

The UN said more than 67,000 people lost their homes after severe rains in the past week.

The River Niger – the third largest in Africa – reached its highest level for 80 years, said the regional river authority, the ABN.

But the rains came too late to rescue this year’s crops, which have already failed.

“This year was a double whammy,” Christy Collins of the aid agency Mercy Corps told the Associated Press news agency.

In most years, even if the country’s primary crop fail, at least the secondary crops survive, she explained.

This year there was so little rain during the growing season that not only did the fields of millet not bloom, but the secondary greens used for animal fodder also failed.

Not only are many villagers going short of food, but their livestock – their only asset – have died off.

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King’s College London
elliot.davis(a)kcl.ac.uk

In 2005, the World Health Organisation (WHO) estimated that three quarters of all HIV positive individuals in Malaysia contracted the virus through intravenous drug use. Described by the UN as a “concentrated epidemic”, the result was a country failing in its Millennium Development Goal of reversing the spread of HIV/AIDS. Since 2005, however, the Malaysian government has radically altered its approach to managing intravenous drug use in the country. Its previously tough stance has been softened, while needle exchange and methadone maintenance programmes have been piloted and are now starting to be rolled-out across the country. These schemes remain in their infancy, yet recent evidence suggests they are already starting to have a positive impact on HIV infection rates.

HIV and AIDS continue to represent a significant public health risk across South and South-east Asia. Recent estimates by the WHO suggest that there are now around 3.8 million children and adults living with HIV in the region. This means only sub-Saharan Africa has a greater burden of infection, with an estimated 22.4 million individuals being HIV positive [1].

In several South and South-east Asian countries, HIV prevalence rates exceed 1 per cent of the 15 to 49-year-old population. Cambodia (1.6 per cent), Thailand (1.4 per cent) and Burma (Myanmar, 1.3 per cent) are among those most severely affected [2]. In Malaysia, which is often lauded for the quality of its healthcare service, the HIV prevalence rate is much lower at 0.5 per cent. But while this figure is below that of even the United States (0.6 per cent), the country faces its own serious challenge. This is because three quarters of the estimated 69,000 HIV positive individuals living inMalaysia contracted the virus through intravenous drug use [2-3].

The extent of the problem was brought into sharp focus by a United Nations (UN) report in 2005. Reflecting on the country’s progress towards achieving its Millennium Development Goals (MDGs), the UN stated that: “Malaysia has achieved commendable successes towards all the MDGs except in halting and reversing the spread of HIV/AIDS” [4-5]. Branding the problem a “concentrated epidemic”, the report went on to point out that, although the general population was perceived to be at low risk, infection rates among high-risk groups – specifically intravenous drug users (IDUs), sex workers and prison inmates – were bordering on 20 per cent. This figure is forty times higher than the 0.5 per cent prevalence rate reported for the Malaysian population as a whole [2-5].

With its MDG of reversing the rise in HIV prevalence by 2015 under threat, the Malaysian government acted swiftly in a bid to stem the tide of rising infections, sparking a rapid and dramatic turnaround in the country’s previous drug policy.

Prior to 2005, Malaysia had exercised a zero tolerance approach when it came to drug use, declaring it “public enemy number one” and hailing 2003 as a “year of total war against drugs” [6-7].

This tough stance extended beyond mere rhetoric, with one of the government’s main aims being the creation of a drug free society by 2015 [7]. Previous attempts to introduce needle exchange schemes had been dismissed out of hand [6] and drug rehabilitation programmes were overseen not by the Ministry of Health but by the Internal Affairs Ministry, which had a wider remit for national security [8]. Capitalpunishment remained the maximum penalty for anyone convicted of trafficking [9]. Meanwhile, any individual recording a positive urine test for either opiate or cannabis use was likely to face a mandatory two year sentence in a government-run drug rehabilitation centre, followed by a further two years’ probation [6, 10].

To many commentators, this hard line stance resulted in a disjointed approach to not only HIV management but also to health policy in general. First and foremost, there was good evidence that the programmes in place simply didn’t work – with up to 90 per cent of those attending rehabilitation centres going on to relapse [7]. In addition, government policy marked a dangerous precedent in a country where various studies have suggested that up to 43.9 per cent and 89.9 per cent of IDUs are respectively HIV and hepatitis C positive [10-11].

Encouragingly, the evidence to date already suggests that the change in approach is starting to yield results. The Malaysian government has worked with a number of Non-Government Organisations (NGOs) to introduce harm reduction schemes, namely methadone maintenance and needle-exchange projects.

From an initial pilot scheme of three centres in 2006, the needle exchange programme had extended to cover eight of the country’s 13 states by 2008. In the same year, some 1.8 million needles were distributed to more than 12,000 users. Meanwhile, over 7,000 individuals are now registered with central government-run methadone clinics, with a further 10,000 people receiving opiate replacement therapy through private practices [6].

The introduction of methadone maintenance schemes, in particular, seems to have had a major knock-on effect in terms of health benefits. A number of studies from around the world have already suggested that individuals involved in these schemes are more compliant with anti-retroviral treatment (ART) regimens, resulting in improved healthcare outcomes [12-13]. By 2007, up to 25 per cent of Malaysian ART patients were IDUs, marking a sharp rise from the figure of 7 per cent reported in 2003 [6].

Although harm reduction programmes remain a relatively new invention in Malaysia, the progress made so far has been heralded as a step in the right direction. Research from UNICEF suggests that the number of new HIV infections occurring in the country each day has fallen from 17 to ten between 2004 and 2009. There has also been a noticeable drop in the number of these infections associated with intravenous drug use, from the previous 75 per cent to 57 per cent [14] (see Figure 1).

Figure 1: HIV infection rates in Malaysia [2, 14]

Yet there remain problems. A recent article in The Lancet pointed out that IDUs continue to drive the epidemic in Malaysia. Around 1.3 per cent of the population are believed to be IDUs. And although HIV testing is now almost universal amongst these individuals (at close to 100 per cent), just 5.1 per cent said they used a condom during their last sexual encounter. Less than 30 per cent, meanwhile, reported using sterile equipment [15].

Compare these figures with the Ukraine, which is frequently cited as the country in the world with the most significant IDU-driven HIV epidemic, and the extent of the task still facing the Malaysian government becomes clear. Although only 27.6 per cent of Ukrainian IDUs had been tested for HIV in the past 12 months, over 80 per cent use sterile equipment and almost 60 per cent used a condom the last time they had sex [15-16].

The importance of these statistics cannot be over-stated. One recent survey of 526 IDUs not involved in drug treatment programmes across five cities in Peninsula Malaysia reported that 68.6 per cent of those questioned continued to share equipment and that 34 per cent were regularly involved in paid sex. Presciently, the study also identified the sharing of injecting equipment and having multiple sexual partners as the two most significant risk factors for HIV infection [11].

There have also been reports that, initially at least, local anti-drug legislation was slow to catch up with the new approach. Writing in 2007, one group of researchers reported that some pilot methadone maintenance and needle exchange projects had been raided by police with attendees beingarrested [7].

Though there is much work still to do in Malaysia, the results achieved so far do suggest that introducing simple measures like needle exchange programmes and methadone maintenance therapy can have a significant impact on HIV infection rates.

As a result of the initial success of these schemes there appears to be increasing goodwill towards them. Last year alone, the number of government-run health clinics operating needle exchange programmes increased from seven to 12, with RM43.1 million (£9.3 million) being invested in the scheme over a five-year programme. In the coming years, the president of the Malaysian AIDS Council has set a target of granting access to these schemes to a minimum of 60 per cent of IDUs [17].

Time will tell how successful these measures are long-term. However, it could well be that Malaysia emerges as a model of just how effective harm reduction measures can be in curbing the spread of HIV/AIDS in developing nations.

References

1. Joint United Nations Programme on HIV/AIDS and World Health Organisation (2009). AIDS epidemic update: December 2009. Geneva, UNAIDS.
2. United Nations Children’s Fund (2007). The state of the world’s children 2008. New York, UNICEF.
3. World Health Organisation (2007). Country cooperation strategy at a glance: Malaysia [online]. Available:http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_mys_en.pdf [accessed 30 March 2010].
4. United Nations Country Team: Malaysia (2005). Achieving the millennium development goals: successes and challenges. Kuala Lumpur, United Nations Development Programme.
5. United Nations General Assembly (2005). Monitoring the declaration of commitment of HIV/AIDS. New York, United Nations.
6. Kamarulzaman A. (2009). Impact of HIV prevention programs on drug users in Malaysia. Journal of Acquired Immune Deficiency Syndrome 52(S1):17-19.
7. Reid G, Kamarulzaman A, Sran SK. (2007). Malaysia and harm reduction: The challenges and responses. The International Journey of Drug Policy18(2): 136-140.
8. Scorzelli JF. (1992). Has Malaysia’s antidrug effort been effective? Journal of Substance Abuse Treatment 9(2): 171-176.
9. Mazlan M, Schottenfield RS, Chawarski MC. (2006). New challenges and opportunities in managing substance abuse in Malaysia. Drug and Alcohol Review 25(5): 473-478.
10. Chawarski MC, Mazlan M, Schottenfeld RS. (2006). Heroin dependence and HIV infection in Malaysia. Drug and Alcohol Dependence 82(S1): 39-42.
11. Vicknasingam B, Narayanan S, Navaratnam V. (2009). The relative risk of HIV among IDUs not in treatment in Malaysia. AIDS Care 21(8): 984-991.
12. Palepu A, Tyndall MW, Joy R, Kerr T, Wood E, Press N, Hogg RS, Montaner JS. (2006). Antiretroviral adherence and HIV treatment outcomes among HIV/HCV co-infected injection drug users: the role of methadone maintenance therapy. Drug and Alcohol Dependence 84(2): 188-194.
13. Roux P, Carrieri MP, Villes V, Dellamonica P, Poizot-Martin I, Ravaux I, Spire B; MANIF2000 cohort study group. (2008). The impact of methadone or buprenorphine treatment and ongoing injection on highly active antiretroviral therapy (HAART) adherence: evidence from the MANIF2000 cohort study. Addiction 103(11): 1828-1836.
14. United Nations Children’s Fund (2009). HIV and AIDS in Malaysia: Fact sheet. Kuala Lumpur, UNICEF Malaysia Communications.
15. Arasteh K, Jarlais DCD. (2008). Injecting drug use, HIV, and what to do about it. The Lancet 372: 1709-1710.
16. United Nations Regional Task Force on Injecting Drug Use and HIV/AIDS for Asia and the Pacific. (2009). Malaysia country advocacy brief: injecting drug use and HIV. Geneva, UNAIDS.
17. Edwards A. (2009). Needle syringe exchange programme injects hope. The Star, May 2009.

Many Liberians suffer from trauma, depression, and other mental health issues following more than a decade of civil conflict. With only one psychiatrist in the entire country, and just a handful of nurses with mental health training, treating those who suffer from mental illnesses has been almost impossible. Jane Bigham is assistant program coordinator for the Carter Center’s Mental Health Program and recently traveled to the West African country. Below, she reflects on her journey and what a new Carter Center mental health initiative will mean for the people of Liberia. Bigham will receive her master’s in global health from Emory University in December 2010.

I recently traveled to Monrovia, Liberia, to work on The Carter Center’s Liberia Mental Health Initiative—our first international project to improve access to mental health care. The initiative will assist the Liberia Ministry of Health and Social Welfare to implement the national mental health plan, a set of priorities and goals established by the Liberian government to improve access to mental health services in the country. Among other activities, The Carter Center will help create training systems for mental health professionals, such as nurses; develop support systems for family caregivers; and work to reduce stigma and discrimination against people with mental illnesses.

Photo credit: The Carter Center/M. Benckert
Jane Bigham and the team depart the Carter Center offices on U.N. Drive in Monrovia.

This was my first visit to Africa, and I was somewhat nervous, but very excited. During my flight from the United States, I had my first encounter with the impact of the Liberian civil war. I sat next to Nathan, an older gentleman and self-described “military man,” who served in Liberia in 1996 as a member of the Ghanaian peace-keeping force. He described his time there as the hardest peace-keeping mission of his service; he encountered many child and adolescent soldiers who had experienced severe cuts and scrapes, amputations, and scars. Recalling his experience brought tears to Nathan’s eyes.

Photo credit: The Carter Center/M. Benckert
Liberia is rebuilding its roads and infrastructure, but must also improve its collective mental health.

I couldn’t fathom the level of anguish and emotional turmoil that the people in Liberia experienced because of the war. And once I arrived, I saw firsthand the immense challenges facing the country. After 14 years of brutal civil conflict, the physical wounds remain visible and the emotional trauma lies close to the surface for many.

During my stay in Monrovia, I heard many accounts of how people with mental illnesses often are feared and discriminated against, underscoring the importance of the mental health work we were preparing to do.

A young man named Guzt, from Bong County, told me about a woman in her early 40s who suddenly started hearing voices and went to her church to seek help. She was assumed to have a mental health problem and was held against her will in the church, chained at the ankle. Two days later, she died. Guzt suspected the woman did not have a mental illness, but rather cerebral malaria—a common health problem in Liberia that might have been treatable if she had been given access to adequate medical care. Unfortunately, people with severe psychological disorders often are “treated” through starvation, neglect, or restraint with chains, due to myths about the causes and treatments for mental illnesses and the desperate lack of mental health services.

Photo credit: The Carter Center/M. Benckert
Dr. Janice Cooper (left), with The Carter Center, and Marion Subah, with Rebuilding Basic Health Services, participate in a mental health workshop co-hosted by The Carter Center and Liberia’s Ministry of Health and Social Welfare.

Although many such challenges exist, mental health is a high priority for the Liberian government and its Ministry of Health and Social Welfare. The government’s National Mental Health Policy and Strategic Plan for Implementation will address the need for mental health care professionals as well as challenge negative attitudes and misconceptions associated with mental illness.

Photo credit: The Carter Center/ J. Bigham
Many Liberians suffer from trauma, depression, and other mental health issues following more than a decade of civil conflict. Through its first international project, The Carter Center’s Mental Health Program will assist the Liberia Ministry of Health and Social Welfare to improve access to mental health services in the country.

Despite all the suffering I saw or heard about, I believe the people of Liberia are a testament to human resilience and resolve. I left Monrovia hopeful about what Liberia and The Carter Center can accomplish together to address mental health issues associated with the recent conflict as well as create ongoing mental health services. The country can and has, in part, rebuilt its roads and infrastructure. But to fully recover from the horrors and devastation of war, it also must heal its collective mind and improve its mental health.

For more information about the Carter Center’s Liberia Mental Health Initiative, please visit http://www.cartercenter.org/health/mental_health/index.html

“Waging Peace. Fighting Disease. Building Hope.”
A not-for-profit, nongovernmental organization, The Carter Center has helped to improve life for people in more than 70 countries by resolving conflicts; advancing democracy, human rights, and economic opportunity; preventing diseases; improving mental health care; and teaching farmers in developing nations to increase crop production. The Carter Center was founded in 1982 by former U.S. President Jimmy Carter and his wife, Rosalynn, in partnership with Emory University, to advance peace and health worldwide. Visit our Web site CarterCenter.org | Follow us on Twitter @CarterCenter | Favorite us on Facebook Facebook.com/CarterCenter | Join us on Causes Causes.com/CarterCenter | Watch us on YouTube YouTube.com/CarterCenter

1) Why did you decide to study medicine?
The ways that the human body functions really intrigue me. I like a discipline in which there is practical application. Medicine was the natural choice. I enjoy the interaction with people too.

2) Can you share some things that you wish that someone had told you before you applied to study medicine?
Dissection is really not that bad or scary, however, the embalming fluid does smell a little offensive. When people say studying medicine is hard-work – it’s not a lie. Having said that, it’s a lot of fun too.

2) What profession would you be in if you weren’t in medicine?
I would have been studying music to become a pianist. I’ve always been passionate about music. I sometimes wonder if there might be some connection between medicine and music because there are many fellow students and lecturers in my faculty who play musical intruments or sing.

4) What is your biggest motivation?
I want to become a good doctor who practises good medicine. It’s also very motivating when you watch medically-related dramas on television and know what they’re talking about.

5) What are you most interested in so far and why?
Internal medicine has been fascinating. The scope of the practice is so big and the different conditions of patients encountered in this field is unique to each patient. I see it as a challenge.

6) What has been your most difficult module so far and why?
I find Embryology difficult because it is very hard to conceptualise the developments of the embryo and foetus in three dimensions. Some anatomical parts in embrology also have very long names which can be difficult to memorise.

7) What is the most memorable positive moment in your medical studies so far?
Towards the end of my second year, when I was interviewing and examining patients in groups of two people. I identified an ejection-systolic murmur on auscultation in a patient with aortic stenosis. We presented our patient to the consultant who was teaching us and he confirmed it. The feeling was very rewarding because there are many moments where murmurs are just seem like noise – something I’m still in the process of learning to appreciate.

8 ) What is the worst horror story in your medical studies to date?
We had to go on an ambulance shift in our emergency medicine module. The ambulance staff and I transported a trauma patient to casualty. When someone took off the patient’s shoe, a pool of blood spluttered onto the floor at casualty. The patient had a stab wound on his feet and blood had been collecting in his shoe.

9) Where do you see yourself in 10 years time?
a) the wishful thinking version
It would be great to be one of the people who helped discover the cure for HIV/AIDS in ten years time. In South Africa, I see many patients who arrive at our academic hospital with HIV/AIDS related conditions. It’s my wish everyday to see this world free of this pandemic.

b) the perhaps slightly more realistic version
After completing my internship and community service, I would love to specialise in the field of internal medicine. Many physicians from my academic hospital (Groote Schuur Hospital) are truly inspiring doctors who are passionate, knowledgeable and caring. I strive to be a doctor like them someday.

10) Can you share some tips/advice for others
a) wanting to study medicine
Many years ago, I’ve always been overwhelmed by the thought of becoming a doctor. It seems like a fantasy that would unlikely to come true because the sheer amount of knowledge and skills that one is suppose to grasp in a few years is just insurmountable. In actual fact, nobody expects a medical student to gather all this knowledge and skills in a single day. Learning is a continuous process that takes place over a long period of time extending well beyond your graduation. Take things a step at a time, and eventually you’ll be studying medicine before you know it (assuming that’s what you really want).

b) already studying medicine?
Sometimes I might feel that what I am learning or doing is completely irrelevant to becoming a doctor. Often later I realise that what I was doing actually helped me develop personally and professionally, therefore be inquisitive and take every situation as a learning opportunity. Be compassionate to your patients because most people will get sick some time in their lives including yourself and me. Become a doctor that you and others will want to seek help from. Enjoy and experience the process of becoming what you want to be because it’s truly a privilege.

Talking with a doctor can be a bewildering experience for lay-people. Their conversation is sprinkled with latin, interspersed with obscure terminology and it is possible to leave having not understood a thing that’s been said. Although recognised by other members of staff, the language used by healthcare professionals can impede doctor-patient communication.

A lay-person may view their stomach as the area of fat above the belt and below the chest that inflates proportional to the number of beers drunk in a lifetime. On the other hand, an anatomist could define it as a muscular, hollow section of the alimentary tract; the potential for confusion is apparent.

The employment of technical terms is not unique to the medical profession, however as healthcare makes the transition to a patient-centred approach, it should be used wisely.WHY DO WE TALK THE WAY WE DO?

To aid memory

There is a wealth of knowledge that every medical student must be able to retain and regurgitate on request. Acronyms are used as a memory aid to ensure one has learnt all the relevant information. For example, the letters in “SOCRATES” can help 3rd year medical students recall the 8 essential questions to ask whilst taking a pain history. Mix-ups arise, however, when one assumes others use the same memory tools and when in doubt it is safest to use the whole word.

To save time

As is evident in any episode of ER, conversations between medical professionals can (and, arguably, must be) fast-paced. It is for this reason that many protracted names such as “Methicillin-resistant Staphylococcus aureus”, aka: MRSA, have been abbreviated to a more manageable form.

To form a barrier

Although distancing oneself from the patient is generally unprofessional, there are times when it could be excused if the intention is to minimise anxiety on the patient. For example, when it is in the medical best interests to remove a man’s testicles a surgeon may employ the term “orchidectomy” as this will conjure up less horrific images than it’s equivalent; “castration”. This technique increases the likelihood of them signing the consent form.

To follow tradition

Whilst medics pride themselves on logical thinking, a good number of terms still exist which are named simply after the discoverer of the disease, equipment or technique. These usually seem to have no reason behind them save egotism and their use is apparently only maintained to avoid change.

WHAT PROBLEMS DOES THIS CAUSE?

When doctor-patient communication breaks down it is inevitably the patient’s health that takes the hit. It can make the patient:

* unsatisfied, making them less likely to seek help with future symptoms
* find it difficult to follow medical advice, prolonging their morbidity
* unable to answer questions put to them which can result in them withholding relevant information inadvertently
* intimidated by the doctor’s greater knowledge

Inappropriate use of medical language by healthcare professionals contributes to this failure.

WHAT CAN BE DONE?

Medical language can be demystified by both medical professionals and their patients. In every interaction where medical language is used, it is the healthcare professional’s duty to both explain any technical terms. They may not appreciate that although a term may be part of their everyday speech, it may be the first time the person sat in front of them has ever heard it.

Patients should feel empowered to clarify terms they don’t recognise. For those who don’t, there is a wealth of online medical dictionaries to decode their doctors. The need for technical language in medicine is the same as any other vocation. It allows healthcare professionals to discuss patient care in a time-effective manner without the confusion that using everyday language can cause. However, as medicine adopts a patient-centred approach, both individuals and organisations should take it upon themselves to ensure that communication acts as a bridge between the scientific literature and lay-people; not a barrier.

Matthew Rinaldi
matthew.rinaldi07(a)imperial.ac.uk

Many consider access to safe childbirth and women’s health a basic human right. The 1996 Nepal family health survey found a maternal mortality rate of 539 out of 100,000 live births and a neonatal mortality of 39 in 1000 live births (1). Why such a poor track record for mortality?

A recent Nepali article highlighted one of the most important causes of neonatal mortality is a high incidence of home births with no trained attendees. Nearly 90% of Nepali women give birth at home. Poor antenatal care is a critical factor, and half of Nepal’s child-bearing women still receive no antenatal care (2). Partly to blame are logistics: poor infrastructure and large hills which make travelling to clinics in rural areas unfeasible. We witnessed this first hand when trekking through the Annapurna circuit. To travel from one settlement to another requires enough people to make the ‘bus’ journey viable. No fewer than 25 people must cram onto a jeep to enable the locals to travel along a slippery ravine-edge to the next town. Whilst myself and a friend clutched each other for dear life, a woman in the front had commenced labour and was being escorted by her family to the nearest hospital. It quickly became apparent that she would not make it in time and would have to find a house in the next town to give birth.

Unsafe abortions account for one third of all maternal deaths in some parts of the world. Deaths from the complications of abortions are largely preventable with adequate access to family planning information and the provision of safe abortion care (1). Nepal took strides towards safeguarding women’s health by legalising abortion in 2002. Compared to neighbouring countries, such as Pakistan where abortion is illegal, Nepal is commendable for its provision of free and safe abortion care (3). Our first day visiting Nepal’s Women and Children Hospital was spent taking part in a training day for the Family Planning Association of Pakistan (FPAP) (4) to enhance their pre, intra and post abortion care skills. Abortion is only permitted in Pakistan to save the life of the woman, and to preserve physical and mental health. Despite this, the FPAP were obliged to take training outside of their country due to religious hegemony surrounding the issue of abortion.

Nepal is admirable in that, despite being one of the poorest countries in the world, the government and other stakeholders have been proactive for policy change. Several bodies have been set up, such as the Safe Motherhood Programme under the Directorate of Health Services of the Ministry of Health’s guidance (5). The aim of this programme was to reduce maternal and neonatal mortality by advocacy and media strategy as well as more practical interventions such as cord blood banking and improved access to skilled birth attendants. In concordance with the Second Long-term Health Plan of 1997-2017, Nepal intends to reduce the Maternal Mortality Rate (MMR) to 250 by 2017.

Upon analysis, Nepal compares favourably with countries of similar Gross Domestic Products (GDP). Afghanistan, for example, has a MMR six times as high. In comparison, South Africa has a GDP seven times that of Nepal, yet has a comparable MMR. The aspiration to reduce MMR in Nepal to 250 brings it on a par with India’s ratio, which boasts a GDP more than double that of Nepal.

Despite bring a poor country, the Government of Nepal, aided by the Indian Government, have provided free hospital healthcare to the poorest members of society at Bir Hospital since 1889. There was a trained midwife present from 1920 onwards, and obstetrics and gynaecology moved to Prasuti Griha hospital in 1985 for more space. From humble beginnings, the hospital now has 321 beds and provides outpatient services as varied as colposcopy, comprehensive abortion care, family planning services and sub-fertility clinics and is the tertiary referral centre for women in the country. The majority of these services are entirely free, with no additional basic healthcare perks reserved for privately paying patients. The atmosphere of the hospital is that of adequate provision of healthcare staff, with a greater emphasis on nurses running the wards. The overall impression was that of efficiency in terms of cost in order to afford the skilled healthcare professionals needed.

This led me to question the financial and material wastefulness of the western world. At Prasuti Griha, adequate care is provided to as many people as possible, within the context of limited resources. This is an echoing theme throughout the corridors of the world’s hospitals, irrespective of a country’s prosperity. Despite all this, if I were faced with an internal examination at Prasuti Griha compared to the shiny Norwegian International Hospital across the road, I know which I would choose.

Sian Cooper
Barts and the London Medical School
siancooper1(a)gmail.com

1. Status of maternal health in Nepal. Vaidya, Achala.
2. A glimpse on the maternal, child health and family planning in Nepal. Giri, Kanti. s.l. : N. J. Obstet. Gynaecol Vol. 1, No. 1, p. 76 – 79 May 2006.
3. Publications – Abortion. [Online] [Cited: 29th July 2010.] www.un.org/esa/population/publications/abortion/doc/pakistan.doc.
4. Association, Family Planning. [Online] 2010. www.fpapak.org/.
5. Motherhood, Safe. http://www.safemotherhood.org/. [Online] 29th July 2010. http://www.safemotherhood.org.np/pages/default.php?function=content_ssmp&secid=35.
6. World, Gapminder. gapminder.org/world. [Online] 2008. [Cited: 29th July 2010.] http://www.gapminder.org/world/#$majorMode=chart$is;shi=t;ly=2003;lb=f;il=t;fs=11;al=30;stl=t;st=t;nsl=t;se=t$wst;tts=C$ts;sp=5.59290322580644;ti=2008$zpv;v=0$inc_x;mmid=XCOORDS;iid=phAwcNAVuyj1jiMAkmq1iMg;by=ind$inc_y;mmid=YCOORDS;iid=pyj6tScZqmEcVezxiMl.

Waiting for relief. Source: BBC

Covering one-fifth of the country with water, displacing two million people across three provinces, injuring and killing more than 3500 people and rampaging across the livestock and agricultural resources, Pakistan’s floods are the worst natural disaster in the eighty year history of the region.
 
Wiping out homes, schools, farms, villages, and towns they began late last month when torrential monsoon rains flooded the Indus River, the nation’s life-blood. The floodwaters coursed from the north, battered the region, before making its way towards the south, spanning three provinces and causing misery and destruction in its wake.

Losses exceed and resist estimation. Agricultural land and crops have been obliterated, shattering an already fragile economy that relies on agriculture as a mainstay. Food-related inflation is soaring. Economic ramifications will be felt for months in an already poverty stricken nation.

Damage to the health care infrastructure has been no less. Where there were a few hospitals across the rough mountainous terrain of the north, all have been wiped away by the deluge or rendered inaccessible because of the collapse of bridges and tearing up of roads. In such places, every unaffected structure is being utilized to its maximal extent. Hospitals have been turned into schools; classrooms into labour rooms. People awaiting treatment sit on desks; patients lie sprawled on the floor. Medicines are short in supply, doctors are scarce and those waiting to be treated are endless.

The situation only worsens proceed towards the south. The evacuees, now spread across camps throughout the country, are battling with starvation, the scorching heat and fatigue while mourning their losses. Many wonder if they’ll survive to ever see home again. But their battle for survival has only begun. Crowding in fly-infested camps is providing the ideal conditions for infestation with water and vector-borne diseases. Lack of proper sanitation, insufficient clean water and inadequate personal hygiene are posing a monumental threat. Up to 3.5 million children are at risk of contracting water-borne diseases, according to Maurizio Giuliano from the U.N.’s Office for the Coordination of Humanitarian Affairs. [1]

The WHO has reported acute watery diarrhea, acute respiratory infections and skin diseases as primary diseases affecting the population. From the inception of the floods until 12 August 143,870 cases of skin infections, 115,922 cases of acute diarrhoea and 113,981 cases of respiratory tract infection have been recorded. [2] As the stagnant waters continue to rise, malaria is imposing itself as a significant threat. In the province of Sind, the cases being reported are fast rising. And, delivering health care after the demolition of more than two hundred hospitals and clinics is becoming a daunting task. The UN Secretary General Ban Ki-Moon has called the crisis a “slow motion tsunami”. [3]

The United Nations has estimated the costs of providing clean water, food, sanitation and immediate medical services to be $ 460 million   But the response has been unenthusiastic; with less than half of the target funds raised, jeopardising relief efforts. An epidemic could prove disastrous at this point. The writing is clear: Pakistan needs aid. And with the monsoon season only about half way over, it needs it fast.

Maria Siddiqui

University of Karachi

mariatsiddiqui(a)gmail.com

1. http://www.bbc.co.uk/news/world-south-asia-10984477
2. WHO  http://www.who.int/hac/crises/pak/sitreps/16august2010/en/index.html
3. http://www.un.org/apps/news/story.asp?NewsID=35670&Cr=pakistan&Cr1=

“Is it legal for employment to be refused as a result of the outcome of a 3 station OSCE devised by a Trust when a 5 year programme, quality assured by the GMC has provided evidence that the applicant is fit for purpose?” [1]

Such was Professor Tony Weetman, Chair of the Medical Schools Council’s comment, reflecting on the pitfalls underlying the British Government decision to reform the medical career pathway.
Medical Career Pathway in the UK

Since the introduction of the Modernising Medical Careers programme, in 2005, British medical careers are made up of 4 steps. The medical degree, typically consists of 5 years of study in one of the 32 medical schools of  United Kingdom. After graduating, junior doctors enter a 2-year multidisciplinary clinical training called the foundation program. Once they have completed this, doctors can apply for specialty registrar positions, and train to a specialty. This training varies  in length depending on the chosen specialty, and gives access to hospital consultancy or general practice.

Figure 1: Modernising Medical Careers’ organisation with average duration of each step.

A flawed selection process?

While the Modernising Medical Careers programme has made transitions between career steps more harmonious, it is now the access to foundation programme positions that is questioned. The issue was raised in 2008, when a NHS study “The Next Stage Review: A High Quality Workforce” stated that “New work needs to be undertaken to develop more reliable and valid selection tools for recruitment”. Following this declaration, the British department of health took immediate action, committing a panel of international experts to analyse and reflect upon the current selection methods. [2]

The current selection is based upon 2 scores. The first one, a knowledge score, is obtained by ranking medical students on the basis of their medical school results. From this sorted list, each medical school divides its own students into four quartiles, and scores are allocated to students of each quartile. Students from the first quartile receive 40 points, and all those from the second, third and fourth quartiles receive 38, 36 and 34 points respectively. This allocating method has been depicted unfair and two crucial issues were highlighted. First, since students from the first quartile of any medical school get the same amount of points, some students may theoretically be lead to choose a less competitive medical school to rank in the first quartile more easily and thus be more likely to obtain the foundation placement of their choice. [3] Then, there are currently enough foundation positions to ensure employment to every junior doctor. However, it may not always be the case, and the day the ever-increasing number of junior doctors will overcome the number of posts available, some will ultimately be refused. And refusing employment on the basis of a selection process, which is not considered as sound, transparent and fair would open the way to a myriad of potential legal challenges. [2, 4]

The second part of the current selection process is a professionalism score. Students’ professional traits are assessed by a series of open-ended ‘white space’ questions they answer during their spare time at the end of their final year. Their answers are marked by a panel of doctor from the applicant’s first choice base unit. The criticisms on this method are numerous. Firstly, it has been identified that the ‘white space’ format for answers compromised the objectivity of the assessment. [4] Then, despite the fact a random selection of 10% of applicants is asked to provide evidences of their answers, this method is said to open the way to cheating and plagiarism. [4, 5] Finally, the panels responsible for the marking of the forms complain about the time-consuming aspect of the task. [6]

Options study

During the 9 months following these findings, the panel of experts assessed various selection methods, and proposed the “Improving Selection to the Foundation Programme Project”. In order to define the ideal selection criteria, they firstly raised the crucial question of what expectations hospitals have of ‘good doctors’. Three attributes were retained: clinical knowledge, clinical skills and professional traits. [7] They then considered the traditional options available to assess such criteria: structured interviews, multiple-mini interviews, a national examination of clinical skills and knowledge, a national test of professional traits, and a standardised score from medical schools. All these selection methods were assessed upon several criteria, ranging from transparency to fairness and cost. As a result of this feasibility study, interviews were dismissed for their inherent lack of objectiveness and their cost, just like national examinations of which the OSCE component was considered to be too expensive, and the assessment of knowledge too redundant with students’ finals. [8]

Figure 2: Results of the feasibility study showing the cost of every method over five years on the ordinate and their reliability score in arbitrary units on the abscissa. (Adapted from Option Review in Paul O’Neil’s presentation: Pilots for FP Recruitment and Selection 2013)  [8]

Proposed selection process : what is going to change?

At the end of the study, the panel reached a conclusion and proposed a recommendation framework. As other methods to assess clinical knowledge and skills had been ruled out, experts decided that medical school should keep the responsibility of this assessment. However, the quartile distribution would be replaced by a more granular process allowing standardisation of every student’s grades in a fair and reliable way: the Educational Performance Measure (EPM).

As far as ‘white space’ questions are concerned, they would be replaced by another professionalism assessment, which would this time be a national computer-marked test: the Situational Judgement Test (SJT). The Medical Schools Council describes it as “similar to GP short-listing tests”, and it is very likely to be on the form of small scenarios and identifying the most appropriate action to take. It should also put an emphasis on solving ethical and professional dilemma rather than focusing on students’ extra-curricular achievements. The rest of the process should on the whole not be reformed. [8] In practical terms, for students this reform would mainly replace the professionalism “take-home essays” by a National Situational Test, and change the way their medical school achievements are converted into a standardised score.

Figure 3: Proposed Selection Process. (Adapted from «Proposed Selection Process» in Denis Shaughnessy’s presentation: Improving the Selection Process) (7)

Figure 4:  Situational Judgement Test, sample question. A suggested answer to the above question is: A-D-C-B-E. (2)

This new selection process is currently in its stage of development and still has to be tested, legally reviewed and approved by the ministry before it can go live.

Dr Richard Price, careers coordinator at Newcastle University adds: “All we know currently is that the planned changes will be piloted  in selected medical schools alongside the existing system for the next two years, and  will  be  thoroughly evaluated prior to their full introduction.”

These trials are to start in October 2010 on a sample of a few hundred applicants, before expanding to a few thousand by March 2011. These pilots will be followed by a legal review, an approval, and a preparation phase that could last until autumn 2012. This last stage is an unavoidable part of the process since it is during this preparation that will be decided how to combine the EPM and SJT to produce a representative overall score.

Thereby, the new selection process should not go live until the academic year 2012-2013, at the earliest. However, experts recommend to continue with the current method unless the pilots show sound reasons for change. [8]

Figure 5: Introducing the changes: a timing overview. (Adapted from “Timing Overview” in Denis Shaughnessy’s presentation: Improving the Selection Process) [7]

So how do other countries sort the matter?

Generally, four main methods are broadly accepted internationally to determine selection of junior doctors’ first placements after graduation. Most countries opt for one of these solutions, or a close alternatives.

1. A national examination ranks applicants according to their results and allocates everyone to his first available choice, starting from the top of the list. [9]
2. Applicants get systematically appointed to the university hospital the graduated from. [10]
3. The government decides where junior doctors are appointed to, depending on current needs. [11]
4. Applicants are scored against various criteria before an algorithm matches them with to their most highly ranked choice. [12]

In France, students do not graduate until they have finished their internship. But the 6-years lecture-based studies are separated from the clinical internship by an examination. This latter is a national examination after which students are ranked upon their score. Students may then choose their positions in the order of their ranking.  There are generally more positions than applicants, however applicants with the lowest scores may not have the choice of their specialty. [9]

In Italy, after graduation junior doctors complete a three-month unpaid supervised placement. It consists of two months in the university hospital they graduated from and a month shadowing a general practitioner in a local surgery. After they successfully complete these, a national examination must be passed to obtain full license to practise. [10]

India : Compulsory Rural Service

In India, the degree of Bachelor of Medicine and Bachelor of Surgery (MBBS) is awarded to students once they have completed five years and a half at medical school. However, in an attempt to improve health care standards in the most rural communities, some states have decreed that junior doctors should, as a priority, be appointed to tribal areas. Thereby, young doctors are now bound to practice medicine in rural settings for a year after graduation, before they can apply to any other post. [11]

During their last year of medical school, American students apply to residency programmes via the online Electronic Residency Application Service (ERAS). These programmes then short-list the applicants they want to interview. Criteria used for such a selection can vary widely. A study undertaken in 2000 shows these variations as 94% residency programmes reported to base their selection on examination scores, 87% on potential letters from deans, 85% on application forms, and only 61% on personal statements. [13] After the interview stage, programmes rank their interviewee by order of preference, and applicants similarly rank the programmes they applied to. An algorithm, the National Residency Matching Program, is then responsible to match programmes and applicants with their most highly ranked choice. In 2008, of the almost 36,000 applicants, 20,940 matched. [14] For the unmatched applicants, it is during a period known as the ‘Scramble’, during which the applicants who did not match try to secure a remaining available position. But this process is barely structured and offers minimal chances of success. Dr. Freedman, an American leader in medical education, describes the situation: “Jammed fax machines and lines of communication make this process challenging. […] In 2008 by 6pm the day after the Scramble, only 179 positions of the 1,388 positions remained open.” The Association of American Medical Colleges has, however, acknowledged the issue and is currently leading a study to give a more defined structure to the Scramble. [12]

References

1- Pr. Weetman T., Written Evidence Submission – The Evaluation Of the Foundation Programme, Medical Education England.

2- Improving Selection to Foundation Programme Briefing Pack – Stage 2 of Project, Medical Schools Council: 2010.

3- Kelly C., Should UK Medical Students Sit a National Qualifying Exam?, Student BMJ: 2008 – 16:184|17.

4- Pr. Paice E., Dr. Rainsberry A., House of Commons, Health Committee, Modernising Medical Careers, Volume II, Written evidence: October 2007 – p127.

5- Medical Schools Council, Characteristics of the Current System for Selection into the Foundation Programme, Appendix B.

6- KSS FP Evaluation Final Report from KSS Deanery: 2006 – p25-28.

7- Shaughnessy D., Improving The Selection Process, Presentation: March 2010.

8- O’Neill P., Pilots For FP Recruitment and Selection 2013, Presentation, UKFPO: 2010.

9- Postes et Rangs Pour l’Examen National Classant, Journal Officiel, Direction de l’Information Légale et Administrative: 2009.

10-Pr. Torre G.C., Corso di Laurea in Medicina e Chirurgia, Facoltà di Medicina e Chirurgia, Università degli Studi di Genova.

11- Sai Gopal M., Opinion Divided Over Compulsory Rural Service, The Hindu: February 2010.

12- Freedman J. MD, The Residency Scramble: How It Works and How It Can Be Improved,  The Student Doctor Network: March 2009.

13- Adams L. J. MSW, Brandenburg S. MD, Blake M. MS, Factors Influencing Internal Medicine Program Directors’ Decisions about Applicants, Academic Medicine: May 2000 – Volume 75 – Issue 5 – p 542-543.

14- Advance Data Tables For The 2008 Main Residency Match, National Residency Matching Program, March 2008 – p3.

This week in TLS News

Superbug jeopardises ‘medical tourism’ in India and Pakistan

Gurmeen Kaur writes about effects of the recent antibotic resistant bacterial strain on the medical tourism in South Asia.

Antibiotic resistance: Are we reaching the tipping point?

In this blog, medical student Joseph Fitchett reports about the new antibiotic resistant bacterial strain NDM-1.

After floods: Medical conditions in Pakistan

In this blog, Ahmad Jawad  brings an update from a medical camp that he attended to provide aids to the victims of the devastating flood in Pakistan.

Merlin and maternal care in Liberia

In this blog, Clare Logan, a student from the Liverpool School of Tropical Medicine, writes about her experiences of  maternal health care in post-conflict reconstruction in Liberia at one of the 81 medical facilities supported by Merlin.

Why so slow? The international response to the Pakistan floods

In this blog, TLS student editor Joanna Hunter comments on the international response to Pakistan floods.

Editorial – I’m a humanitarian aid worker

In this blog, TLS student editor Versha Prakash writes about World Humanitarian Day and its agenda this year.

This week’s Elective Report

Oncology in Tanzania

Charlotte Brown shares her varied experiences from a Cancer hospital in Tanzania.

This week’s 10-point Medical Student Questionnaire

Anil’s TLS Ten Question Challenge

Anil Joshi has accepted this week’s TLS ten question challenge.

This week’s Articles

Fractured

In this article, Tamsin Cargill writes about the fractures health care system in Malawi and what can be done in future.

Engaging men to empower women: The emerging role of husbands and fathers in child health in Tanzania and Uganda

In this article, Ben Penderson and Tyler Weber discuss the emerging role of husbands and fathers in Tanzanian and Ugandan family life.

News and Events

Scapel Undergraduate Surgical Conference

On Oct0ber 9th, Scapel, the University of Manchester Surgical society present its second annual conference. The aim of this will be to give students a fantastic opportunity to gain experince in presenting research, case reports of interest or audits to their peers and senior surgeons on a national level. There will be the opportunity to deliver both oral and poster presentations, with prizes given for the best presentations as judged by a select panel of senior surgeons.The conference is open both to medical students who wish to present and those who simply wish to attend. There will be plenty to do throughout the day.

Key Conference Dates:

• Abstract submission closes: 1st September 2010 @ 6pm
• Abstract selection announcement: 8th September 2010

For more information visit the website on http://conference.scalpelmanchester.com/ where you’ll find more registration and programme information.

This week’s Lancet Seminar

Pre-eclampsia

Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity. It is a pregnancy-specific disease characterised by de-novo development of concurrent hypertension and proteinuria, sometimes progressing into a multiorgan cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Predisposing cardiovascular or metabolic risks for endothelial dysfunction, as part of an exaggerated systemic inflammatory response, might dominate in the origins of late onset pre-eclampsia. Because the multifactorial pathogenesis of different pre-eclampsia phenotypes has not been fully elucidated, prevention and prediction are still not possible, and symptomatic clinical management should be mainly directed to prevent maternal morbidity (eg, eclampsia) and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery—the only definitive cure. Pre-eclampsia foretells raised rates of cardiovascular and metabolic disease in later life, which could be reason for subsequent lifestyle education and intervention.

Have a great weekend and please get in touch,

The Lancet Student Editorial Team

Source BBC

Yesterday, amidst floods and threats to life across the globe, the international community celebrated the second anniversary of World Humanitarian Day. The day was established by the United Nations (UN) in 2008 to raise awareness for the victims of conflicts and natural disasters and to pay tribute to more than 800 humanitarian relief workers who have lost their lives in service over the past decade. August 19 also marks the tragic anniversary of the 2003 terrorist bombing of the UN headquarters in Iraq, in which twenty-two people lost their lives.

World humanitarian day may have its roots in Iraq but this year’s theme (I am a humanitarian aid worker) aims to create a global humanitarian community. Both man-made and natural calamities are on the increase worldwide and cause fear and suffering to millions of people each year. Globally, there are more than 27 million internally displaced people and 10 million refugees. One out of every six people in the world is malnourished. This is the international community served by humanitarian workers. Because they do not carry guns, they represent easy targets to militant groups. Moreover, the increasingly widespread notion that relief workers are mainly ‘westerners’ is creating a rift between aid workers and the people they help. This has manifested itself with an increased number of attacks on humanitarian workforces. Just twelve days ago, ten medical aid workers were brutally murdered in remote Afghanistan while many lost their lives in Haiti earlier this year.

What conclusions can be drawn from these humanitarian crises? Frustration is an easy response to the countless headlines tragedies worldwide. But this response will only slow down the progress that humanitarian workers have made so far. There is much more we can do to advance their noble cause, and to offer the prospect of a brighter future to hundreds of millions of people around the world.

For more information on the goals and aims of World Humanitarian Day visit the website http://ochaonline.un.org/whd/

Summary 

Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity. It is a pregnancy-specific disease characterised by de-novo development of concurrent hypertension and proteinuria, sometimes progressing into a multiorgan cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Predisposing cardiovascular or metabolic risks for endothelial dysfunction, as part of an exaggerated systemic inflammatory response, might dominate in the origins of late onset pre-eclampsia. Because the multifactorial pathogenesis of different pre-eclampsia phenotypes has not been fully elucidated, prevention and prediction are still not possible, and symptomatic clinical management should be mainly directed to prevent maternal morbidity (eg, eclampsia) and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery—the only definitive cure. Pre-eclampsia foretells raised rates of cardiovascular and metabolic disease in later life, which could be reason for subsequent lifestyle education and intervention.

Introduction

Complicating 2—8% of pregnancies, pre-eclampsia, along with the other hypertensive disorders of pregnancy, is a major contributor to maternal mortality worldwide.1, 2 In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be assigned to hypertensive disorders.1 The incidence of pre-eclampsia has risen in the USA. 3, 4 This finding might be related to an increased prevalence of predisposing disorders, such as chronic hypertension, diabetes, and obesity.3 Some ethnic groups (eg, African-American and Filipino women5, 6) and low socioeconomic status are associated with a heightened risk.7 Furthermore, severe pre-eclampsia is a major cause of severe maternal morbidity (eg, stroke and liver rupture) and adverse perinatal outcomes, such as prematurity and intrauterine growth restriction.2 Although the generalised seizures of eclampsia complicate 2—3 cases per 10 000 births in Europe, eclampsia is 10—30 times more common in developing countries than in high-income countries. 2

Other hypertensive disorders in pregnancy are pre-existing hypertension and gestational hypertension. Pre-eclampsia is generally defined as new hypertension (diastolic blood pressure of ≥90 mm Hg) and substantial proteinuria (≥300 mg in 24 h) at or after 20 weeks’ gestation.8 However, how best to define the maternal syndrome of pre-eclampsia, and how to differentiate mild from severe disease is being debated.9—12Table 1 shows recent classification frameworks, evolving from previous work of the American College of Obstetricians and Gynecologists13 and the International Society for the Study of Hypertension in Pregnancy.14 The main differences between the classification systems are: (1) inclusion or exclusion of complicated non-proteinuric gestational hypertension as pre-eclampsia; (2) differentiation between clinical and research definitions in the Australasian guideline; (3) use of early-onset pre-eclampsia as a severity criterion in Canada (<34 weeks) and the USA (<35 weeks); (4) clinical importance of assessing white-coat hypertension; and (5) definition of severe hypertension. Although perinatal risks have long been recognised to be highest remote from term, the 20-fold increase in maternal mortality that is associated with pre-eclampsia arising at less than 32 weeks (compared with that at ≥37 weeks)15 seems not to have been, emphasising the importance of early-onset pre-eclampsia as a severity criterion. The debate between setting the systolic blood pressure definition of severe hypertension at either 160 mm Hg or 170 mm Hg needs to be resolved because of rising concerns about lethal maternal stroke risks at the lower threshold for blood pressure.16, 17 None of these classification systems seems to have been independently assessed for the ability to identify women and fetuses at heightened risk of the adverse events that make pre-eclampsia so important.

Table 1 International comparison between recent classification systems

Pathogenesis

Although the cause of pre-eclampsia remains largely unknown, the leading hypotheses strongly rely on disturbed placental function in early pregnancy (figure). Impaired remodelling of the spiral artery has especially been considered as an early, but not necessarily the primary, defect causing pre-eclampsia.19 Remodellingis a multistep process20 in which the first decidua-associated step should be initiated around implantation. Disturbances at this stage could increase risk of pre-eclampsia, and might explain its higher incidence in women with unexplained subfertility or recurrent miscarriage.21, 22 Decidua-associated vascular changes also arise in the inner (junctional zone) myometrium, followed by trophoblast invasion with associated remodelling.23 Interaction of trophoblastic HLA-C, HLA-E, and HLA-G with uterine natural killer cells or dendritic cells, or both, is thought to be important in regulation of invasion,24—26 and some combinations of HLA-C and killer cell immunoglobulin-like receptor isoforms predispose to pre-eclampsia.27

Figure 1 Possible pathophysiological processes in pre-eclampsiaAV=anchoring villus. COE=coelomic cavity. CY=cytotrophoblast. DB=decidua basalis. DC=decidua capsularis. DP=decidua parietalis. EN=endothelium. ET=extravillous trophoblast. FB=fetal blood vessel. FV=floating villus. GL=gland. IS=intervillous space. JZ=junctional zone myometrium. MB=maternal blood, leaving the intervillous space with various components such as antiangiogenic factors. MV=maternal vein. SA=spiral artery. SM=smooth muscle. ST=stroma. SY=syncytiotrophoblast. TM=tunica media. UC=uterine cavity. sFlt-1=soluble form of the vascular endothelial growth factor receptor. Centre panel of figure adapted from Karumanchi et al,18 with permission from Elsevier.

Intervillous flow seems to start 7—8 weeks of gestation by the appearance of connecting channels between spiral arteries and lacunae in the wall of the implanted blastocyst.28 Early trophoblast plugging might protect the embryo against high oxygen concentrations. Researchers29 have postulated that premature loss of these plugs could result in early miscarriage, or, dependent on timing, pre-eclampsia. Gradually plugs are resolved by intravascular migration of the trophoblast. Intervillous flow is thought to start in lateral regions,29 whereas trophoblast invasion and associated deplugging of spiral artery outlets starts in the centre and spreads to the periphery. Peripheral onset of intervillous flow should result in high local oxidative stress, leading to villous regression and formation of the chorion leave. Insufficient lateral spread of endovascular plugging could therefore result in extensive chorionic regression and a small placenta,29 contributing to intrauterine growth restriction, early-onset pre-eclampsia, or both.

Overlaying trophoblast invasion and spiral artery remodelling steps on Jauniaux’s placental oxygen curve 30 shows that decidua-associated remodelling in decidua and junctional zone myometrium develops during the steep rise in placental oxygen (10—12 weeks), whereas at 10 weeks some decidual arteries are already filled with endovascular trophoblast over their entire length.31 Placental flow defects can be detected as early as 12 weeks in women who subsequently develop pre-eclampsia.32 Deep invasion of the myometrial arterial segments comes after the steep rise in placental oxygen from 15 weeks onwards, and can therefore be triggered by increased flow.31 Thus, impaired invasion of myometrial spiral arteries in pre-eclampsia might result from, rather than cause, maternal flow defects. As myometrial spiral arteries have a more pronounced muscular coat and elastica than do the corresponding decidual vessels, failed remodelling at this level leadsto reduced uteroplacental arterial flow and episodesof irregular placental perfusion. Such hypoxia or reoxygenation episodes in some cases generate reactive oxygen species,33 leading to placental oxidative stress and placental dysfunction, with endoplasmic reticulum stress and impaired protein synthesis.34 We believe that the unidentified causes of the first (placental) stage of pre-eclampsia35 might include excessive or atypical maternal immune response to trophoblasts,36 and either impaired decidualisation or failure of proper uterine preconditioning.37 Thus, pre-eclampsia is a disease of failed interaction between two genetically different organisms. As such, Haig’s maternal-fetal conflict hypothesis could be relevant.38

The second stage (figure) of systemic maternal disease is associated with an exaggerated endothelial activation and a generalised hyperinflammatory state compared with normal pregnancy.39 Episodes of placental hypoxia or reperfusion result in oxidative stress, subsequent apoptotic and necrotic disruption of syncytial architecture,40 and release of various components from the intervillous space into the maternal circulation, stimulating production of inflammatory cytokines.41 The circulating bioactive trophoblast debris includes syncytiotrophoblast membrane microparticles41 and an excess of syncytiotrophoblast-derived antiangiogenic factors, such as soluble endoglin and the soluble form of the vascular endothelial growth factor (VEGF) receptor (sFlt-1).18 Increased production of anti-angiogenic factors by trophoblasts was also recently shown in molar pregnancy, a disorder known to pre-dispose women to pre-eclampsia.42, 43 The excessive systemic inflammatory response of pre-eclampsia44 results in endothelial dysfunction and associated increased vascular reactivity, preceding onset of symptomatic clinical disease.45 Loss of endothelial integrity contributes to derangements of sodium-volume homoeostasis and reversal of many cardiovascular changes (eg, increased cardiac output and intravascular volume) accompanying normal pregnancy. Thus, pre-eclampsia is a low-output, high-resistance state with paradoxically decreased aldosterone and renin activity.46

Linking mechanisms between stages 1 and 2 can be different for several phenotypes of pre-eclampsia, including haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome,47 and sometimes varies between individuals. Whether pre-eclampsia will be of early (often complicated by intrauterine growth restriction) or late onset can be dependent on whether the placenta in stage 1 becomes phenotypically small because of a greater angiogenic imbalance.48 Poor placentation should not be regarded as the cause of pre-eclampsia, because not all of such pregnancies have poor outcomes, but instead as a powerful predisposing factor.39 In the presence of a placenta with an appropriate size for gestational age, predisposing cardiovascular and metabolic syndrome-like disorders might also be able to set off a cascade of placental and systemic inflammation and oxidative stress, resulting in late onset pre-eclampsia (also called maternal pre-eclampsia).49 This view is substantiated by findings of normal villous morphology in late-onset pre-eclampsia, by contrast with early-onset pre-eclampsia,50 although no such data seem to exist for the placental bed.

Although interactions between maternal genetic and constitutional factors with environmental factors contribute to the second stage, such factors are now thought to have an effect on the first stage of the disease.49 Decreased antioxidant and phase I and phase II biotransformation activities in the maternal blood and decidual and placental tissue probably contribute to an increased risk of pre-eclampsia.51 The protective effect of smoking against pre-eclampsia52 could result from beneficial carbon monoxide effects on trophoblast invasion and spiral artery remodelling, increased stage 1 placental blood flow, and decreased stage 2 inflammatory responses.53 Decreased placental release of sFlt-1 is possibly associated with this protective effect.54

Screening

Table 2 shows factors that can easily be measured at the first prenatal appointment and that increase the likelihood of pre-eclampsia in any pregnancy.8, 55 In risk assessments done after 20 weeks’ gestation, attention should be paid to the possible onset of pre-eclampsia by identification of any of the following signs and symptoms: new hypertension, new proteinuria, symptoms of headache, visual disturbance, epigastric pain, vomiting, reduced fetal movements, and an infant that is small for gestational age.56 Such risk assessment before and after 20 weeks can be used in the community to offer referral for specialist input.

Table 2 Risk markers for pre-eclampsia at antenatal booking according to the PRE-eclampsia Community Guidelines (PRECOG8)

Next to history taking, physical examination including measurement of blood pressure and assessment for presence of proteinuria, are the cornerstones of screening in antenatal care. Blood pressure should be measured as for non-pregnancy, with the woman at rest, sitting upright, with the arm supported, and the sphygmomanometer cuff at the level of the patient’s heart.11 Korotkoff sound V (disappearance of turbulence) should be used to define diastolic blood pressure and values recorded to the nearest 2 mm Hg. Thigh cuffs (18×36 cm) should be used for women with an arm circumference of 41 cm or more.56 Of the automated blood pressure measuring devices on the market, only the Microlife 3BTO-A and Microlife WatchBP Home57 have met the British Hypertension Society’s criteria for accuracy. Mean arterial blood pressure might be a better predictor for pre-eclampsia than is systolic or diastolic blood pressure or an increase in blood pressure.58 Although dipstick testing for screening of proteinuria is prone to issues of intraobserver and interobserver variability and limited sensitivity and specificity,59 it is readily available, widely used, and might be the only test available in low-income and middle-income countries. Although 24 h urine collection is still used to confirm and quantify a substantial amount of proteinuria,56 this method seems vulnerable to issues of overcollection, undercollection, and large coefficients of variation between tests in the same women.60 The spot urinary protein-to-creatinine ratio, often used as a screening method,56 is less cumbersome than is 24 h urine collection, and is suggested to be an equivalently accurate measure of clinically significant proteinuria in pregnancy.61 Still to be established, however, is whether this ratio remains constant throughout a 24 h period.62

Prediction

Early prediction of pre-eclampsia would allow for close surveillance and preventive strategies. Many tests have been assessed for their relation to placental perfusion, vascular resistance, and placental products, including tests for Down’s serum screening analytes and hormones, renal and endothelial dysfunction, oxidative stress, and fetal-derived products. Of 27 tests reviewed by Meads and colleagues,63 only a few reached specificities above 90%. These were body-mass index of 34 kg/m2 or higher, α-fetoprotein, and bilateral uterine artery Doppler notching. Sensitivity of higher than 60% was achieved only by uterine artery Doppler resistance index and combinations of indices. Kallikreinuria (sensitivity >80% and specificity >90%) and cellular and total fibronectin (specificity >90%) seem worthy of further investigation. No single test, however, met the clinical standards for a predictive test—a conclusion also drawn by authors of another systematic review.64Because any single biomarker is unlikely to be effective in prediction of the onset of a disorder as heterogeneous as pre-eclampsia, researchers65 have suggested that combinations of tests such as ultrasound assessment of uterine artery Doppler waveforms, placental thickness and homogeneity, and serum markers raise the effectiveness of history and physical-based screening. Logistic regression analysis combining information on uterine artery pulsatility index, mean arterial pressure, serum pregnancy-associated plasma protein-A, serum-free placental growth factor, body-mass index, and presence of nulliparity or previous pre-eclampsia showed promising high sensitivity and specificity in prediction of early pre-eclampsia.66 Similarly, ratios of antiangiogenic and proangiogenic factors (eg, ratio of sFlt-1 to placental growth factor)67, 68 might have better discriminatory power than do other methods.69 However, whether or not these tests will also be useful across the range of placenta-related complications remains unknown.

Clinical presentation

Maternal organ systems that are susceptible to excessive inflammation and endothelial damage are the CNS, lungs, liver, kidneys, systemic vasculature, coagulation, and the heart—the placenta and fetus are also at risk. The more organ systems that are affected, the more maternal and perinatal complications arise. Clinicians should take caution not to undervalue clinical signs and symptoms in (severe) pre-eclampsia (table 1) because they can be non-specific (eg, nausea and vomiting). Caregivers should always remember that pre-eclampsia can potentially fulminate, and therefore they should not be given a false sense of security because mild disease has been designated. Some risks pertain to development of the HELLP syndrome of microangiopathic haemolysis and platelet consumption, and hepatocellular damage from periportal or focal parenchymal necrosis. Patients frequently (40—90%) have epigastric or right upper quadrant pain.70 These clinical symptoms, along with headache, visual changes, and nausea or vomiting seem to be more predictive than are laboratory parameters for adverse maternal outcomes.71

HELLP syndrome complicates 10—20% of cases of severe pre-eclampsia, and develops mostly preterm (50%). In 20% of women, however, it presents in late gestation, or in 30% post partum.72 HELLP without hypertension or proteinuria is reported in 10—20% of cases. Direct complications of HELLP syndrome are abruptio placentae (9—20%), disseminated intravascular coagulation (5—56%) and acute renal failure (7—36%). Less frequent complications are eclampsia (4—9%), pulmonary oedema (3—10%), and subcapsular liver haematoma (less than 2%).72 Estimates of complication rates can be quite high because they are derived mainly from tertiary care centres. Overall, significant maternal morbidity is encountered in about 15% of women with severe pre-eclampsia,73 including retinal detachment and cerebrovascular bleeding, and complications related to HELLP syndrome, but with lowered frequencies. The brain is at risk because of impaired cerebral autoregulation due to endothelial damage together with decreased sympathetic innervation in the posterior cerebral circulation, and a lessened ability for neurogenic response to increase blood pressure. Cortical blindness and some cases of eclampsia could evolve from the acute cerebral illness, posterior reversible leukoencephalopathy syndrome (PRES).74

Eclampsia, complicating 1—2% of severe pre-eclampsia,75 is defined as the occurrence of tonic-clonic seizures in a pregnant or recently delivered woman that cannot be attributed to other causes. Although difficult to predict, in 79% of cases promonitory signs and symptoms are present during the week before the first eclamptic seizure: headache (56%), visual disturbances (23%), epigastric pain (17%), hypertension (48%), proteinuria (46%), and concurrent hypertension and proteinuria (38%).76 Hypertension and proteinuria can last for several weeks post partum.77 Pre-eclampsia can also deteriorate or present de novo after delivery, occasionally evolving into severe forms that are similar to eclampsia.78 Women with symptoms and signs of pre-eclampsia might have other maternal diseases,79 and therefore differential diagnoses should be considered and excluded (panel 1). Perinatal concerns in women with pre-eclampsia relate to risks of placental abruption (0—6%), intrauterine growth restriction (5—18%), and perinatal mortality (0—9%), dependent on severity and gestational onset of disease.80

Management

For women with pre-eclampsia, dependent on severity, review at day assessment units or admission to hospital is indicated according to local guidelines.56Table 3 and panel 2 show our suggested management paradigms according to gestational age at presentation. Although we recognise that there is no universally accepted standard of care, which is dependent on local facilities, we believe that risk reduction for women with pre-eclampsia needs a series of strategies—namely standardised assessment and surveillance, avoidance and management of severe systolic and diastolic hypertension, prevention and treatment of seizures of eclampsia, and avoidance of use of aggressive rehydration in women admitted with severe pre-eclampsia. Although debate exists about routine use of some individual tests, standardised assessment and surveillance of all vulnerable organ systems in women with pre-eclampsia has been associated with reduced adverse maternal outcomes,86 and proposals for blood tests have been developed.56 Tests for uric acid is one of the controversial tests that has been suggested. Although researchers have suggested that uric acid is as important as proteinuria for identification of fetal risk in women with gestational hypertension,93 it is a poor predictor of maternal and fetal complications in women with pre-eclampsia.94 In a review,62 researchers concluded that the amount of proteinuria is not a good marker of severity of pre-eclampsia, and that this measure should not guide management.

Table 3 Antepartum management options for women with pre-eclampsia by gestational age at diagnosis.

NICU=neonatal intensive care unit.

For women who are remote from term (<34 weeks’ gestation), there is both randomised controlled trial and cohort-based evidence81 that expectant management (compared with stabilisation and delivery, which is the sole cure for pre-eclampsia) confers some perinatal benefit with a minimum amount of additional maternal risk. However, insufficient data are available for straightforward recommendations for either expectant or interventionist care,82 and policies could differ for women cared for in low-resource settings. For women who present before 24 weeks’ gestation, expectant management is unlikely to offer any perinatal advantages, although maternal risks accumulate.81, 83 Women at term with pre-eclampsia (and non-proteinuric gestational hypertension) are best managed by a policy of induction of labour.95 In the case of women with HELLP syndrome at or near term, expedited delivery should be standard management. Remote from term, clinicians could consider expectant management in some cases with vigilant expectancy, but no evidence exists to advise for which women such policy can be applied without substantial maternal risks.81, 82 Such practices should only be attempted in institutions with much experience in management of pre-eclampsia. Failure to exhibit due clinical care in combination with a policy of expectant management can prove lethal.96 Corticosteroids have not been shown to benefit primary maternal and perinatal outcomes in women with HELLP.72, 97, 98

The present Cochrane review99 does not support the choice of any one antihypertensive agent over another for management of severe pregnancy hypertension, concluding that the choice should depend on the clinician’s experience with a specific drug. It does, however, advise against use of diazoxide because, although more effective for reduction of blood pressure than is hydralazine,100 diazoxide might result in increased rates of maternal hypotension. Ketanserin seems to be less effective than is hydralazine. Neither magnesium sulphate (MgSO4) nor nimodipine are recommended as antihypertensive agents.99 In another systematic review,89 nifedipine (within the class of calcium-channel blockers) seemed to be more effective in bringing blood pressure within the target range, with less hypotension, than was hydralazine. By comparison, labetalol was less effective but was associated with fewer adverse maternal and perinatal events than was hydralazine.89 Nifedipine capsules (5 mg or 10 mg) are no longer available in all markets, and should not be used in women with known coronary artery disease, those who have had diabetes mellitus for more than 15 years, or those who are older than 45 years because of the risks of sudden cardiac death.101 Clinicians who choose the alternative of intermediate-acting nifedipine tablets should recognise the slow onset of action so that women are not over-treated because of an expectation of a rapid blood pressure response.102 Nifedipine and MgSO4 can be used together effectively and safely.103 Antihypertensives for use in women with non-severe hypertension, although generally not related to improved pregnancy outcome except for less severe hypertension,90, 104 are also shown in panel 2.

Prevention and management of eclampsia seizures is based on giving MgSO4.87, 88 Women with severe pre-eclampsia should be considered for MgSO4 prophylaxis.104 Findings from randomised controlled trials87, 88 support a regimen of MgSO4 given as a 4 g intravenous loading dose during a 15—20 min period, followed by an infusion of 1 g/h, with a first or recurrent seizure treated with another 2—4 g intravenous loading dose. This regimen does not need testing of blood concentrations of MgSO4 because clinical effect can be monitored with deep tendon reflexes. Additionally, it adds a wider therapeutic index between effect and toxicity risk than does the historical 2 g/h regimen. Despite a reduced intravascular volume in pre-eclampsia, plasma volume expansion has not proven to provide any benefit.91

Timing of delivery should be designed to keep perinatal outcomes at an optimum while obviating maternal risks. In pre-eclampsia, this timing should be based on criteria of fetal wellbeing and gains to be made in terms of perinatal outcomes by achievement of additional intrauterine time. Fetal wellbeing is assessed by ultrasound (biometry, umbilical artery Doppler, ductus venosus Doppler, and amniotic fluid) and cardiotocography (preferably computerised).105 Antenatal corticosteroids for fetal lung maturation should be given to all women at risk of delivery at less than 34 weeks of gestation.84 Previable fetuses can be delivered with misoprostol induction.85 In early-onset pre-eclampsia and often concurrent intrauterine growth restriction and placental pathology, the fetus is unlikely to tolerate labour. However, the closer the pregnancy gets to term, the more reasonable an attempt at induction of labour is for women with pre-eclampsia who require timely, but not emergency, delivery.

When women have severe disease, issues of peripartum management of thrombocytopenia and HELLP syndrome arise.11, 72 Although routine prophylactic platelet transfusions are not recommended, ordering blood products, including platelets, should be considered when platelet counts are fewer than 50×109 platelets per L, falling rapidly, or when coagulopathy is present. Platelet transfusion is always indicated before, during, or after either caesarean section or vaginal delivery when platelet counts are fewer than 20×109/L or in case of significant bleeding (eg, ecchymosis, bleeding from gums or wound).70 Preanaesthetic assessment of a woman with pre-eclampsia is essential, including an airway examination and assessment of coagulation status (such as platelet count). There is no role for tests of platelet function.9, 11, 106 Use of regional analgesia or anaesthesia, or both, is not contraindicated in women when platelet counts are higher than 75×109/L in the absence of a coagulopathy, falling platelet count, or concomitant use of either an antiplatelet agent (eg, aspirin) or anticoagulant (eg, heparin).

Regional anaesthesia (epidural, spinal, or combined spinal-epidural) is appropriate for women taking low-dose aspirin (without either coagulopathy or platelets <75×109/L), and those given low-molecular-weight heparin at least 12 h after a prophylactic dose or 24 h after a therapeutic dose.107 Early insertion of a spinal or epidural catheter for obstetric or anaesthetic indications should be considered (in the absence of contraindications) to reduce the need for general anaesthesia in case of caesarean section. A difficult airway due to pharyngolaryngeal oedema should always be anticipated. Intubation could increase risk of severe hypertension (and subsequent cerebral events) and aspiration. Measures should be taken to avoid a speed that compromises maternal safety, even in the presence of acute fetal compromise. Central venous access or pulmonary artery catheterisation should only be used for specific disorders (ie, pulmonary oedema and cardiac disease) in a high dependency setting. Ergot alkaloids should be omitted for active management of the third stage of labour if the mother is hypertensive.16

Preconception care and future health

Women at high risk for pre-eclampsia, including those with a history of the disease or other complications in their obstetric history, should be offered preconception care by obstetricians with experience in management of the disorder. If present, severity of chronic hypertension, diabetes, connective tissue, or renal disease should be assessed and pharmacological treatment adjusted for safety in pregnancy. Risks of occurrence and recurrence (10% for previous mild disease and up to 40% for severe disease) and perinatal mortality and morbidity should be explained and a management plan, available for all associated caretakers, should be drawn up. Obesity and an increase in body-mass index between pregnancies108 increases risk of (recurrent) pre-eclampsia,109 and partly neutralises the protective effect of smoking.52 Although preconception weight loss has not yet been properly investigated, studies after bariatric surgery suggest positive effects.110 Other risk factors (table 2), should also be discussed.

Nutritional preventive measures should not be advised for management of the occurrence or recurrence of pre-eclampsia in women at high risk or the general population. Neither diets low in energy or salt, nor supplementation with either antioxidants vitamins C or E, fish oil, garlic, zinc, selenium, folic acid, or magnesium are effective.63, 111, 112 An evidence-based review113 showed no relation between calcium supplementation and risk reduction of pre-eclampsia, although supplementation might have some effects in high-risk populations that are calcium-deficient. Low-dose aspirin prophylaxis has long been of interest because it is thought to correct an imbalance in the ratio of thromboxane A2 to prostacyclin that is associated with increased vasoreactivity. Findings from a meta-analysis114 of individual patients’ data from 31 randomised trials showed that asprin was associated with a 10% reduction in pre-eclampsia and prematurity (less than 34 weeks’ gestation), and that aspirin seemed to be safe. The number needed to treat to obtain these results was, however, very large. Low-dose aspirin should be offered on an individual basis and decisions made on the basis of the woman’s risk profile from their obstetric and medical history. Neither progesterone or diuretics nor antihypertensives in women with chronic hypertension reduce risk of pre-eclampsia.111 The damaging effects of smoking on general health and perinatal outcomes especially115 outweigh its incidence-lowering effects on pre-eclampsia.52

Inherited or acquired thrombophilias are a heterogeneous group of coagulation disorders that predispose women to an extra risk of thromboembolic events during pregnancy and puerperium.116 Although pre-eclampsia is related to reduced uteroplacental blood flow, its direct correlation with thrombophilia remains controversial. Placental thrombotic and inflammatory lesions associated with early-onset pre-eclampsia or fetal growth restriction do not arise more often in women with thrombophilia or hyperhomocysteinaemia than in those without these disorders.117 Meta-analyses118 often showed positive, though mostly weak, associations of thrombophilia with pre-eclampsia, although there were instances of heterogeneity between studies. Results from three large, prospectively designed studies119—121 showed no associations with any of the inherited thrombophilias for mild or severe pre-eclampsia. In small studies,122, 123 investigation of recurrence rates of pre-eclampsia in women with thrombophilias showed conflicting results. Associations with hyperhomocysteinaemia are often biased by delivery to test-time interval and maternal age.124 There are no completed trials to establish the effects of heparin on pregnancy outcomes for women with a thrombophilia.125 Therefore, in view of WHO criteria by Wilson and Jungner,126 routine screening of women who had pre-eclampsia and treatment when they were positive for thrombophilia does not yet seems justified, unless the intent is to randomly assign women in definitive randomised controlled trials. Thrombophilia testing, however, should be recommended for those with a personal or family history of thrombosis.127

Pre-eclampsia, especially of early onset, can be followed by symptoms of maternal post-traumatic stress.128, 129 Timely recognition of those women at risk and referral reduces the duration of treatment necessary.129 Women with pre-eclampsia are at increased risk for future cardiovascular disease. Pooled relative risks for hypertension, fatal and non-fatal ischaemic heart disease, and fatal and non-fatal stroke are 3·70 (95% CI 2·70—5·05), 2·26 (1·86—2·52), and 1·81 (1·45—2·27), respectively, 10—14 years after the index pregnancy.130 Early-onset disease and other additional concurrent placental pathology confer cumulative risk.131 Increased pre-pregnancy serum concentrations of triglycerides, cholesterol, LDL cholesterol, non-HDL cholesterol, and blood pressure are positively associated with risk of subsequent pre-eclampsia and could explain, together with abdominal obesity, the link with future cardiovascular disease.132, 133 Identification of such young women possibly offers opportunities for strategies to decrease remote cardiovascular risk.130 As the absolute risk for disease within 12 years is low (less than 0·5—1·5% dependent on pre-eclampsia severity)130 a first focus might be on lifestyle modifications, including smoking cessation, weight reduction, healthy diet, and exercise,134 in individualised intervention programmes, including use of the internet. Because the risk of developing chronic hypertension could be higher than 20%,130 blood pressure should be checked regularly. Other individual cardiovascular risk factors should be treated as indicated, but there seems to be no place for further screening or preventive drug interventions until further evidence is available. Pre-eclampsia has been suggested to predispose to reduced thyroid function in later years.135

Perspectives

Although genetic contributions to the risk of pre-eclampsia are recognised by familial clustering of this disorder, underlying mechanisms remain uncertain.136 Maternal constitutional and environmental risk factors for pre-eclampsia could be implicated by interference with the epigenetic programming of the gametes, placenta, and fetus.137 Derangements in genomic imprinting in placental tissue, resulting in disturbed paternal versus maternal gene expression, have additionally been suggested to contribute to pre-eclampsia.137, 138 Therefore, high priority will be given in the near future to elucidation of gene-gene and gene-environment interactions and underlying epigenetic mechanisms139 that are associated with the programming of trophoblast cells and how they relate to placental causes and systemic linkages of different phenotypes of pre-eclampsia. Such phenotypes include that for HELLP syndrome and other placental complications such as isolated intrauterine growth restriction. These insights could direct future specific preconception and early pregnancy preventive measures to favourably affect placentation in women at high risk. Such measures might also be targeted at decreasing excessive inflammatory and oxidative stress (eg, by statins or metformin) or improvement of endothelial health.

A lowered incidence of hypertensive disease in pregnancy was suggested after periconception low-dose aspirin treatment.140 Trophoblast complement inhibitory therapy with heparin might seem beneficial in some subgroups of patients.141 However, to be able to keep spiral artery remodelling at an optimum with prophylactic treatment, a need for more comparative research to understand the placental bed remains. Additionally, pharmacological approaches to counteract the anti-angiogenic state in the second stage of the disease could be promising. Epigenetic modification of fetal vascular tissue during a pregnancy that is complicated by pre-eclampsia might also relate to future reproductive status and cardiovascular health.137, 142 Men and women exposed to pre-eclampsia as a fetus,143 and women born small for gestational age,144 have an increased risk of having (or fathering) a future pregnancy that is complicated by pre-eclampsia. These children also have a heightened risk of high blood pressure, features of metabolic syndrome, and cardiovascular diseases at relative early age.145, 146

In preconception care, development of simple rules for prediction of recurrent early-onset hypertensive disease in pregnancy is important.147 During pregnancy, proteomics-based identification of clinically useful predictive biomarkers might become feasible.148, 149 Furthermore, development and validation of disease severity criteria that objectively identify women at incremental risk of adverse outcomes need to be developed. Randomised controlled trials are much needed to establish recommendations for management of early-onset severe pre-eclampsia. In the UK, substandard care contributes to 72% of maternal deaths that are related to hypertensive disease in pregnancy,16 and to 96% of those in the Netherlands.96 In the Dutch enquiry,96 no instructions about danger signs to women had been documented in 80% of cases. Therefore, patient education is of major importance. The need for drills and simulations for obstetric emergencies such as severe hypertension and eclampsia, and for audits of pre-eclampsia-related maternal mortality and severe morbidity should be further advocated.

Search strategy and selection criteria

We searched PubMed and the Cochrane Library with the search terms “pre-eclampsia” and “hypertension and pregnancy”, and cross-referenced them with the following terms: “epidemiology”, “definition”, “aetiology”, “pathophysiology”, “prediction”, “prevention”, “management”, “clinical trials”, “preconception care”, and “thrombophilia”. We mainly restricted our search to studies done in human beings. We largely selected publications from the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We also searched the reference lists of articles identified by this search strategy and selected those that we judged to be relevant. Review articles and book chapters are cited to provide readers with more details and references than this Seminar provides. Our reference list was modified on the basis of comments from peer reviewers.

Contributors

EAS designed the structure of the review and coordinated writing of the Seminar. All authors contributed to the literature search, writing of the Seminar, and addressing of reviewers’ comments.

Conflicts of interest

We declare that we have no conflicts of interest.

Acknowledgments

No funding was used for the preparation or submission of this report. We thank the PhD fellows Durk Berks, Meeke Hoedjes, Nienke Bergen, and Evelyne van Uitert for assisting in the literature search; Jolanda Claessens for her secretarial support; and Frits Wilbrink for his contribution to the graphics of the figure. Peter von Dadelszen receives funding support from WHO, the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, and the Child and Family Research Institute.

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The articles analysed the CRESCENDO trial on anti-obesity drug rimonabant, the long-term outcomes of aortic root replacement, and the effect of antiretroviral therapy on population viral load and yearly new HIV cases.

These articles were accompanied by comments on the abrupt halt of the CRESCENDO trial, the concept of a living heart valve, the effect of highly active antiretroviral therapy (HAART) on the HIV epidemic,  HIV and drug addiction in Mexico, the re-evaulation of HIV lexicon, the need for praziquantel in Africa and the loss of health workers to international bodies in poor countries.

The world reports discussed the work of the ESC to tackle congenital heart disease in poor countries and the effect of the Deepwater Horizon oil spill upon the mental health of those living on the US Gulf Coast.

The series concludes with part 7 on HIV in people who use drugs.

Floods in North-West Pakistan. Source: BBC ‘In Pictures’ 

The Pakistan floods have secured a place in the British national consciousness; the disaster has dominated news headlines for well over a week and London is plastered with appeals for aid. The death toll has now exceeded 1,500 and the total number of lives affected by the rising waters is estimated to be a staggering 13 million [1]. Simon Rogers observes that this is more than the combined total of the 2004 Indian Ocean tsunami, the 2005 Kashmir earthquake and the 2010 Haiti earthquake [2].  Meanwhile, the World Health Organisation is expressing grave concerns at reports of cholera in the Khyber Pakhtunkhwa province. ‘I have visited the scenes of many natural disasters, but nothing like this’ declared UN secretary General Ban Ki-moon upon his return from the disaster area last week [3].  

Yet despite widespread media coverage, the international response to the floods has been lukewarm. On Tuesday, UNICEF warned that a lack of funds had ‘seriously jeopardised its work in Pakistan’ and, short of half its target donations, the UN called a special session today in an attempt to boost financial aid [1, 4].

Many theories have been put forward to explain the sluggish response of the international community to the floods. These range from the political (is Zardari’s government competent to distribute funds? How do we know we aren’t funding Islamic extremism?) to the financial (we’re in a recession; can we afford to donate?) [5]. It is probable that both the effect of politics and the global downturn, among many other factors, have slowed the response to fundraising campaigns.

However, explanations must not serve as excuses. Millions and millions of people, twice the entire population of New York City by one twitterer’s account, have been made homeless. Waterborne diseases pose a serious threat to life and flood waters show no sign of abating. Instead of averting our eyes and mumbling ‘politically sensitive’ or ‘financially difficult’, we must encourage our governments to dig deep and give generously. It is, another twitterer observes, ironic that donors seem more generous when many are dead. If funds are withheld much longer, cholera will make short shrift of this final barrier.

1. UN. http://www.un.org/apps/news/story.asp?NewsID=35655&Cr=Pakistan&Cr1= (accessed 19.8.10)
2. Simon Rogers. The Guardian, 9^th August 2010 http://www.guardian.co.uk/news/datablog/2010/aug/09/pakistan-flood-aid (accessed 19th August 2010)
3. Ban Ki-moon. http://www.un.org/apps/news/story.asp?NewsID=35629&Cr=Pakistan&Cr1= (accessed 19th August 2010)
4. UNICEF http://www.unicef.org.uk/press/news_detail.asp?news_id=1563 (accessed 19th August 2010)
5. Ros Atkins. BBC World Service http://www.bbc.co.uk/blogs/worldhaveyoursay/2010/08/on_air_why_havent_we_given_mor.html (accessed 19th August 2010)

Improvements that will build upon past successes of such programs should include targeted curriculum focused on empowering men to become more involved in maternal and child health issues. Moreover, these programs would benefit from actively supporting and encouraging the positive roles men do fill within their communities. In doing so, international public health organizations would be able to more effectively utilize the familial and social resources within the communities that they serve.

The role of men within community-based Integrated Management of Childhood Illness (c-IMCI) programs throughout East Africa has traditionally been through their training as community health volunteers, as their status as community leaders has important influence on the success of these projects. A recent Lancet World Report on child health in Uganda reports on how expanding the role of men within these programs has positively influenced the c-IMCI underway in the Mbarara district [1]. By framing the roles that men play as resource gatekeepers in these communities and emphasizing how they could become more proactive in the area of maternal health, this project has successfully expanded its volunteer base and has encouraged many men to lead the way in areas of child health education and promotion. The importance of this direct partnership with men in the areas of child health became clear to me on a recent trip to Tanzania.

After finishing my first year of medical school, I spent the summer of 2009 working with a US-based public health NGO conducting a mid-term project evaluation of a USAID-funded c-IMCI program in the Karatu district of Northwest Tanzania. My time there brought me into the lives of many families and gave me a brief, but broad, perspective on the various social, cultural, and economic factors that have both positively and negatively influenced the impact of the health education initiatives of this c-IMCI project. One experience, in particular, emphasized the emerging need for international public health agencies to become more proactive in engaging men within the area of maternal health.

After a day of interviews in the small farming village of Rhotia, a few dozen miles east of Karatu, we agreed to squeeze in the eldest of the midwives into our land cruiser and give her a lift into town. On our way home, she told us a story of a recent, and in her view, potentially avoidable disaster. A few weeks prior to our visit, she had been working with a young first time mother-to-be as she prepared for delivery. The midwives in this village serve as support during the delivery and liaisons between local health facilities. When the day came for this young mother to deliver the midwives helped prepared her house for the arrival of the new baby and took care of the mother after her water broke. At this first sign of delivery, the young husband was so unsettled that he quickly gathered his up his cell phone and money and fled, leaving the women stranded. Without the phone they couldn’t coordinate a car to pick them up to take them to health facility, without the money they couldn’t pay for the car, and without him, she emphasized, they couldn’t experience this important event in their lives together as a family. Fortunately, the midwives delivered the baby safety at home. The lesson, she wanted to impress upon us, was that it was time that we start teaching fathers about child delivery and supporting them in becoming more involved in this process.

Similar stories of injustice and societal complications were narrated by my friend, a fellow public health student who recently worked with a women’s group on a mosquito net distribution program in the Masaka district of Uganda. All of these issues are leaving lasting negative impact on child health. There is an opportunity for western-based NGOs implementing the Maternal and Child Health (MCH) and c-IMCI in these regions to rethink how they are integrating men into their programming to improve health outcomes.

The evidence exists to support the involvement of men in MCH programming. In Tanzania, a study found that pregnant women were more likely to deliver in a healthcare facility if both partners were involved in the decision-making process of the delivery location [2]. In Uganda, a UNFPA led program focused on including male elders in the decision making-process was able to reduce female genital cutting by roughly 35% [3]. New doors of opportunity could open for men to expand their responsibilities within the healthcare of their children, as has already been found to be working in Haiti and Kenya in areas such as breastfeeding and neonatal care [4,5].

The acceptance and response of integrating these gender-inclusive training programs will certainly vary from region to region depending on cultural differences and educational resource availability. These successful programs noted above demonstrate the balance between preserving the sensitive culture-specific gender dynamic while focusing on making changes to improve the health of young women and children through education-base interventions. With knowledge comes responsibility. The education and involvement of men in MCH issues may consequently increase the call for men to become more specifically invested in the health of mothers and infants.

The idea of involving men in MCH issues is not new. In 1994, the International Conference on Population and Development in Cairo, men were beginning to be included in the conversation surrounding reproductive health [6]. A snowballing effect has occurred since, and now there are a number of organizations and programs that highlight the need to include men in the area of MHC.

A global alliance of NGOs and UN agencies emerged over the past decade to promote the role of men in gender equality and women’s health. These organizations include: the International Center for Research on Women, International Planned Parenthood Federation, WHO, UNFPA, UNDP. Moreover, many useful web-based resources such as EngenderHealth.org and MenEngage.org have been created to outline actionable strategies that organizations can adopt to expand their current programs. The formation of MenEngage.org has made it clear that there is a growing call for the inclusion of men and fathers in MCH issues. Taking advantage of these resources and proven models will be essential for future MCH programming throughout the world.

Beyond improving safe delivery and rearing practices, such programming can empower men in other important and new ways. When interviewed about his experience with one such program in northwest Tanzania one husband’s response was:

“What I have appreciated most is accompanying my wife to the health centre for her antenatal clinic visits. That way, I will know if she has complications, and I can budget in advance to take her to a bigger hospital. I never went with my wife to the antenatal clinic when she was pregnant with our other children. I think I missed out. But in the past, men were not allowed. Now, if you go with your wife, the clinic staff treat you like someone important.”

Joseph, age 42, a resident of northwestern Tanzania’s Geita District [5]

In East Africa and across the globe, there is an opportunity to start recognizing men as partners in the health of women and children. This need is slowly being addressed in pockets of East Africa; perhaps the most recently successful is an on-going USAID-supported breastfeeding campaign started in 2009 in Western Kenya that has encouraged men to support their wives as they breastfeed [6]. By reshaping MCH programming with the aid of such successful models and available resources, we may hope to include more men like Joseph in MCH interventions. This will consequently facilitate a greater and more widespread dissemination of information and skills. To continue improving the health and wellbeing of the women and children who benefit from MCH and c-IMCI project we need to begin integrating creative and meaningful ways that engage both parents in a manner that empowers women and men to work together on the shared goal of improving the health of the next generation.

Ben Pederson* & Tyler Weber T.W.

University of Minnesota School of Public Health, MPH2; B.P. University of Minnesota School of Medicine, MS2. *corresponding author: ben.pederson(a)gmail.com

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6. Earth Negotiations Bulletin [homepage on the internet]. Cairo: Proceedings of the International Conference on Population and Development; 1994 [cited 2010 Apr 10]. Reproductive Rights and Reproductive Health; [one screen]. Available from: http://www.iisd.ca/vol06/0639016e.html.

7. United Nations Population Fund. UNFPA at Work: Six Human Rights Case Studies. New York, NY; United Nations Population Fund; 2008.

In today’s blog, Clare Logan, a student from the Liverpool School of Tropical Medicine, writes about her experiences of  maternal health care in post-conflict reconstruction in Liberia at one of the 81 medical facilities supported by Merlin. Accompanying the blog is this week’s TLS challenge by Anil Joshi.

Two tiny clenched fists punch the air as the little baby boy wriggles on the set of scales. Merlin-trained midwife Florence Davis adjusts the settings. 3.2kg – a decent size for a newborn. His mother lies on the bed exhausted, relieved that the seven hours she has spent in labour are over. This is the third delivery Florence has attended today at the Martha Tubman Memorial Hospital in Zwedru, south-eastern Liberia, resulting in three healthy mothers and three very bonny babies. Sadly, as the day unfolds it becomes clear that this isn’t always the outcome of every birth here Midwives saving lives A mother is rushed onto the ward in a critical condition. She has been in labour at home alone for the past two days. Her uterus has ruptured causing severe internal bleeding. With only very basic equipment and drugs to hand, Florence and Relda Kollie, the other midwife on call, work quickly to assess and stabilise the mother, and arrange life-saving surgery. As a result of the expertise of the obstetric team, the mother survives but sadly, she had arrived too late to save the baby. “Managing lots of emergency cases is one of the biggest challenges we face as midwives in Liberia,” notes Florence. “Many people deliver at home so we see a lot of complications that present themselves very late.”

Merlin is training and supporting midwives in Liberia, to ensure long-term reductions in maternal deaths. The training provides a skill set that can be passed on to generations of midwives who will continue to deliver hope to many more mothers and their families. Staggeringly, in Liberia the chance of a woman dying during childbirth is one in eight. The dire consequence of each of these deaths is far reaching: affective newborn survival, the well-being of children left behind, the social fabric of the community, and the economic and development potential of Liberia as a whole. 

There is no need for scientists to scratch their heads in search of solutions. We already know what works. Almost all maternal deaths would be avoided if women are able to deliver into the safe hands of a skilled birth attendant, who could ensure appropriate emergency obstetric care is provided on time if a complication occurs. Merlin’s Midwife Training Coordinator in Liberia, Mama Zeena, says: “If a mother has access to a trained midwife, a mother should not have to die.” There are thousands of health workers like Florence, Relda Kollie and Mama Zeena in crisis countries around the world, making a huge difference. Merlin’s Hands Up For Health Workers campaign is calling for these health workers to be paid, supported, trained and equipped. Without this investment, the health MDGs simply will not be met and people will continue to die needlessly; more than a third of mothers who die in childbirth live in a country that’s either mired in, or emerging from, conflict.

Our campaign calls for effective and resourced national health work force plans and for greater efficiency with current aid allocations. We want 10,000 people  to add their name to our petition we’re taking to world leaders this September, demanding just this. If we shout loud enough they will listen so please raise your hand for a health worker and join our campaign for change.

Clare Logan

Liverpool School of Tropical Medicine

Click here to add your name to the Hands up for Health Workers petition and here for more information about Merlin’s work.

Here are his answers:

1. Why did you decide to study medicine?

At school I studied a combination of both arts and sciences and I viewed medicine as encompassing both. Along with science there was sociology, ethics, philosophy, history, language and many  more. Furthermore the fact that this lead into a career where everyday will present with new challenge really attracted me! A medical career for me was more than a single subject which stays in the workplace. It was applied knowledge and skills which you can use globally for the rest of your life.

2. Can you share some things that you wish that someone had told you before you applied to study medicine?

I was actually quite well informed before I applied and not much came as a surprise to me. Which emphasises the point of researching the course, the city, the university, the career choice and the job itself very well before applying. Work experience is invaluable. Make sure you speak to doctors of all levels to know what to expect and then decide if its for you or not. You really need to be fully dedicated as it’s a massive life choice to study medicine, and well worth it.

3. What profession would you be in if you weren’t in medicine?

I always enjoyed learning new languages and can speak French and Gujarati, so I would have tried for a career utilising this skill. This would have also given me the prospect of travelling as well. Fortunately, medicine still gives me the opportunity to use my language skills and travel which is an added bonus, so I’m happy!

4. What is your biggest motivation?

The variety. Everyday is not the same, from psychiatry to orthopaedic surgery. The patients you see, their families, the pathology you witness, the different hospitals, and the different doctors who teach you are always changing. Also there are so many opportunities to do whatever interests you outside the scope of the curriculum, such as research and option modules. This way if you’re anything like me who cannot decide when there is so much choice, you can try things out and see how you feel.

5. What are you most interested in so far and why?

Since the beginning I have always been fascinated by the heart, and subsequently all my option modules have been based around cardiology. The doctors we work with on our placements tend to be our role models and we often associate our own characters with theirs. I associated mine with cardiologists and consequently really enjoyed working with them

6. What has been your most difficult module so far and why?

I found paediatrics the most challenging module. Although fascinating, there were a lot of things to learn, and it proved difficult to revise it in such a small time. It was the whole of medicine again but for children under 16 to 30 weeks premature babies. Furthermore it was emotionally difficult with the amount of child abuse witnessed in the hospital in which I was based. Nevertheless I really enjoyed the module and added social aspect of it.

7. What is the most memorable positive moment in your medical studies so far?

My elective in East Timor allowed me to work in an environment where not all the usual medical resources were accessible. It was a turning point in my academia, which obliged me to focus on my patient histories, improve clinical decision making, and develop my skills in diagnosing and formulating a management plan in all specialities. I feel a lot more confident for my fast approaching final exams, and my foundation years thereafter.

8. What is the worst horror story in your medical studies to date?

I was doing my first ever delivery on my obstetric placement, after waiting so long to do one. As the baby’s head came out, his shoulders got stuck and it turned out to be shoulder dystocia. I was holding a blue head in my hands, midwife panicking and alarms screaming which caused about 10 people to rush in order to help save the baby and mother. Luckily we got the baby out in time by performing the McRobert’s manoeuvre on the mother. Everyone lived happily ever after but it was a moment of fear and panic I will never forget it.

9. Where do you see yourself in 10 years time?

a. Wishful thinking version: I’d like to be working abroad in a developing setting or as a humanitarian doctor.

b. Perhaps slightly more realistic version: I know it’s not the easiest thing to do but I’ll try my hardest to get there and I hope I do! There is no easy route for anything in medicine; it’s just a matter of trying your hardest. I believe if you want something enough, you will get it.

10. Can you share some tips/advice for others

a. Wanting to study medicine: As well as being a part of  medical school you will also be part of a larger university with a whole array of extracurricular activities. If you are not already, make sure you get involved in something outside medicine and academia.This will give you means to relax at times and will prevent you from cracking under the pressure as the course can be really demanding at first.

If you haven’t applied to med school yet then being involved in extracurricular activities often works in favour of your application. Don’t forget the prospect of a gap year too, contrary to belief, it’s not frowned upon  and is even commended. It gives you enough time to mature and prepare yourself before starting the 5 year course. To study medicine is a massive choice and a life changing one, so make sure you’re certain and mentally prepared.

b. Already studying medicine: Intercalating is a great idea. As well as developing your interest in a particular area, it gives you a midpoint in your medical studies. Personally, I changed city for a year after my 2nd year and this turned out to be a great personal and professional experience. It will give a more rounded approach to the rest of the course. Personally, I was more focused after.

Anil Joshi
mda05aj@sheffield.ac.uk

Floods due to the monsoon rains persists in Pakistan for over a week now, being the largest and most widespread in the recorded history of the region. The extent of the damage caused is enormous. Entire towns have been literally swept away by the floodwater. UN has categorized this flood as more destructive than the tsunami, with an estimated 1.5 million people affected and over 2000 lives lost. Families who were airlifted to the camps are just left with their lives and the clothes on their backs, as their homes and livelihood are no more.

Refugees are brought to medical camps with a wide range of diseases. Injuries caused by floating rubble and snakebites are two medical emergencies that are treated immediately. Most of the other IDPs (internally displaced persons), especially children, are diagnosed with cholera and gastroenteritis for which ORS, antibiotics and antiprotozoal drips are administered. This is due to the complete corruption of the potable water supplies. Many who arrive at the camps, especially at later days, have not had much to eat or drink and so suffer from various degrees of starvation too.
Due to the relatively congested conditions of medical camps and lack of ample resources for the affected, spread of diseases such as malaria and the hepatitis is inevitable, both of which are already an endemic to the locality. The prognosis to these outbreaks is even poorer, since a majority of the patients can not afforded the costs of treatment. Psychiatric conditions are also bound to appear – many families have wiped out, and many more lost their siblings, parents and children to the floods.

Medical conditions are expected to persist even after the catastrophe settles down. Outbreaks of hepatitis and tuberculosis are unlikely to fall to normal levels. Mental health would be affected for a lifetime. Finally, malnutrition and other such conditions would spread as large number of people have now fallen below the poverty line.

The source of all this floodwater was the annual monsoon rains. Nevertheless, monsoon occurs every year, with a much less significant damage – in fact monsoon is celebrated by farmers each year as rainwater is used by crops. The rains this year, however, were of an increased intensity and continued for a much longer duration. And, this is not the only catastrophic flood that has occurred recently. Many places around the world are being hit by natural disasters. As environmentalists predicted, the initial effects of global warming have made an appearance. In Pakistan, the harsher and more erratic climate has now exceeded the yearly capacity to develop and implement preventive technology. How much longer before this gets common?

Ahmad Jawad
ahmadjawadmufti(a)gmail.com

The BMC has a developing oncology department, which was founded just eight months ago with the arrival of a Tanzanian oncologist, who had just finished his specialist training in Italy. A placement at Bugando enabled me to see the reality of oncological care in Tanzania, whilst also providing an opportunity to experience other medical and surgical specialities in one of Tanzania’s largest hospitals, serving a population of over 10-million people [2]. I spent three weeks at the BMC, spending time in the oncology department whenever possible. I spent a further week on placement in a small village in the North of Tanzania, called Bukumbi, which was a stark contrast to my time in Bugando.

The structure of the healthcare system in Tanzania is entirely different from that of the United Kingdom. Healthcare is provided by a variety of government, private not-for-profit organisations (e.g. mission hospitals), private for-profit organisations (including traditional healers) and company services [3]. The majority of facilities in the health sector are provided by the government, and Tanzania is one of the leading countries in sub-Saharan Africa with regard to healthcare provision [3]. However, the health sector is pitifully under-resourced, and basic requirements such as a regular supply of drugs at all government establishments remains a problem [1]. The structure of health services is as follows:

– Village Health Service – each village assigns two village health workers, who are subsequently given a short training brief before providing services- Dispensary Services – each dispensary caters for between 6,000-10,000 people, and supervises all the village health posts- Health Centre Services – are expected to cater for 50, 000 people- District Hospitals – each district is supposed to have one of these. Many are provided by religious organisations who designate voluntary hospitals

- Regional Hospitals – offer similar services to those offered at a district level, but may have specialists in various fields

- Referral/Consultant Hospitals – there are currently only four of these in Tanzania. One of these is the Bugando Medical Centre

This pyramid structure of healthcare provision does not take into account the role of the traditional healer, an aspect of the healthcare in Tanzania that I found particularly memorable. Whilst placed at both the BMC and Bukumbi Hospital, I experienceed first-hand the ‘failures’ of the traditional healers. One particular case that a colleague of mine observed was that of a young boy who attended Bugando with his father. The child had just been diagnosed with Burkitt’s lymphoma, and had clearly evident ascitic swelling of his abdomen. Confusingly, the child also had a sizeable scar on his abdomen, apparently from a relatively recent burn. It later transpired that the boy had been taken to see a healer, who had attempted to burn the cancer out of him. I found it very hard to understand the reasoning behind this encounter, and it made all too clear to me the dangers associated with the strong culture of traditional medicine. While at Bukumbi, I was given the chance to visit the local traditional healer. This was an invaluable experience for me, and as I set aside my own personal views and pre-conceived ideas, I was able to gain some understanding into the local beliefs and traditions.

Whilst on placement, I was determined to discover what oncology in the developing World was really like. Having experienced cancer care at home, I couldn’t imagine how patients could cope without the support that we are so fortunate to be provided with in the UK.

Cancer is a leading killer worldwide, accounting for approximately one in every eight deaths [4]. According to the World Health Organisation (WHO), people in low-income countries tend to develop chronic diseases such as cancer ‘at younger ages, suffer longer – often with preventable complications – and die sooner than those in high-income countries’ [4]. The WHO states that ‘a well-conceived, well-managed national cancer control programme lowers cancer incidence and improves the life of cancer patients, no matter what resource constraints a country faces’ [5]. My time in Tanzania has highlighted to me that even working within a budget as small as that of the BMC there are improvements to be made in order to tackle the problem head-on. An example is the provision of training facilities within Tanzania itself. There are no oncological training facilities within Tanzania [6], and any doctors wishing to practice in the field of oncology must study abroad. This often poses its own difficulties, and staff may return to Tanzania to find that what they have spent time learning abroad is in many ways irrelevant to life in Tanzania [6].

Twalib Ngoma is one name with an extremely strong link to cancer care in Tanzania [6]. As a medical student with a keen interest in oncology, Ngoma pioneered the establishment of the Ocean Road Cancer Institute (ORCI) in Dar-es-Salaam in 1996 [6]. Ngoma found that ‘the priority rating for cancer was low’ [6], yet has managed to develop provision for cancer sufferers in Tanzania, with plans to open four more cancer centres in the next decade [6].

Presently, there are only a small handful of population-based cancer registries in Africa, covering little over 11% of the total population [7]anzania itself lacks a population-based cancer registry [8] and therefore it is very difficult to estimate the total burden of the disease in the country as a whole. It is currently estimated that the incidence of cancer in Tanzania is 70 per 100,000 of the population [8] though I believe this to be an underestimate.

Evidently, healthcare in Tanzania is run to a low budget, which goes a long way to account for much of the variation, for example, lack of histopathology departments and availability of chemotherapy agents, particularly second-line drugs. However, many of the differences I found are due to the different organisation of UK and Tanzanian cancer provision. For example, the multidisciplinary team (MDT) forms the foundation of healthcare provision in the U.K., perhaps in the oncology setting more than most. In Tanzania it seems that although various health professionals work alongside each other, they don’t work to support each other. I attended a screening clinic at Bugando, and after being overjoyed to find a screening clinic up and running, I was saddened to see the lack of people attending. I spoke to the oncologist at length about why the clinic was so quiet, and he informed me that in his opinion education has the biggest role to play in the process of making people more health aware. This is supported by a recent paper published in the East African Journal of Public Health, which found that although about 80% of the patients attending the ORCI had received some formal education, less than half had even heard about cancer as a disease [8].

Something that became all too familiar to me during my time in Tanzania was the presentation of patients with extremely advanced disease. In the same study mentioned above, nearly 45% of the patients at the ORCI felt stigmatised about their disease [8], which was a significant factor in preventing patients from consulting. Another reason for patients presenting late in their disease was the use of a herbalist or traditional healer, which over 30% of patients admitted to doing before attending hospital, and 4% of patients thought their problems were due to charms [8]. Once again, the problem of traditional medicine is brought to focus.

Furthermore, despite being highly curable with relatively simple, inexpensive regimens if diagnosed early, paediatric cancers are among the most dismal in terms of overall survival [9]. Postulated figures for 5-year survival among children in Tanzania is in the region of 5-10% [9]. There are no formally trained paediatric oncologists in Tanzania, and there is typically no expertise in the histological diagnosis of paediatric malignancies, with delays of up to one month for pathology reports across Tanzania [9].

Having painted a somewhat bleak picture, I want to present a few cases that show evidence of the strength of a handful of healthcare workers, who are determinedly working together to provide care for cancer sufferers. One particular case which stands out for me, is that of a 7 year-old boy with Burkitt’s lymphoma. I met this patient on the male oncology ward, just as the nurse was preparing the chemotherapy. As she came onto the ward, the boys all leapt into their own beds, and this one child sat waiting to receive his toxic drugs. The nurse connected his cannula to an infusion of cyclophosphamide and left, there was no conversation between the two. I was so saddened to think of this poor child going through the process alone. I was reflecting on the times I have spent at home in the chemotherapy department, and the support that the patients received at such a difficult time. I found it very hard to comprehend such a small child going through the treatment alone, and I tried to find ways to keep him amused. The experience was definitely a sad one, but in many ways this child was lucky to be one of a distressing minority actually accessing the healthcare he required. When I asked the oncologist whether the boys were allowed to go home between chemotherapy cycles, he answered no. He explained to me that if he let the parents take the child home, it would almost certainly result in them not returning for the next treatment. I was relieved to see someone taking responsibility for the children’s welfare.

There are so many interesting and thought-provoking cases and experiences that I could write about, but I will finish this report with the case of a 70 year-old male, who presented with an extremely advanced carcinoma of the eyelid. The lesion was at least the size of a small mango. The first time I saw this gentleman, the lesion had been biopsied and was bandaged. The overall opinion was that there was no further treatment that could be provided for him at Bugando, and he was to be discharged. It was later decided that if he was able to receive some radiotherapy, the lesion may be amenable to surgical removal. However, radiotherapy is not available at Bugando, and the patient could not afford to make the journey to the ORCI in Dar-es-Salaam. I thought that this would be the end of the case. However, over a week later, another medical student from Hong-Kong who I had met in Tanzania informed me that the patient had been transferred to the ORCI to receive his treatment. Apparently, the oncologist at Bugando had paid for the patient’s care with his own wages. I understand that this is not a sustainable solution to the problem, but it certainly reinforced my belief that the makings of a dedicated oncology team in Tanzania are present, and it is only a matter of time before cancer care in Tanzania becomes recognised as one of the major specialities.

Charlotte Brown
Fifth Year Medical Student, University Of Birmingham
CVB617(a)bham.ac.uk

References

1. Tanzania national website; Health [online]. Available at http://www.tanzania.go.tz/health.html. Accessed on 08.07.10
2. The directfund foundation [online]. Available at http://www.directfund.org/. Accessed on 08.07.10
3. Shiner A. Shaping healthcare in Tanzania – who’s pulling the strings? The Lancet 2003; 362: 829-830
4. Global cancer facts and figures 2007; American Cancer Society [online]. Available at http://www.cancer.org/acs/groups/content/@nho/documents/document/globalfactsandfigures2007rev2p.pdf. Accessed on 09.07.10
5. World Health Organisation; National Cancer Control Programmes [online]. Available at http://www.who.int/cancer/nccp/en/. Accessed on 09.07.10
6. Shetty P. Twalib Ngoma: Creating cancer care in Tanzania. The Lancet 2008; 371: 1657
7. Louie K.S., Sanjose S et al. Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review. Tropical Medicine and International Health 2009; 14:1287-1302
8. Kazaura R, Kombe D et al. Health seeking behaviour among cancer patients attending Ocean Road Cancer Institute, Tanzania. East African Journal of Public Health 2007; 4:1
9. Ribeiro R.C., Steliarova-Foucher E et al. Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My Child Matters support: a descriptive study. The Lancet 2008; 9:721

The emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK has sparked new fear in the threat posed by microbial strains unaffected by chemotherapy [1]. The enzyme New Delhi Metallo-beta-lactamase 1 (NDM-1) was isolated primarily among gram-negative bacteria Escherichia coli and Klebsiella pneumoniae, responsible for urinary tract infections, pneumonia and, in certain cases, blood-stream infections. Worryingly, most isolates were from community-acquired infections, indicating that the gene encoding the enzyme NDM-1 is prevalent in the environment.

The evidence, published in The Lancet Infectious Diseases, indicates that NDM-1 confers resistance to one of the most potent classes of antibiotics: the carbapenems. With genes encoded on mobile plasmids capable of transmission among bacterial populations, NDM-1-containing bacteria were highly resistant to several classes of antibiotics, with the exception of tigecycline and colistin. There are currently few antibiotics available to treat carbapenem-resistant strains.
Of the 37 patients with NDM-1 positive isolates in the UK, 17 (46%) had visited India or Pakistan within the last year and 14 of these patients (82%) were admitted to hospital in one of these countries for a variety of reasons. However the Indian Ministry of Health and Family Welfare has strongly rejected claims by the scientists that India is the source of infections in the UK [2]. Officials also rejected “the naming of the enzyme as New Delhi Metallo-beta-lactamase 1”, citing the incident as a conspiracy damaging the country’s growing medical tourism industry. It is not the first time that governments have publicly denounced scientific findings. In 2009, for instance, the Mexican government condemned naming the H1N1 Influenza A virus as “Mexican Flu” [3], now commonly referred to as “Swine Flu”.

Resistance to conventional antibiotics is not a new phenomenon. Multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB) have become a public health emergency of growing urgency worldwide and since the definition of XDR-TB was agreed in 2006, 58 countries have reported at least one case [4]. The WHO has described XDR-TB as “virtually untreatable” and resistance threatens to resurrect the pre-antibiotic era [5].

With drug development pipelines drying up, and unprecedented levels of travel and globalisation, the threat of spreading NDM-1 is concerning. Strong leadership and concerted action by healthcare workers worldwide will be crucial for infection control, at a time when infectious disease transmission has truly become a global issue.

Joseph Fitchett
joseph.fitchett06(a)imperial.ac.uk

References

[1] Kumarasamy KK, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. The Lancet Infectious Diseases 2010; doi:10.1016/S1473-3099(10)70168-7

[2] Pandey G. India rejects UK scientists’ ‘superbug’ claim. BBC News, [online] 12 August 2010. Available from: [http://www.bbc.co.uk/news/world-south-asia-10954890]. Accessed 12 August 2010.

[3] Pilkington E. What’s in a name? Governments debate ‘swine flu’ versus ‘Mexican flu’. The Guardian, [online] 28 April 2009. Available from: [http://www.guardian.co.uk/world/2009/apr/28/mexican-swine-flu-pork-name]. Accessed 12 August 2010.

[4] World Health Organisation. Multidrug and Extensively Drug-Resistant Tuberculosis: 2010 Global Report on Surveillance and Response. Geneva: WHO, 2010. Available from [http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf]. Accessed 12 August 2010.

[5] Chan ED, Iseman MD. Multidrug-resistant and extensively drug-resistant tuberculosis: a review. Current Opinion in Infectious Diseases 2008; 21:587-595

Much hue and cry has been created over the discovery of the NDM1 antibiotic resistant gram-negative bacterial species after an article was published in the latest issue of The Lancet Infectious Disease [1]. Lately gram-negative bacterial resistance had been a cause of more concern than gram-positive infections; and the discovery of the NDM-1 has finally ‘pulled the plug’.

The introduction of NDM-1 has been so worrisome to the UK that it prompted the release of a ‘National Resistance Alert 3’ notice by the Department of Health on the advice of the Health Protection Agency [2]. It is being called the ‘Superbug’ with the potential to be a worldwide hazard. Reuters reports that, “A new superbug from India could spread around the world — in part because of medical tourism — and scientists say there are almost no drugs to treat it.” [3]

NDM-1 is actually a new gene called the New Delhi-beta-metalolactamase, which is resistant to multiple antibiotics including the carpenepenems that are the usual class of drugs used in treating resistant bacterial infections. The gene is transferred from one bacterium to the other by means of a ‘plasmid’.
In the study pioneered by Walsh et al, samples were collected from hospital patients in two places in India, Chennai and Haryana, and from patients referred to Britain’s national reference laboratory from 2007 to 2009. They found 44 NDM-1-positive bacteria in Chennai, 26 in Haryana, 37 in Britain, and 73 in other sites in Bangladesh, India and Pakistan [1].

Antibiotic resistance is fairly common worldwide and several nosocomial as well as community acquired drug resistant strains are well known. Why the new NDM-1 is creating such havoc is because it is predicted that NDM-1 could be fatal because of the failure of usual antibiotics to treat the infection. It has been found to be susceptible to only tigecycline and colistin [1].

Scientists are comparing the severity of infection to that caused by MRSA (methycillin resistant Staphylococcus aureus) and VRSA (vancomycin resistant Staphylococcus aureus) which are greatly feared in hospitalized as well as community-based gram positive bacterial infections due to the same reason – lack of easily available antibiotics to fight the bacteria and its high virulence.

Many of the UK NDM-1 positive patients had travelled to India or Pakistan within the past year, or had links with these countries [1]. U.S. Health officials said on Wednesday that there had been three cases so far in the United States – all from patients who received recent medical care in India, a country where people often travel in search of affordable healthcare [3].

This puts India and Pakistan in an evidently grim situation. In the recent years ‘medical tourism’ has been a booming industry in these countries because of low cost of treatment while getting the same professional expertise. The cost of surgery is only about 10% of that in the European countries and people are increasingly using this lucrative option especially for cosmetic surgery. After the recent report and the public health announcements in UK and USA, this industry is in for a massive lowdown that may take substantial time to recover.

The Indian government and the Indian Council of Medical Research have dismissed the report suggesting that the study could be a conspiracy to malign the Indian medical tourism industry. “Such infections can flow in from any part of the world. It’s unfair to say it originated from India,” said ICMR director Dr VM Katoch [4].

But reputed Indian physicians realize that the multi-centric study, published in a journal of very high repute and with adequate declaration of conflicting interests cannot be ignored or falsified and steps to need to be taken to bring the situation under control. By the ICMR director’s own admission, India cannot scientifically fight back allegations of being the source of such superbugs, as the country does not have a registry of such hospital-acquired infections [4].

In an interview with popular TV anchor Prannoy Roy, Dr Naresh Trehan, CMD of Medanta- Medicity (which happens to be one of the best hospitals in India in recent times) has expressed his disappointment at the naming of the bacteria after the capital city of ‘New Delhi’. In a valid and fierce statement he states that it is very insulting and when the HIV virus was found in the United States it was not named ‘HIV-USA1’ so why the name NDM-1 [5].

Thus while the world is fighting over the superbug and its name, the need of the hour is to have strict antibiotic and hospital infection control policies so that never again does a bacteria succeed in threatening the existence of humankind.

Gurmeen Kaur
kaur.gurmeen(a)gmail.com

References

1. The Lancet Infectious Diseases, Early Online Publication, 11 August 2010 doi:10.1016/S1473-3099(10)70143-2

2. HPA. Health protection report. London: Health Protection Agency, 200

3. http://www.reuters.com/article/idUSTRE67A0YU20100811

4. http://timesofindia.indiatimes.com/india/Drug-resistant-superbug-traced-to-India/articleshow/6295662.cms#ixzz0wflacME2

5. http://profit.ndtv.com/video/show/147732/page/3?schedules=twentyfourseven

Fractured health care

Disparities in health care availability, access and quality are entrenched internationally between developed and developing nations as well as within countries, both between urban and rural regions and affluent and poorer areas. Thus from the outset of life, in terms of health outcomes, where you live matters. In London, a baby born today would expect to survive to the grand old age of 80. Compare this to Malawi, one of the poorest nations in the world, where the average life expectancy at birth is just 50 years [2].

The distorted allocation of human capital to deliver heath care services is one situation which fuels these gross inequities in health outcomes. Malawi has a huge deficit in health care professionals, with less than one doctor per 10,000 citizens [3]. Despite the fact that only 18% of the population reside in urban areas [4], a disproportionate number of doctors work at central referral hospitals in these regions. Consequently, some district hospitals serving rural populations do not employ a single doctor. This leaves medical assistants, nurses and clinical officers (akin to specialist nurse practitioners in the UK) to provide the medical care [5].

This fractured state of heath provision in Malawi is further exacerbated due to acute shortages of specialists in many areas within the medical profession itself. This includes orthopaedic surgeons of which there are only nine to serve the entire population [6]. With the huge focus on communicable diseases such as HIV/AIDS in the developing world, it is easy to forget the significant contribution of musculoskeletal conditions to morbidity and mortality in these countries. Although this burden is not well documented in Malawi, the fact that motor vehicle accidents are the eighth commonest cause of death amongst adults [7] argues for increased resource allocation to the orthopaedic specialty.

Local solutions – the Orthopaedic Clinical Officer

The desperate state of orthopaedic care in Malawi was observed by Dr Edward Blair whilst working as a Rotary International volunteer orthopaedic surgeon in the mid 1980s. At the time Malawi was completely reliant on expatriates, having no orthopaedic specialists of its own. Compelled to improve the situation, he developed an 18 month programme to educate existing clinical officers to manage common orthopaedic problems, reserving the expertise of orthopaedic surgeons for more serious cases. The significantly lower input costs and training time in comparison to full orthopaedic surgical education enabled the rapid deployment of specially trained paramedical professionals, now known as Orthopaedic Clinical Officers (OCOs), to expand orthopaedic facilities, particularly in rural areas [6].

Professor Chris Lavy restarted the course in 1990s after it had fallen into financial hardship, obtaining funding from the United Kingdom Department for International Development and the Nuffield Foundation through THET (Tropical Health Education Trust). He says of the OCOs, “They are great at what they can do, which is the delivery of conservative care to people with common fractures and dislocations. These common conditions make up the vast majority of injuries that present at district hospitals in Malawi.” The OCO impact on access to orthopaedic care has been remarkable. Collectively, by the mid 1990s actively practicing OCOs were seeing approximately 150,000 patients per year, the majority of diagnoses being trauma related. Furthermore, with over 50% employed by District and Mission Hospitals, this goes some way to fill the void of musculoskeletal expertise in rural areas [6].

An additional advantage of the scheme has been that the OCO profession has not been subject to the migratory ‘brain drain’ that occurs in other healthcare sectors, with all practicing OCOs still working within the county [6]. The exodus of healthcare workers out of Malawi to nations with stronger economic prospects has been particularly damaging to the nursing and midwifery pool, with over 100 personnel per year emigrating to countries such as the UK. This exacerbates an already critical situation, where over 60% of nursing posts are vacant nationally [5]. As their qualification is not recognised outside Malawi the OCO specialty triumphs by being exempt from this phenomenon, which keeps indispensible frontline healthcare staff in the country and means the investment in their training is fully realised.

Looking to the future

Currently the programme has an annual intake of 10-15 students per year but because OCOs will continue to be the key deliverers of primary orthopaedic care for the foreseeable future, the need for expansion remains [6]. Of course this is dependent on the concomitant amplification of financial backing which has changed in recent years, when income from its major donor THET ended in 2007 [6]. Alternative sources have had to be sought to allow training to continue as Stuart Palmer, the current course director in Malawi, explains. “The Ministry of Health is now on board here in Malawi as a core funder for the course but we still need to keep working with them and others to see it grow further.” The dependence on external bodies for the support of the course highlights the need for continued awareness, both inside and outside Malawi, of the importance of the multifaceted benefits OCOs deliver to ensure that care of musculoskeletal conditions is not put on the back-burner. 

Despite the apparent successes of the scheme it is important to recognise the limitations of the care that can be provided by OCOs. Their role is no replacement for the expertise of orthopaedic surgeons that is required to manage more complex presentations. Current postgraduate arrangements aim to produce between one and three graduate orthopaedic specialist doctors per year but an escalation in training places will be required to produce enough surgeons for equitable nationwide coverage [6]. The existence of OCOs should not detract from the need to train more orthopaedic surgeons.

As shown by the success of the OCO course in Malawi, it is possible for low cost programmes utilising existing paramedical professionals to rapidly meet the needs of side-lined specialties such as orthopaedics. Stakeholders in public health in developing countries need to recognise the potential of such interventions as an important tool in redressing the gross urban-rural inequity in healthcare access that prevents so many from receiving the care that they deserve.

Tamsin Cargill

4th Year Medical Student, Imperial College London

tnc06(a)ic.ac.uk

 References 

1. Constitution of the World Health Organization. Basic Documents, Forty-fifth edition, Supplement, October 2006. World Health Organization Web site. Available at: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf Accessed: June 2010

 2. WHO World Health Statistics Report 2009. World Health Organization Web site. Available at: http://www.who.int/whosis/whostat/EN_WHS09_Table1.pdf Accessed: November 2009

 3. World Health Statistics Report 2009. World Health Organization Web site. Available at: http://www.who.int/whosis/whostat/EN_WHS09_Table6.pdf Accessed: November 2009

 4. World Health Statistics Report 2009. World Health Organization Web site. http://www.who.int/whosis/whostat/EN_WHS09_Table9.pdf Accessed: November 2009

 5. Record, R., & Mohiddin, A. (2006). An economic perspective on Malawi’s medical “brain drain”. Globalization and Health, 2, 12.

6. Mkandawire, N., Ngulube, C., & Lavy, C. (2008). Orthopaedic clinical officer program in malawi: A model for providing orthopaedic care. Clinical Orthopaedics and Related Research, 466(10), 2385.

7. WHO Country Health System Fact Sheet 2006 – Malawi. World Health Organization Web site. Available at: http://www.who.int/whosis/mort/profiles/mort_afro_mwi_malawi.pdf Accessed: November 2009

This week in TLS News

Home births

Suzanne Murphy writes about the recent debate over home births as a measure to protect mother and child.

Leading the Ladies

In this blog, medical student Pamela Verma presents an interview from Dr Atsuko Heshiki, President of  Women Medical International Association.

Air pollution and respiratory health

In this blog, Laura Musselwhite highlights the impacts of increasing air pollution on children’s respiratory health.

Humanitarian Medicine Conference – Tei, Israel

In this blog, Sanjai Dayal writes about his experiences from the Humanitarian Medicine Conference that he attended late in July this year.

Editorial – Tackling obesity: the cheaper option

In this blog, student editor Joanna Hunter comments on the role of anti-obesity drugs on the the ever increasing risk of obesity worldwide.

This week’s Elective Report

Common Things Occur Commonly. Except when you’re in India.

Danniel Monnery shares his insightful experiences from his elective in a rural hospital in southern India.

This week’s 10-point Medical Student Questionnaire

Katie’s TLS Ten Question Challenge

Katie Ball, medical student at University of Liverpool, UK has accepted this week’s TLS ten question challenge.

This week’s Articles

The global burden of  tuberculosis

In this article, Haris Riaz writes about the threat posed by Tuberculosis in many nations all over the world.

Stronger Together

In this article, Devina Wadhwa and Salman Ali discuss the importance of interprofessional healthcare as a prospect of strengthening current medical system.

Have a great weekend and please get in touch,

The Lancet Student Editorial Team

Credit WHO/Chris de Bode

The publication of the Comprehensive Rimonabant Evaluation Study of Cardiovascular Endpoints and Outcomes (CRESCENDO) randomised trial in this week’s Lancet marks an interesting new chapter in the global fight against obesity [1]. Rimonabant, a selective cannabinoid-1 receptor antagonist which reduces an individual’s appetite, performed well in preliminary studies and hopes were high that it would prove a valuable tool in the promotion of weight loss [2]. However, the trial was ended prematurely amid fears over serious psychiatric side effects, thereby consigning rimonabant to an ever-increasing scrap-heap of rejected anti-obesity drugs [2].

The detrimental health effects of obesity have been well documented. A high body-mass index (BMI) significantly increases the risk of an individual developing diseases such as type II diabetes mellitus, cerebrovascular disease, and coronary heart disease. [3] Even moderate weight loss in an obese individual can lead to a dramatic reduction in their chances of developing such diseases, and much time and attention has therefore been dedicated to treating obesity.

Yet, in the millions of pounds spent on surgery and medication it is easy to forget that obesity is no longer a disease of the developed world, and that such products are unlikely to ever benefit a great proportion of the world’s obese. The disease profile for obesity has changed dramatically over the past century [4]. With cheap calories came the less privileged consumer, for whom feeding a family on fast food is a cost-efficient and time-efficient way to provide calories. Around the world, obesity is now associated with poverty and lack of education and is rife in developing countries [4].

A recent study of obesity in the USA reveals that individuals from ethnic minorities or from less educated backgrounds are disproportionally affected by excess weight [5].The same report called for a more holistic treatment of obesity through the implementation of policies designed to promote healthy behaviour [5]. In a review published in the UK earlier this year, Michael Marmot went one step further. He clearly demonstrated a link between ill health and socioeconomic background before arguing that to tackle the end points of social inequality such as obesity, social inequalities themselves must be addressed [6].

In the light of such research, one cannot ignore the role of lifestyle and socio-economic background in determining whether or not a person becomes obese. Clearly, behaviour influences a person’s weight: if more calories are ingested than expended, adipose tissue is produced. Furthermore, an individual is more likely to succeed in maintaining a healthy BMI if they have the time and the money to invest in healthy food, access to a safe space to exercise in, and the education and self-efficacy needed to engage in health-promoting behaviour [6].

As the Comment writers in The Lancet note, the implementation of behavioural changes in tackling obesity has hitherto been difficult to achieve [6]. Perhaps the demise of rimonabant will prompt governments to search elsewhere for answers to the obesity problem. Ultimately, the likelihood of drugs and surgery being of benefit to obese people in developing counties is small. It is ironic that, through poverty, such people have been spared the side effects of these products.

Based on Lancet press release.

References

1. Topol EJ, et al. Rimonobant for prevention of cardiovascular events (CRESCENDO): a randomized, multicentre, placebo-controlled trial. Lancet 2010; 376: 517-525.
2. Boekholdt SM, Peters RJG. Rimonabant: obituary for a wonder drug. Lancet 2010; 376: 489-490
3. Clark ML, Kumar P. Clinical medicine London: Elsevier, 2009
4. WHO. Fact sheet no. 311: obesity and overweight, September, 2006. http://www.who.int/mediacentre/factsheets/fs311/en/index.html (accessed Aug 06, 2010)
5. Anon. Vital signs: state-specific obesity prevalence among adults – United States 2009 Mortality and Morbidity Weekly Report (MMWR) 2010; published online Aug 3. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm59e0803a1.htm Accessed 06/08/10 (accessed Aug 06, 2010).
6. Marmot M. Fair Society, healthy lives: The Marmot Review. 2010. http://www.marmotreview.org/ Accessed 9/8/10. (accessed Aug 09 2010).

The articles analysed the treatment of hyperglycaemia on microvascular outcomes in type II diabetes, exenatide as an adjunct to metformin in the treatment of type II diabetes, the regeneration of articular surfaces in rabbit joints and the effect of anti-retroviral therapy on the prognosis of patients in HIV-1 in sub-Saharan Africa.

These articles were accompanied by comments on the treatment of hyperglycaemia, incretin-based treatment for type II diabetes, ART in low-resource settings, alcohol in HIV/AIDS and international research in Singapore.

The world reports discussed donors and the Zambian Health Ministry and UN women in a new drive for gender equality.

The series continues with HIV in people who use drugs part five and part six.

Medical students from over 25 countries participated

From July 25th-28th, medical students from over 25 countries gathered together in Tel Aviv to get a better understanding of the challenges and dilemmas that occur in humanitarian medicine. For most of them, it was their first time in Israel.

Israel has been on the front line of international aid for decades. From emergency medical aid in the West Bank to the tragedy of the Haiti earthquake, Israel has shown exemplary levels of humanitarian aid, both locally and internationally (1). Israel’s heightened sense of awareness, due to the constant conflicts in the region, has enabled them to develop unique ways to approach humanitarian crises.

There were several insightful moments during the conference. However,  a speech from Dr. Rivkind, detailing his treatment of a terrorist, and the story of Jana were perhaps the most touching examples demonstrating the spirit of humanitarian aid.
Dr. Avi Rivkind, a surgeon and head of the Hadassah trauma unit in Jerusalem, was at the hospital when Hassan Salameh, the mastermind of a series of bus bombings which killed 45 Israelis in 1996, was admitted (2). Hassan Salameh was wounded by Israeli soldiers and brought into Hadassah.

Dr. Rivkind eloquently explained how treating Salameh was no different than treating another patient. “I want to prove him that when you come to an Israeli Jewish doctor, you receive the best treatment in the world. To show them we are human beings.” It’s a message Dr. Rivkind and colleagues at Hadassah hope will inspire and change perspectives.

Hadassah is the epitome of how medicine can be used as a bridge to peace. Every patient gets equal treatment. There is a harmonious spirit at Hadassah, with a mixture of Israelis and Arabs working together. Patients often leave with a new perspective and a belief that one day Israelis and Palestinians can live together in peace.

Perhaps the most touching moment in the conference was when a Palestinian family reunited with the Israeli regiment commander who saved their daughter’s life. Their beautiful daughter Jana had almost been killed by a stone throne by a Palestinian four years prior, when she was five years old. With Jana unconscious and blood pooling from her head, Ibraheem, Jana’s father, was desperate for help. Ibraheem quickly sought the help of a military jeep down the road.

It was their urgent response and subsequent arrival from the Israeli regiment commander, Erez Kachal, which saved Jana’s life. After lying unconscious for 10 days and subsequent rehabilitation work at the Alyn Rehabilitation Center in Jerusalem, Jana has largely recovered from her injuries.

From left to reight: Jana, Ibraheem, and Erez Kachal discussing their remarkable story

These stories illustrate how despite differences in ethnic background and political beliefs, times of humanitarian crisis are moments of bridging differences between people. As humans, we are intimately connected with each other, sharing resources without boundaries. Disease and pollution have no borders. Without addressing the needs of populations in crisis, we cannot effectively resolve the issues that have brought so much of life to the brink of crisis.

Sanjai Dayal
M.D. Candidate, Class of 2013
The Medical School for International Health
sanjaidayal(a)gmail.com

References

(1) http://www.mfa.gov.il/mfa/humanitarianaid/overview/
(2) http://www.cbsnews.com/stories/2003/10/31/60minutes/main581163.shtml

Interprofessional healthcare locally and globally is a key driver towards decreasing healthcare costs and improving patient outcome. The advances in patient care are increasing both the quantity and quality of life, but at the same time are generating vast amounts of knowledge. As medical students, we will be expected to step into existing interprofessional teams and work effectively. To do this successfully, we first must learn the skills to work as a member of a team, and second, educate ourselves about the roles of our peers. The concept of interprofessionalism can be expanded to include professions outside healthcare, and this is relevant in tackling global poverty.

“We have to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere”

- Jong-wook Lee

Our world today is in a predicament with the disparity that exists in healthcare between the developed and developing world. The global advances in medical technology and diagnostic acumen are increasing exponentially; however, pockets of the globe remain severely underprivileged, polarising the healthcare landscape (1). On one hand, life expectancy is deteriorating in some of the poorest countries of the world due to preventable and treatable illnesses such as HIV, malaria, and diarrhoeal diseases (1). On the other, the richest nations in the world are facing an epidemic of obesity and its comorbidities – diabetes and cardiovascular disease. Today, healthcare providers are struggling to balance the basic healthcare needs of the global population, while providing complete and comprehensive health services to a demanding Western population.

Solutions to such problems are often intimidating and complex. The World Health Organization (WHO) has recognised that existing global-health systems are fragile and healthcare authorities will need to work together to increase the capacity and capabilities of the current infrastructure. Globally, healthcare providers need to work together towards improving health services under a common goal: the health and wellbeing of the patient, free of social and political distractions (1). Today, healthcare systems and their providers in Canada and elsewhere are beginning to address the central issues surrounding healthcare delivery. As it stands, the healthcare system is being stretched to its limits as the prevalence of preventable diseases and illnesses increases and healthcare moves towards a patient-centred model. More emphasis is being placed on improving patient wellness, as opposed to simply focusing on the patient’s disease. Inherent in this concept is the addition of alternative disciplines, both Western and Traditional, to the improvement of patient outcome. As we move forward healthcare will continue to progress towards an “interdisciplinary, multidisciplinary, and multidimensional” (1) model, and we, as young professionals, are responsible for not only keeping pace with our studies, but also learning about the roles and practises of our future colleagues. To truly treat the whole patient and population, we must draw upon the strength and expertise of various disciplines.

The concept of multidisciplinary care presents us with an immense amount of perplexity and its definition and implementation can often become very complex. At its heart, multidisciplinary medicine carries the core concept of collaboration. Fundamentally, teams can draw expertise from multiple areas with the intention of maximising patient care (2). The increasing difficulty of treating patients is paving the pathway towards clarifying the purpose of interprofessional collaboration in our society. New advances in diagnostic and treatment modalities are requiring more experience, more expertise, and more intellectual capacity than ever before to solve the puzzles that present in our offices everyday (3).

We are currently presented with the task of acquiring the necessary skills to enable our own personal success as members of a team comprised of professionals from dynamic and diverse backgrounds. Additionally, the competency framework created by the Royal College of Physicians and Surgeons of Canada (CanMEDS) expects that our medical education will provide us with the skills required to be successful physicians. How do we learn and develop the skills required to work as a member of an interprofessional team, and how do we ensure that our team is centred on the patient?

As medical students we need to be exposed to the concept of interprofessional collaboration during the initial footsteps of our professional education (3). Education is the foundation upon which we shape our future, and without it we have no scaffold onto which we can build our experiences. Early exposure to the concept of interprofessionalism is the key to being able to become professionals who have the ability to understand the spirit of interprofessional teamwork (4). Furthermore, it will also help clarify the roles and responsibilities of other healthcare professionals in order to build trust and a foundation for solidarity (5). Thus, effectively communicating in a team that improves patient care is a skill that needs to be learned in the preclerkship years as students are building their foundation for the way they will practice. Medical students and faculty across Canada have taken responsibility for this education outside the required curricular objectives. Thus, we need to push for interprofessional education in our core curriculums.

The principle of interprofessionalism is not only limited to the field of medicine. To truly create a sustainable change in healthcare, we must integrate all aspects of daily living into the interdisciplinary conversation. Expanding our outlook to a global level, international development ties health, education, and finance together to improve all outcomes. The years ahead are an opportunity to develop the skills that we all learned as children, and build upon it the knowledge and awareness of the global healthcare landscape. The pandemic of preventable illnesses is arguably our greatest challenge, and an interprofessional approach will play a key in tackling it.

Devina Wadhwa & Salman Ali
devinamay(a)gmail.com

References

1. The world health report 2006: Working together for health. The World Health Organization. Switzerland

2. Arcangelo VP. The myth of independent practice. Nursing Forum. 1994;29: 3–4

3. Chatterjee N. Infusing the interdisciplinary into Medical/Health Sciences Education: Vitamins or Vaccines? Med Educ Online [serial online] 2002;7:3 http://www.med-ed-online.org

4. Freeth D, et al. A critical review of evaluations of interprofessional education. Working Paper. Higher Education Academy, Health Sciences and Practice Network, London, UK, 2001 http://www.health.ltsn.ac.uk/publications/occasion

5. Frank JR, Jabbour M, et al. Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada. March, 2005

Last year I encountered a four year-old girl with a severe asthma exacerbation on my pediatrics rotation. She required hospitalization that summer for a flare that took place during a wave of “poor ozone levels” as reported by local weathermen. Upon further questioning her mother, both parents smoked at home, they lived near a busy street, and she was not consistently taking the maintenance therapy prescribed by her primary care provider at the nearby Lincoln Health Clinic. While it would be incorrect to attribute her state of health to these exposures, I reflect back on her situation and wonder from an environmental health perspective, whether improving the region’s air quality could have prevented her and other children’s’ respiratory hospitalizations that summer in Durham, North Carolina.

Recent studies have associated poor air quality to school absences due to acute respiratory illnesses and have also found decreased lung function in children from areas with higher NO2 levels, particulate matter, and nitric acid vapor—all of which are traffic-linked pollutants [1, 2]. Furthermore, it is known that children who are outside more often in areas with high ozone levels have a higher incidence of asthma, suggesting that not only is poor air quality linked to exacerbations, but also a risk factor for acquiring the disease [3].

Using previous research studies as our guides, we should focus on reducing outdoor pollutants as a necessary, short-term public health goal. To do so, we should hone in on improving public transportation to limit the number of vehicles producing harmful emissions. While it is argued that disincentivising urban sprawl might also be transiently beneficial, long-term, it would add to the growing emissions nationwide [4]. It is more practical to introduce health measures in public and private transit, by investing in alternative zero emissions fuels and to make this a constituent priority when politicians are seeking re-election. Long-term, more active community and statewide surveillance systems are needed to evaluate whether the proposed policy changes are effective. Until we address air quality and its impact on childrens’ health, we are not guaranteeing the safety of our nation’s most vulnerable citizens.

Laura Musselwhite

Global Health Scholar, Johns Hopkins Bloomberg School of Public Health
M.D. Candidate, Duke University School of Medicine

laura.musselwhite(a)jhmi.edu

References

1. Gauderman WJ, Gilliland GF, Vora H et al. Association between air pollution and lung function growth in Southern California cildren: results from a second cohort. American Journal of Respiratory and Critical Care Medicine. 2002;166:76-84.

2. McConnell R, Berhane K, Gilliland F, et al. Air pollution and bronchitic symptoms in Southern California children with asthma. Environmental Health Perspectives. 1999;107:757-760.

3. McConnell R, R, Berhane K, Gilliland F, et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet. 2002;359:386-391.

4. Kunzli N, McConnell R, Bates D, Bastain T, Hricko A, Lurmann F, Avol E, Gilliland F, Peters J. Breathless in Los Angeles: The Exhausting Search for Clean Air. American Journal of Public Health. 2003;93l:9

Here are her answers:

1. Why did you decide to study medicine?

I considered studying medicine from an early age but decided against it as I felt unable to commit to 5 or 6 years at university and a lifetime of learning. Instead, I did a degree in Biochemistry. After my degree I became a health care assistant due to my persistent interest in medicine. My enthusiasm for care of the elderly and a desire to help vulnerable people confirmed that medicine was the only route for me.

2. Can you share some things that you wish that someone had told you before you applied to study medicine?

I wish someone had emphasised the importance of researching different types of medicine courses available. I am currently doing a problem-based learning (PBL) course and although I like it and think it has a place in medical learning today, I feel that in hindsight, I personally would have suited a course that combined a traditional and PBL approach. Hearing opinions from current student on different courses, or having a ‘taster day’ might have helped me make a more educated decision.

3. What profession would you be in if you weren’t in medicine?

I considered applying for a PhD to lead into a career in research.

4. What is your biggest motivation?

I am very conscientious and this makes me motivated. I like people and so caring for vulnerable people motivates me.

5. What are you most interested in so far and why?

I believe that too much emphasis is placed upon specialities and too often patients get shifted from one specialist consultant to the next. In my paediatric rotation however, I noticed that there was a much more holistic approach to medicine which I found fantastic. In paediatrics, the doctor is not only treating the child, they are interacting and helping the whole family. I think that this is a real skill of communication and a great challenge.

6. What has been your most difficult module so far and why?

Although I enjoyed psychiatry and neurology, I was overwhelmed by the amount we had to learn in such a short amount of time. I really struggled with remembering the relevant information for psychiatry and found neuroanatomy incredibly difficult. The brain is incredible but how on earth can people understand it!

7. What is the most memorable positive moment in your medical studies so far?

It sounds pretty pathetic but, a doctor telling me that I would make a nice GP during a teaching session is one of my most memorable moments from my studies so far. It was just before my exams and their confidence in me gave me the boost that I needed.

8 ) What is the worst horror story in your medical studies to date?

Watching a lady in labour horrified me! The midwives said it was a good labour. I found it thoroughly traumatizing! I’ve been really fortunate and not had a truly horrendous experience…yet.

9) Where do you see yourself in 10 years time?

a) The wishful thinking version: A paediatrician trusted and respected by colleagues and patients. My only real aim is to be personally requested by my patients – a sign of a really good doctor!

b) Perhaps slightly more realistic version: I hope (a) is true. If it isn’t I think I’ll quit! To be honest, I will probably end up being a GP with a special interest in Paediatrics.

10) Can you share some tips/advice for others

a) Wanting to study medicine: If you believe medicine to be the only way for you, get lots of work experience. Work hard and go for it!

The reason I didn’t do medicine originally was because my parents, who are also in health care, highlighted the fact that medicine is not only a job, it is a career and lifestyle choice. If you do not feel ready to commit to studying for the next 5 or 6 years, take a break. Do something first and postpone the decision. I wouldn’t have done it any other way.

b) Already studying medicine: Support your friends. You’ll need them too at some point. Don’t compare yourself too much to others- there will always be people better and worse than you.

Not only do patients want a doctor with great clinical ability, but also one who is approachable and who listens to them. Good communication skills are a necessity, that need to be practiced.

Dr Atsuko Heshiki

Dr Heshiki welcomed over 600 female doctors and medical students from across the world to the 28th International Congress of the Medical Women International Association (MWIA) held in Munster, Germany from July 27-31st, 2010.

A Professor Emeritus in Radiology from Japan, Dr Heshiki completed her 3 year Presidential Term, handing the reigns to President-Elect Dr Afua Hesse of Ghana.

Please tell us about your early career days in Medicine

I chose to study medicine as a young person because of my passion for learning. I wanted to be in a career where I could study for a lifetime and this is something that medicine could offer me.

Of the 80 medical schools in Japan, I attended the Tokyo Medical Women’s College, the only all-women college. Following this I trained in the US Hospital during the Vietnam War and then travelled to America to do further training at North western University and my residency in Radiology at John Hopkins.

I like radiology because there is such rapid progress of technology and diagnostics in the area.

What do you think about the status of medical women in Japan?

I think that there is a generation gap. Historically, medicine was one of the only prestigious professions that women could partake in. Women doctors comprised an elite part of society and they took great pride in this duty. A great deal of sacrifice was involved. But now, I feel that women are taking other priorities into their duties and often practice less medicine. I hope that we can encourage this younger generation to continue their careers. For example, of the 40 women I graduated with all have continued in medicine, but they also take time to enjoy their lives.

In addition to being a doctor, tell us about your role in International Leadership

I am very fortunate that I made rapid progress in my career. I planned very early to become a professor. In this role I was able to serve as a voice to society, academia, and students alike. However, this status does not come the day after you plan for it, it takes time and dedication. I think that women as leaders can be very generous. Women leaders can include men, but sometimes male leaders can segregate women and we must be careful with this.

How did you become involved with the Medical Women International Association (MWIA)?

I was invited to represent Japan as its National Coordinator at the MWIA meeting in Guatemala because of my strong English skills, having trained in the United States. I became fascinated with this organization, being able to meet women from so many different countries and specialties. I have attended all each MWIA meeting since.

In 2005, I served as Secretary General for the organizing committee when Japan was selected as the host country. I decided that near my retirement I would dedicate more time to the organization and was nominated for this Presidency at an opportune time.

What are some highlights of your time as President of the MWIA?

I wanted to learn more about the issues that medical women face in their work and conducted a survey of our members. Over 615 women doctors participated and I was surprised to find that there were very common themes – medical women across the world face very similar challenges.

Some of the major findings were generational. Younger women did not find that they were discriminated for professional promotion, however women in their 40s to 60s did. It seems that access to senior positions is still limited for medical women. Long working hours were another concern for women, particularly the more senior Obstetrician-Gynaecologists.

With respect to family planning, it was interesting that women generally felt well supported by their supervisors during their pregnancies, being provided options like safer working conditions and flexible hours. However, difficulties arose after their children were born. Finding reliable and affordable childcare was a major concern for women and often limited their ability to continue providing medical care. It was even more difficult to find care for when their children were ill.

I hope that in the future we can begin to lobby at the international level to improve working conditions for medical women. I also hope that we can conduct a broader study as participants for this survey were already active members of the MWIA. What about the women who are not as well connected in the profession?

What advice to you have for young medical women?

I think it is very important to plan what you want from your career early. However, it is still important to maintain some flexibility and not worry too much. I think it is best not to worry and just take action. In this way, everything will be possible.

Pamela Verma
University of British Columbia
pamverma(a)interchange.ubc.ca

For more information about the Medical Women International Association, please visit: http://www.mwia.net/

Their Special Interest Group for Medical Students and Young Doctors can be found on Facebook:
http://www.facebook.com/profile.php?id=781478991#!/group.php?gid=38931816104&ref=ts.

I had accumulated reasonable experience in the field of infectious diseases through various placements, student selected components, conferences and also a research module in which I worked with malarial parasites. Throughout these experiences, the medical student mantra ‘Common things occur commonly’ has always held out, and I have more routinely seen evidence of complicated pneumonias, HIV and MRSA than Malaria, dengue and typhoid. I decided to make rarer infectious diseases the objective of my elective planning hoping to be able to work with cases I had only read about in text books. If I happened to find the other 3 S’s along the way, so be it!

A few days later my university was visited by ‘Work the World’, a company which organises electives in Africa, Asia and South America. I discussed my situation with Abby, the project co-ordinator and she told me about the options available through their company. I was immediately taken with the description of India, a place I had not thought about before because of friends who had battled against mountains of red tape to get the correct visas and the right kind of placement. However, ‘Work the World’ are well established and their agreement with the Kerala state government allows their students access to a range of hospitals and clinics. Most importantly for me, they could arrange a placement at a state-run hospital in Trivandrum that included 4 weeks of adult and 4 weeks of paediatric tropical disease. On top of this, accommodation, food and transfers from the airport were all included, and there is local staff on hand 24-7 that could support me if things didn’t go to plan. I didn’t need much convincing to sign up!

When I arrived in Trivandrum, I had 24 hours to settle in to the accommodation, orientate myself within the city and recover from jet-lag before I started work at the General Hospital, one of the few state funded hospitals in Kerala that treat people below the poverty line (the equivalent of 300 rupees/ £4.30 per month). The catchment area included not only the people dwelling in the city, but also the surrounding rural areas. It was filled beyond capacity at all times and outpatient clinics (consisting of 2 doctors) could see in excess of 400 patients in a day. When the wards did not have enough beds to accommodate all of the inpatients, people would just sleep on the floor. It was very clear that this hospital, while commendable for offering some kind of service to the poorest people in the community, was severely underfunded and under resourced.

My first day on the adult ward for infectious and tropical diseases and I was confronted by roughly 40 patients suffering from a range of diseases including Dengue, Malaria, Typhoid, Leptospirosis and TB. This was something I had wanted, but faced with such a desperate state of healthcare economics every day on the ward rounds was hard to accept. There were no side rooms or areas where infectious patients could be kept in isolation from the others, and despite hundreds of mosquitoes in the wards, the only method to prevent the spread of malaria from one infected patient to another, was the provision of mosquito nets. Although this makes sense on one level, closer inspection showed these nets were old and riddled with holes and many patients, not understanding their condition, simply removed them when they became too hot. TB patients fared no better, taking on another battle when it came to a lack of medication. Although a number of drugs were paid for by the government, the rest had to be funded by the patient. Needless to say, none of those living below the poverty line were able to afford any of these additional drugs, so all patients on the ward, regardless of their disease, were prescribed the same cocktail of crystalline penicillin, cefotaxime, ranitidine and B complex vitamins. When I asked one of the doctors if they were concerned about spreading antibiotic resistance by using the same antibiotics for every patient they simply asked, “What’s the alternative?”

Male Infectious Ward

Now I should probably point out that I am not so stupid as to believe that the hospitals in India would be similar to those we have in the UK. I knew I was going to a state hospital, and I had conjured up what I thought was an appropriate expectation – I wasn’t shocked that the floors were bare concrete, or that food was being cooked next to the patients’ beds. I wasn’t even that surprised that the sluice ran in a trough down the middle of the ward so that you had to jump over it to get in and out. That being said, I had not prepared myself for actually witnessing people dying as a direct result of a poorly funded healthcare system. A memory that will always stay with me is that of a 13 year old girl who was brought into the paediatric outpatient’s clinic unconscious and in a dehydrated state. Her parents reported that she had suffered 6 days of diarrhoea, and had lost consciousness during the previous night. She was admitted to the paediatric intensive care unit (PICU) and started on multiple saline infusions and a dopamine infusion in order to bring up her blood pressure (which had not been recordable on admission). On taking a detailed history from her parents, it was discovered that the episode of diarrhoea had started after she had eaten an ice-cream which they didn’t believe was made with clean water. It was decided that the girl was probably suffering from acute infective diarrhoea (AID) and was started on IV Cefotaxime. After 12 hours the girl’s hydration status had returned to normal but she had not regained consciousness. There was doubt about the causative organism of the condition, but the parents could not afford to pay for any further investigations such as a CT scan, stool or blood cultures, and these tests were not provided by the state funding. Unfortunately, the girl died after 28 hours in hospital. Post mortem revealed that she had been suffering from Shigella Encephalitis.

General Hospital, Trivandrum

Rural patients arriving at the hospital when it was too late, or when expensive treatments were the only possibility remaining, was a common problem throughout my time in Kerala. It made me realise a lack of resource by the hospital and a shortage of funds from the patient’s family were not the only problems. The healthcare system in India is hugely affected by the level of public education and although Kerala boasts nearly 100% literacy because the state provides compulsory primary education, levels of health education vary widely between the urban and rural areas. In the urbanised areas, there is a high level of awareness about common infections, what symptoms they present with and when an illness is at the stage where it requires medical intervention. This is not the same in the rural areas, where there is little knowledge of different infections, and often Ayurvedic Medicine (Indian traditional herbal medicine) is used in preference to western medicine.

Ironically, it is in the rural areas where many of the infectious agents are more prevalent, for example leptospirosis, which is spread easily amongst the workers in the rice paddy fields. There is also an ongoing problem with rabies. Over recent years there has been a change in government attitude towards the treatment of stray dogs in India and whereas before they would be culled frequently to prevent the spread of disease, the government has decided that dogs should not be killed due to widespread religious beliefs. This has unsurprisingly resulted in a rise in the incidence of rabies, which has, in turn, necessitated the provision of public health education about what to do if bitten. Whilst this information is widely known in urban areas, it is not so in rural communities and many people from those areas either do not seek medical attention at all when they are bitten or attend an Ayurvedic doctor instead. These patients then present to the state hospital in Trivandrum at a later date, once the disease has irreversibly progressed to the terminal phase. I saw one such patient who presented to the outpatients department with hydrophobia and dehydration having been bitten by a pet one month previously. He had not sought medical help prior to this point and was clearly in the terminal phase of the disease, he was admitted to one of the hospital’s ‘Rabies cells’ (darkened rooms without any stimuli to the hydrophobia). In this cell he was administered some rectal diazepam (he was not able to take it orally due to laryngospasm) to keep him relaxed. He died a day later.

Resource Room

Aside from the medical aspect of my time in India, I was also able to see a lot of the state of Kerala and experience some of the culture. I was very fortunate to be in Trivandrum at the time of the Pongala festival. During this festival, 3 million women from around India line the streets of Trivandrum and cook dishes which they then take to the temple as an offering to the gods. While men aren’t allowed on the streets during the festival itself, in the week leading up to this day there are various parades taking place across the city which everyone can attend and I was fortunate enough to be able to see one of them. It was quite a magnificent spectacle!

Pongala Festival

To finish up this article, I should probably offer some guidance to those thinking of pursuing something similar for their elective, based on my experiences. I think a few things that I would highlight are:

• The importance of travelling with a reputable company that can give you the kind of placement that would be most rewarding
• The idea that you cannot necessarily predict what you will see. Nor can you predict the patient’s outcome. So prepare to be shocked!
• It can be fascinating to go in search of something you’ve never seen before.
• UNcommon things occur commonly in India- so go and see them!

I’d like to conclude by saying that my time in India was fantastic despite some of the unfortunate cases I witnessed. I learnt a huge amount and gained a lot of experience in both tropical diseases and Indian culture and healthcare. This placement has really made me appreciate the NHS and how fortunate we are to have free healthcare for everyone, and has also inspired me to consider infectious/tropical diseases as a potential career path.

Daniel Monnery
Medical Student
daniel_monnery(a)hotmail.com

‘Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.’

This is a statement from The Lancet’s recent editorial that is causing worldwide controversy [1].  The editorial based its bold statement on a recent study [2]  which found that babies born at home were more likely to die from heart or breathing problems, possibly because they are not properly monitored for signs of distress. It was found that of 500,000 births worldwide, the death rate for home births was 0.2%, twice as high as that in hospitals. The main causes for increased mortality were breathing difficulties and failed resuscitation attempts, which were attributed to poor midwife training and a lack of access to proper hospital equipment. In the US, only a third of home births are accompanied by a certified midwife.

There is discontent amongst professional organisations regarding home births. The department of health in Southern Australia does offer a detailed policy regarding home births for women with low risk, singleton term pregnancies. Similarly, the United Kingdom’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support home births in women with uncomplicated pregnancies. In contrast, the American College of Obstetricians and Gynaecologists does not support home deliveries, saying that the decision to have a home birth prioritises the process of giving birth over the goal of having a healthy baby. There has been an increase in home births in US recently, which can partly be attributed to the increase in Caesarean deliveries, which currently account for a third of all births, with ninety percent of women who have a Caesarean going on to have repeated Caesareans. Doctors are reluctant to encourage a vaginal birth following a previous Caesarean due to the risk of liability lawsuits [1]. Under UK law, mothers can opt to override medical advice and have their babies at home if they so wish. 3% of births in the UK take place at home, which is three times more than in the US but still far fewer than in the Netherlands, where home births account for a third of all births [3].

The editorial acknowledges that home births do appear to be safer for low-risk mothers, as they are associated with shorter recovery times, fewer lacerations , post–partum haemorrhages, retained placentae and infections.  The central issue raised by the Lancet is one of advocacy. If a mother insists on a home birth at the risk of the unborn child, is it the role of health care professionals to act as an advocate for the unborn child and insist on the baby being delivered in the safest possible setting?

I’m sure that the majority of mothers will do anything to protect their unborn child, but perhaps they do not fully understand the potential severity of a medical emergency should complications occur to either mother or child during a home birth if the house is not near any medical facilities. This editorial is sure to annoy midwives but ultimately it is not about putting down one profession or promoting hospital births over home births. There is no doubt that midwives do a fantastic job, but the fact is that no matter how planned a home birth may be, there is always the potential for something to go wrong.  Hospital delivery should be the preferred option, despite the fact that it is not without its own risks. Of course home delivery should be an option but it is unrealistic to assume it is an option that is available to all. It should only be considered with uncomplicated pregnancies where the expectant parents are aware of the possible risks.  Home births should involve an accredited midwife who is trained in resuscitation. Ultimately, this furore is about best patient care and need to protect the precious new lives that are born every day.

Suzanne Murphy
murphs34(a)tcd.ie

References

1. Editorial; Home Birth- proceed with caution. The Lancet. (2010) 376 (9738)
2. Wax JR. Lucas FL. Lamont M. et al. MAternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010; 203
3. http://www.bbc.co.uk/news/health-10806450

Epidemiological Burden

Approximately 2 billion people across the globe are estimated to be infected with the bacterium, of which 10% are likely to become symptomatic during their lifetime (3). The burden of TB is considerably greater in developing countries compared to the developed ones. For instance the prevalence rate per 100,000 population according to the World Health Organisation (WHO) report of 2009 is diagrammatically illustrated below. (4) 

The top twenty countries most affected by TB are developing countries and account for four-fifths of all cases. Furthermore, the number of cases in all regions increased during 1995-2005 other than those with established market economies (5).

Incidence

The incidence of TB has increased in the last two decades in the African continent from 170 cases to 350 per 100,000 population. In contrast, it has almost halved in the American continents (4). The trend in the South-East Asian, Western Pacific and Eastern Mediterranean have been fairly consistent, whereas Europe has shown a decline in the incidence of TB. 

Incidence per 100, 000

Mortality

The disparity between the prosperous world and its underprivileged counterparts is clearly evident in the mortality statistics for TB. Thus the annual mortality of TB is greatest in Africa (544,000 deaths/ 74 per 100,000 population) and South- East Asia (512,000 deaths/31 per 100,000 population).

These statistics are in striking contrast to Europe (66,000 deaths/ 7.4 per 100,000 population) and the American continents (49,000 deaths/ 5.5 per 100,000 population). (5) The present threat of TB is in terms of extra-pulmonary manifestations of disease, with increasing resistance seen to conventional anti-tuberculous drugs (Multi-drug-resistant TB) and co-infection with Human Immuno-deficiency (HIV) virus. 

Mortality per 100, 000

Extrapulmonary TB

The major risk factor predisposing to extra-pulmonary TB is immunosuppression, which is evident from the fact that the occurrence of extra-pulmonary TB has risen since the arrival of HIV/AIDS. More than half of patients with co-existing HIV and TB infection have extra-pulmonary involvement (6). Bones, lymph nodes and pleura are the most common sites of involvement. The Infectious disease society of America, American thoracic society and Centres for disease control and prevention recommend screening of HIV infection in tuberculosis patients (7).
The most prevalent site for extra-pulmonary TB is Lymph nodes (6). Cervical lymphadenitis is predominantly seen though other groups such as inguinal and axillary may also be involved. The Spine is the first site in which the involvement of the skeletal system is seen. In extra-pulmonary tuberculosis, arthritis and osteomyelitis may spread to other sites (8).

Meningitis is the chief presenting complaint in CNS involvement and intra-cranial Tuberculomas. The latter may manifest itself as space-occupying lesions. Extrapulmonary TB is indicated by a history of travel or habitation in an area of high risk, the presence of ascites with lymphocyte elevation and negative bacterial cultures and pericardial effusion when other causes have been excluded.

TB and HIV

Epidemiological studies suggest an increased incidence and prevalence of HIV in TB burdened regions of the world. South Africa, in which TB is the single most frequent cause of natural death, constitutes 0.7% of the world population and is home to 17% of the world’s total HIV population (9). Facts from 2008 show that of those infected with TB in Africa, 45% were co-infected with HIV, whereas the corresponding figures in Europe were just 3% (4). Conversely TB is the most prevalent infection in persons suffering from HIV (10). The co-existence of TB and HIV has caused serious threats in hampering the spread of two infections. Immunosuppression due to HIV leads to reactivation of latent TB whereas TB itself causes an increase in viral load of HIV causing increased morbidity and mortality (11).

The Way Forward

The facts elucidated above demonstrate the disparity of the TB burden in the developing nations compared to their prosperous counter-parts. There is a prompt need to act speedily and effectively to address and control the menace.

In 2008, it was estimated that the global annual expenditure pertaining to TB would be 3.8 to 5 billion dollars. In addition, 1.3 billion dollars were expected to be spent for drug-resistant TB. Out of these, just one-third, i.e. approximately 1.7 billion dollars were expected to be spent by the developing countries (12). Thus, the regions with the greatest proportion of the disease spent only modest sums compared to the affluent societies. This is due to the paucity of economic resources in such nations. For instance, the government of Pakistan’s health expenditure per person annually is just around 10 US dollars, whereas the international average is 434 US dollars (13). This necessitates the need for enhancing the funds for the health sector. In addition to this, prioritization of the health problems, education of the masses, efforts to reduce the spread of disease from infected individuals, provision of effective treatment to the affected persons, identification and reduction of multi-drug resistant strains of Mycobacterium tuberculosis and collaboration between the governmental and the private sectors in the above measures are some of the methods which can curtail the hazard to prevent the suffering of future generations.

Haris Riaz

Final year student

Dow Medical College, Karachi, Pakistan

harisriaz73(a)yahoo.com

References

1. Shen X, Deriemer K, Yuan Z, Shen M, Xia Z, Gui X, Wang L, Mei J, “Deaths among tuberculosis cases in Shanghai, China: who is at risk? BMC Infect Dis v.9;2009

2. TB —a global emergency. WHO report on the tuberculosis epidemic, 1994.Geneva: World Health Organization;1994. (Accessed on 5/9/2009)

3. Corbett EL, Watt CJ, Walker N, et al. The growing burden of tuberculosis: Global trends and interactions with the HIV epidemic. Arch Intern Med. 2003;163:1009–21.

4. WHO report on Tuberculosis, 2009. Available at URL http://www.who.int/tb/publications/global_report/2009/update/a-1_full.pdf Accessed on 27-7-2010

5. WHO Report on Global Tuberculosis control, 2001.WHO/CDS/TB/2001.287 (Accessed on 28/8/2009) Rieder HL, Snider DE Jr, Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990;141:347-51.

6. Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/ Infectious Diseases Society of America: treatment of tuberculosis.Am J Respir Crit Care Med 2003; 167:603-62.

7. Golden M. Extra-pulmonary Tuberculosis: An overview. American Family Physician 2005. Am Fam Physician. 2005 Nov 1;72(9):1761-8. Review

8. Karim SSA, Churchyard GJ, Karim QA, Lawn SD: HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. Author manuscript; available in PMC 2010 January 7.

9. Alexander PE. De P. The emergence of extensively drug-resistant tuberculosis (TB): TB/HIV coinfection, multidrug-resistant TB and the resulting public health threat from extensively drug-resistant TB, globally and in CanadaCan J Infect Dis Med Microbiol. 2007 September; 18(5): 289–291.

10. Goletti D, Weissman D, Jackson RW, et al. Effect of Mycobacterium tuberculosis on HIV replication. Role of immune activation. J Immunol. 1996;157:1271–8. Available at URL: (Accessed on 20/9/2009) http://www.globalhealth.org/images/pdf/gho/2008_id_expenditures.pdf

11. Zubair M H, Zubair M M, Riaz H. rota virus mortality: A dilemma for the developing world. J Pak Med Assoc. 2009 Aug;59(8):582.

This week in TLS News

Floods wash away the lives of the wounded

Ahmad Jawad, reports on the floods in Pakistan and its implications on the healthcare of Pakistani people.

Heart rate variability: A cardiac risk factor?

In this blog, medical student Inderjeet Sahota discusses heart rate variability as a potential risk factor of cardiovascular diseases.

G8 initiative on maternal, new born and child health fails to eliminate global gap

Robin Lennox from University of Toronto reports the effect of G8 meeting upon worldwide health equality.

Climate change, Campaigning, and the IFMSA (Part II): Raising the voice

In this blog, Ben Warner writes about the students projects that were displayed during the conference and the influence that student bodies can bring out in the world.

Climate change, Campaigning, and the IFMSA (Part III)

In this final blog from the series, Ben Warner continues with his experiences at the IFMSA 59th General Meet being held in Canada.

Health Science Inquiry: A new and exciting student health sciences journal!

Written by Inderjeet Sahota, this blog is about a new student online publication that has recently been started by students across Canada.

This week’s Elective Report

Clinical Oncology Elective in UK

William Lee shares his experiences from his elective in a cancer hospital in UK.

This week’s 10-point Medical Student Questionnaire

Indrashis Podder’s TLS Ten Question Challenge

Indrashis Podder, final year medical student at Calcutta National Medical College, India has accepted this week’s TLS ten question challenge.

This week’s Articles

Hepatitis C: A real cause for concern in Pakistan

In this article, medical students from Pakistan highlight the prevalence of Hepatitis C in the country and the risks it poses.

Global public health: Evolution and implications

In this article, Laura Khan reflects her perspectives on global public health.

Have a great weekend and please get in touch,

The Lancet Student Editorial Team

The articles analysed the effects of statin therapy in the JUPITER trial, the death rates of HIV positive, antiretroviral-naive patients with high CD4 counts and the use of nitric acid to prevent bronchopulmonary dysplasia in premature babies.

These articles were accompanied by comments on the use of HDL cholesterol in determining cardiovascular risk, the detrimental effects of untreated HIV despite a high CD4 count, the treatment of preterm infants with nitric acid, a call for evidence based drug policies, HIV and drug use in women and the story of the BRCA patent.

The World Reports discuss the future of the International AIDS Society, North Korea’s health system, Norway’s law on the use of electronic patients’ records and the potential of an anteretroviral vaginal gel in preventing HIV.

The series continues with HIV in people who use drugs part three and part four.

The full issue includes the following articles:

Development and Deployment of Vaccinations

· Lindsay O’Brecht – The Vulnerability of Aboriginal people to the H1N1 Flu Virus

· Alan McGreevy – Perceived Risk, Shared Benefit and Social Interaction in Vaccination

· Travis W. Marfleet – Cytotoxic T Cell Response and Conserved Viral Epitopes: Considerations for Vaccination Against Newly Emerging Pandemic Influenza Strains

· Matti Allen – Public Mistrust as a Barrier to Mass Vaccination During Influenza A (H1N1)

· Arthur Derman & Sevan Evren – Implications of Vaccinations During the 2009 H1N1 Outbreak and Impact on Future Pandemics

Surveillance and Response to H1N1

· Tess Laidlaw – Epidemic Response Archetypes: Negotiating Unknowns in Pandemic Planning

· Tanya Rac – Designing Mass Immunization Clinics

· Inderjeet Sahota – Post-analysis of the Swine Flu Pandemic: Overreaction or Necessary Precaution?

· Farhan Asrar – H1N1 Pandemic Planning: Correlation Between Human Behaviour and Pandemic Planning

H1N1 as a Global Pandemic

· Jacob Scheer – Naturopathic Medicine is a Viable Therapy in the Prevention and Treatment of H1N1

· Chelsea Himsworth – If a Pig Coughs in Mexico the Whole World Should Hear It

· Diego S. Silva – H1N1 Influenza: Global Pandemic, Global Vulnerabilities

· Janis Huntington & Amanda Jones – H1N1 Brand Power: Marketing a Disaster

This year’s issue of HSI with its focus on the H1N1 pandemic offers an informative read to medical and health sciences students across the world from other students’ perspectives. To download a free copy of this year’s issue and to learn more about the journal itself go to hsinquiry.sa.utoronto.ca.

Inderjeet S. Sahota
Managing Editor, Health Science Inquiry
isahota(a)sfu.ca

The spread of HIV/AIDS, SARS, H1N1 and various non-communicable diseases has confirmed that “diseases do not need visas”. The field of global health has emerged as a significant public health focus, though a clear definition of the discipline remains under debate. Indeed, visionaries such as Julio Frenk see them as one and the same [2], while others, for example the Consortium of Universities of Public Health have a more complex view in which global health is simultaneously a notion, an objective, and/or “a mix of scholarship, research, and practice” [3]. The definition the group ultimately presented read “global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” Despite the burgeoning popularity of global health, however one may define it, training and educational opportunities remain relatively scarce. In the United States, for example, only about 20 universities (out of hundreds) offer a graduate degree program in global health – formerly known as “tropical” or “international” health – and programs at undergraduate institutions are few and far between [4]. There are even fewer programs for global health study in developing countries [5] where the need is arguably greatest. The noticeable recent surges of academic enthusiasm for the field of global health have not been sufficiently matched by significant increases in training opportunities, especially for younger students [6].

A second concept that has emerged to change the face of global health is that of health as a human right. Often still understood from within its conceptual framework or as solely a process for transformation, [7] health as a human right has actually become quite mainstream and certainly is increasingly operationalized by a variety of private foundations, bi- and multilateral organizations and governments. Many countries have even incorporated the right to health into their constitution. Development of the rights-based approach came about in reaction to pervasive stigma and discrimination around the early stages of the HIV/AIDS epidemic and has since diffused to many areas of public health, especially within low resource settings. Whether the rights-based approach is used explicitly or implicitly, it is clear that it is more frequently being applied to programming, rules and regulations along with the right to education, employment and development [8]. This focus may have decreased disparities within countries, but strangely enough has the potential to increase certain disparities between countries as some adopt these principles and others do not. It is thus the role of public health practitioners, policy-makers and government officials, to use a human rights framework in his or her approach and to encourage others to do so as well. Only then will this field become fully integrated.
A third and quite transformational evolution in the field of global health has been the development of new technologies, as well as the new use of old technologies in innovative ways. For example, the challenges presented by the disaster in Haiti and the associated public health issues such as water, sanitation and the spread of disease, gave rise to alternative ways to manage crises. Cell phones were especially useful for mapping damage, coordinating relief efforts, reuniting families, donating money and for helping ordinary people find their voices amidst the rubble [9]. Media attention in the form of live feeds and real-time interviews certainly contributed to the world’s understanding of the crisis and their subsequent outpouring of financial, technical and religious support. Apart from the crisis, service provision and data collection is slowly but surely being revolutionized by the use of cell phones to administer checklists and provide real-time training and support [10]. The idea is that better quality data, monitoring and evaluation will yield more effective uses of resources and more successful future programming.

A fourth development has been the rise of civil society, especially international non-governmental organizations (NGOs) or civil society organizations (CSO). Their increasing prominence, connectedness, and centrality to global health priority-setting cannot be understated [11]. The NGO community has successfully lobbied, instructed and altered the work of multilateral, bilateral and government agencies and is global in scope and influence. For example, successful lobbying on drug access and pricing and tobacco advertising has proven “transnationally” transformative in the support of the public interest [12]. Spurred themselves by new technologies [13], civil society organizations (CSOs) are able to occupy the unique position of both “watchdogs as well as collaborators” [14]. NGOs may have, however, muddied the waters of global efforts towards accountability, though new NGOs have sprung up to monitor the old [15].

Lastly, the increasing popularity of alternative ways and means to improve global health has generated the need and opportunity for creative new partnerships. For example, private foundations such as the Bill and Melinda Gates Foundation have provided enormous financial support for both mainstream and neglected global health issues from sexual health programs for urban sex workers in India to striving to eliminate onchocerciasis (river blindness) in Colombia [16]. Additionally, public-private partnerships (PPPs) are more often being used to leverage private sector efficiency to solve public sector problems [17]. Both have undoubtedly contributed significantly to the often scattered and uncoordinated field of global health with new reincarnations of functional organizational behavior, technological and human resources development, and program management. The realization of the importance of working with both the public and the private sector is essential to global health practitioners’ effectiveness. The fields of business, international relations and finance have certainly contributed to significant advances in global health and we must learn as much possible from this interdisciplinary collaboration.

In light of the developments discussed above, representing only a select few that I find most illustrative, the evidence that the face of global health has been and still continues to evolve is quite convincing. With such growth and development come both significant challenges and opportunities for both practitioners and the public. We tend to point our fingers, in the event of program failure or frustration, at a lack of resources or of political will. But I point mine – in the spirit of constructive criticism – at the scattered understanding and capacity of this emerging field. The palpable lack of accord in priority-setting and the dearth of training opportunities for interested young people have handicapped our ability to tackle the real public health issues. The current relative lack of consensus and preparedness in the wake of expanding interest in and commitment to global health is concerning. It seems, therefore, critically important to cultivate academic, civil society and political enthusiasm for the topic in order to assure that future generations have the focus, capacity, and knowledge necessary to set priorities and work together.

The field of global health is currently almost exclusively pursued at higher institutes of learning in the developed world, to its detriment. With decreasing life expectancy in Sub-Saharan Africa, an obesity epidemic in the United States, and indigenous populations all over the world suffering significantly poorer health than their non-indigenous counterparts, public health should be one of the most active areas of work and study in our world today. However, both low- and high-income settings lack the training opportunities needed in emerging public health fields. Spatial and geographic methods, low-resource-appropriate health technology, complex data management, monitoring and evaluation, demographics of aging, methods for accountability and a better understanding of health economics, systems and policy are just a few of these neglected sub-fields. The challenge is therefore to translate new and welcome enthusiasm into the skills and capacity to enable young people to contribute to the field in a both a constructive and a cooperative manner.

Most importantly, the field of global health should, indeed, be global [18]. It should certainly not be simply a discipline intended to increase a university’s prestige, attract funding, or ever perpetuate the image of professionals from low-income settings as not working in “global health” [19]. It is therefore necessary to increase training opportunities in the low-resource-settings themselves – not for international students, but for locals – and to improve programs already in existence so that they may meet growing needs and interests. New and creative approaches are needed, however, as currently employed programs and incentives do not seem always to attain their desired results [20]. For example, Dr. Lincoln Chen and colleagues in 2004 proposed a health systems approach to improve workforce capacity in low-income settings using a multidisciplinary local approach benefiting from “appropriate international reinforcement” i.e. supplemental funding [21]. Their suggestion to mobilize a collaborative strategic plan can certainly be applied to other aspects of training in global health whether it be integrating human rights into government policy, collaborating effectively with civil society, human resources strengthening by task shifting, or improving efficiency through new partnerships and technologies. The framework’s call for “immediate action backed by simultaneous learning” certainly applies to the need for improved training and capacity building in all areas of the discipline.

The birth of global health and its growing pains can be seen as both an opportunity and a challenge in our globalized world of scarce resources. The changes in the discipline described above can be seen as wonderful developments to be taken advantage of. It is important in discussions of global public health not to bemoan our lack of resources or lack of political will as barriers to achieving our goals. More important is the need for pertinent training [22] and an ability to integrate solutions and work together, whether it be to combat the emergence of a highly infectious disease or disseminate a new checklist to improve patient care. All worthwhile initiatives lack funding, but the difference between those that achieve something and those that do not is the way in which they use the limited resources they have. Nowadays, the field of global health can boast enormous enthusiasm, media coverage, technological partnerships and advancement, human rights street cred, sophisticated techniques for data collection and analysis, and reach far across sectors from business to anthropology. We therefore must stop bemoaning what we don’t have and cultivate what we do.

Laura Nolan Khan
Department of Global Health and Population,
Harvard School of Public Health
LKHAN(a)hsph.edu

References

1. Economist Intelligence Unit. Breakaway: The global burden of cancer— challenges and opportunities. 2009. Available from: http://livestrongblog.org/GlobalEconomicImpact.pdf
2. Fried LP, Bently ME, Buekens P, Burke DS, Frenk JJ, Klag MJ, Spencer HC. Global Health is Public Health. Lancet. 2010;375(9714):535-537.
3. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN et al. Towards a common definition of global health. Lancet. 2009. 373(9679):1993-1995.
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6. Riegelmen RK & Albertine S. Recommendations for Undergraduate Public Health Education. 2008. Association of American Colleges of and Universities & Association for Prevention Teaching and Research.
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8. Tarantola D, Byrnes A, Johnson M, Kemp L, Zwi A and Gruskin S. 2008. Human Rights, Health and Development. Technical Series Paper #08.1. Sydney: The UNSW Initiative for Health and Human Rights, The University of New South Wales.
9. Giridharadas A. Africa’s Gift to Silicon Valley: How to Track a Crisis. Accessed March 22, 2010 http://www.nytimes.com/2010/03/14/weekinreview/14giridharadas.html?ref=todayspaper
10. D-Tree International. D tree approach. Accessed April 6, 2010 http://www.d-tree.org/index.php?pid=7
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Party in the Plenary: Global Medical Students take on the world, their way!

Students sharing ideas and inspiration at the Projects Fair, where medical student organisations around the world display their local projects, many of which are community action projects promoting health and tackling health inequalities

What an incredible atmosphere – after days of candidate presentations, deliberations, and heavy campaigning from all sides, the doors to the Plenary room are locked, and 600 medical students from nearly 60 different countries party (as only medics know how) while the votes are counted for the Team of Officials of the IFMSA at the 59th General Assembly in Montreal, Quebec.

The energy in this GA seems endless. Although officially we’re only 4 days in, to everyone here it’s more like a week: with workshops starting at 8.30, and plenaries running till 3am – then partying the rest of the night until the next day’s work begins – sleep is a distant memory. In this intense atmosphere, friendships that span the world are forged, and a new generation of medical students with a truly global perspective marches on towards a brighter future.

Yesterday, despite a particularly sociable evening at the National Food and Drink Party the night before, contracts for nearly 10,000 research and clinical exchanges were signed by our tireless National Exchange Officers (NEO’s) at the Contract Fair. Meanwhile, the Presidents of every National Member Organisation (NMO) met to debate all the changes to the by-laws and all the elections, which are now being voted, even as I type. Other delegates met in the standing committees, which meet every morning to debate and work on the IFMSA’s core interests of public health, human rights & peace, reproductive health (including AIDS), and medical education. Medsin-UK has spread its delegates across all six standing committees, and we’ve been actively inputting into all of these

One of the most exciting things about bringing together so many excited minds together from all across the world in one place is the synergy of ideas that can spark a whole movement. One example is Medsin-UK’s Global Health Education Project – a home-grown project which works to increase global health education in medical curricula throughout the country. Similar efforts are being made elsewhere, and at a Project Fair stall we held we were able to make connections with such projects in countries such as the Netherlands, Australia, and Canada. In time, we hope, a global health education network may grow out of this, spanning countries and continents, and allowing the sharing of ideas.

Canada’s NMO, CFMS, already has been undertaking work on pre-elective training – a key component of global health education, allowing medical electives overseas to be ethical, sustainable, and educational. The UK likewise has been making inroads in this area, such as the University of Dundee’s Medicine in Malawi Project. The natural step is to link these diverse projects up, saving on duplication of effort. CFMS have developed a national curriculum to be included in pre-elective training, and are looking for other countries to share any guidelines they have already developed – with the hope of developing an internationally agreed set of learning objectives.

But perhaps the most important benefit of these gatherings is to make the individual, personal connections, between like-minded students of different nationalities, races, and religions, united in a common goal of promoting health and fighting the perennial diseases that afflict mankind. The party atmosphere in the room could only happen at a student conference – and yet the subjects being debated are no less weighty than those of our more senior counterparts in other international organisations. The unique combination of youth, enthusiasm, energy, and passion provides an inspiration for all to whom the future of global health, faced as it is with failing millennium development goals, catastrophic climate change, and global insecurity, seems at times overwhelming.

The music stops, and the doors are closed – the results of the votes are about to be announced. The night is young, and the future starts tomorrow.

Benedict Warner

3rd year medical student
University of Dundee
benedict.warner(a)googlemail.com

To hear more about the conference from Medsin-UK log on to twitter.com/medsinuk and medsinatifmsa.wordpress.com

Our ‘Campaigning, Climate Change and Health’ workshop at the Pre-GA: representatives from Denmark, UK, Australia, Norway, Taiwan, Indonesia, Canada, Malta, France, Sweden, Peru, Colombia, USA, Iceland, and Venezuela learn how students can influence policy locally, nationally, and internationally and make positive changes for climate change.

Day 2 of the 59th General Assembly of the International Federation of Medical Students’ Associations (IFMSA) and I’m sprawled on the floor at the back of a vast plenary room; around the central stage are three long tables arranged in a horseshoe, at which sit the representatives of medical students from over 90 countries, while motions and amendments flash up on the screen. Right now, IFMSA-Iraq is presenting its candidature to join the IFMSA. It’s incredible to think about the sheer global extent of this organisation, and the fantastic potential of bringing together future health-care professionals from so many different cultures and backgrounds. All this, organised by students, still in the midst of their studies.

If we can do all this, why do bodies like the UN seemingly achieve so little, time and time again, in addressing global challenges which we all recognise?

The IFMSA has existed for over 50 years, and is officially recognised as the global representative body of medical students to the UN and the World Health Organisation (WHO). It has a long history of its members engaging in positive community action to tackle public health challenges in their home countries, and its Standing Committees (which oversee its core work) include ones on public health, human rights and peace, and reproductive health including AIDS.

Medsin-UK has brought a delegation of 12 to this GA, and we’ve tried to spread ourselves across these Standing Committees; I’ve been attending SCOPH, the Standing Committee on Public Health. The IFMSA is an enthusiastic bunch, and every session opens with an ‘energiser’ – much running around and noise-making. SCOPH-ians are particularly lively, and many wear their Standing Committee’s colour of orange. Then follow talks and sessions, ranging from primary health care (delivered by an inspirational family doctor from USA), to rural health care to antibiotic resistance. Fran, another Medsin-UK delegate who is joining me in SCOPH, delivered a session yesterday on how to campaign, and the role of advocacy in public health.

Campaigning and advocacy is something that Medsin-UK has traditionally been very strong on. Advocacy is one of our three pillars of our network (along with education and community action), and over time our members have achieved successes ranging from the Stop AIDS campaign (which has culminated in the creation of the UNITAID Patent Pool), to Universities Allied for Access to Essential Medicines (UAEM) which is encouraging our universities to ensure drugs which come from their research are priced affordably for poorer countries which are dependent on these drugs.

Medical students have a unique role with respect to advocacy. As future health care professionals, we have a duty to our future patients’ health, and many of the inequities in the social determinants of health have political or social root causes. Furthermore, our education and training allows us to identify these causes and to analyse evidence on them. Indeed, as Fran pointed out in her presentation, many doctors use advocacy on a daily basis in their individual consultations – synthesising their understanding of scientific research and ‘pitching’ it to their patients to encourage healthy actions, whether that is to take a medication or to adopt a healthy lifestyle.

Nonetheless, campaigning is not a concept that is universally acceptable, and attitudes differ from one culture to another. As such, the IFMSA has traditionally been reticent to publish policy statements or to take a stance on many public health issues that could be construed as campaigning. One of the aims of our delegation to this GA is to up-skill IFMSA members in campaigning and to open up the conversation on this vital tool to the improvement of health worldwide.

The IFMSA speaks for 1.2 million medical students. When it speaks, the whole world can hear; at the UN climate talks in Copenhagen in December 2009, 5 medical students from the IFMSA were the only representative of the entire health-care profession in the talks, of 20,000 negotiators and heads-of-states.

Perhaps the vast potential in this huge plenary room could one day be realised – perhaps 1.2 million students could not simply speak – to themselves, across their horseshoe tables, discussing their by-laws and amendments – but could shout, to the world, decrying the man-made health inequalities and the greatest global health crisis of the 21st century: climate change.

Benedict Warner

3rd year medical student
University of Dundee
benedict.warner(a)googlemail.com

(If you’d like to find out more about Medsin-UK’s efforts at the IFMSA’s General Assembly, check them out at www.medsin.org/medsinatifmsa)

Here are his answers:

1) Why did you decide to study medicine?

I chose to study medicine to quench my thirst for knowledge. I dreamt of becoming a doctor from my younger days. I realised that this is the only profession where learning would never cease and I would be able to take up new challenges every day in life – that’s very exciting for me!

2) Can you share some things that you wish that someone had told you before you applied to study medicine?

Chill! You don’t have to love maths!

3) What profession would you be in if you weren’t in medicine?

If not medicine, I would most probably be in biochemistry or biotechnology. Something related to medicine and with a possibility of doing research to impact the medical specialties.

4) What is your biggest motivation?

My motivation has morphed from one form to the other as the challenges changed. In the initial years, I just wanted to be a good student but as years passed by and the clinical rotations started, I realized that there was much more to medicine than what one learnt from the books. Through interactions with patients, peers and preceptors, life in all its colours is now opening up before me and I want to a doctor who communicates well, has excellent clinical skills, who puts patients at ease, and is still passionate 20 years on. I’ve got a long way to go, but keeping this is mind really drives me to work hard and succeed. I also want to pursue active biomedical research and make some contributions in this arena too.

5) What are you most interested in so far and why?

For me the most interesting subject has been ophthalmology. To restore vision to someone’s life I feel is the most fascinating feeling!

6) What has been your most difficult module so far and why?

I believe it was the module of microbiology-pharmacology-pathology -forensic science which comprises the second MBBS curriculum. I found it difficult to cope with due to a skewed curriculum that discouraged lateral thinking and encouraged a rote-learning system. Forensics was the worst of all; I still get nightmares about my visit to the morgue.

7) What is the most memorable positive moment in your medical studies so far?

Playing a part in diagnosing a person with AMI in the emergency room and meeting the occasional patient whose resolution to beat the odds remains an inspiration. But some of the best memories remain in the labour room, helping in the delivery of the pregnant ladies and seeing their ecstasy at the end of a tremendously painful experience.

8 ) What is the worst horror story in your medical studies to date?

When I paid a visit to the morgue as a part of my curriculum; to see the skull being crudely broken apart really was horrible.

9) Where do you see yourself in 10 years time?

a) the wishful thinking version

To become a good clinician; a potent researcher with earth shattering ideas. Winning recognition globally ( a Nobel prize would do!!!) and to settle down with my girlfriend.

b) the perhaps slightly more realistic version

Working at a tertiary academic medical centre in ophthalmology with an active research life, finally becoming a respected member of the profession.

10) Can you share some tips/advice for others

a) wanting to study medicine

If you’re interested enough in medicine to have read all the way to the bottom of this page, you’re probably pretty convinced it’s for you already! Jokes apart: do as much as you can to be sure that medicine’s the right thing for you.

b) already studying medicine

Remember how focussed what we’re studying is. There’s so much else to learn about life and, with that in mind, patients can teach us many things. Stick through the subjects you don’t like, but do remember to get your noses out of the text books occasionally and to enjoy life to the fullest. Finally, don’t get stressed by the doctors who’ve forgotten what is like to be a student- they’ll still be that grumpy when they go home, don’t let them bring you down too!

Indrashis Podder
indra88_podder(a)rediffmail.com

When the Group of Eight (G8) met in Huntsville, Canada on June 25-26, maternal, newborn, and child health (MNCH) was at the forefront of the agenda. Six months earlier at the World Economic Forum in Davos, Switzerland, Canadian prime minister Stephen Harper, host of the 2010 G8 Muskoka Summit, declared that MNCH would be the “signature focus”. The Muskoka initiative – what the MNCH effort was eventually titled – was chosen as a priority theme in an attempt to reach the lagging Millennium Development Goals (MDGs) 4 and 5 by their 2015 deadline. Of the eight goals, MDG 4 – to reduce the under-five mortality rate by two-thirds and MDG 5 – to reduce by three-quarters the maternal mortality ratio (MMR) and achieve universal access to reproductive health, were lagging the furthest behind [1].

Going into the summit, it was estimated that an additional funding of $30 billion for the period period 2010-2015 would be necessary to accelerate progress on achieving MDG 4 and 5. Over the next five years, this would prevent the deaths of 1 million women from pregnancy and childbirth complications and 11 million newborns and children under-five. It would end the current unmet needs for family planning services and significantly decrease the number of unwanted pregnancies and unsafe abortions worldwide [2]. If accomplished, each of these outcomes would constitute a significant and much needed step towards eliminating the global gap in MNCH.

At present, the global gap in MNCH is alarming. In high-income countries, the MMR is 5/100,000 live births compared to 109/100 000 live births in low-income countries. In 2008, 342,900 maternal deaths occurred worldwide, the majority in low-income countries [3]. Of the 7.7 million under-five deaths in 2010, 49.6% occurred in Sub-Saharan Africa, 33% in south Asia, and only 1% in high-income countries [4]. These discrepancies illustrate a need for a bold and coordinated initiative to improve MNCH  and to reduce the gap between the healthcare allotted to mothers and children in developed countries versus developing ones.

In the 2010 G8 Muskoka declaration, the leaders outlined their commitment to the Muskoka initiative, collectively contributing a total of US$5 billion in new funding for MNCH. Canada and the United States pledged the highest amounts, committing $1.1 billion and $1.3 billion respectively [5].

In addition to the G8 countries, Netherlands, New Zealand, Norway, Republic of Korea, Spain, Switzerland, the Bill and Melinda Gates and UN Foundations also committed an additional $2.3 billion. The Bill and Melinda Gates Foundation alone contributed $1.5 billion, the single largest contribution made. Collectively, $7.3 billion in new funds were mobilized at the summit [5].

With this contribution, G8 leaders hope to strengthen country-led national health systems in developing countries by channelling funds through existing mechanisms and supporting proven interventions across the continuum of care during: pre-pregnancy, pregnancy, childbirth, infancy, and early childhood. Elements of the initiative will include antenatal and post-partum care, sexual and reproductive health care and services, including voluntary family planning, disease prevention and treatment, prevention of mother-to-child transmission of HIV, immunizations, and basic nutrition. Access to safe abortion was not explicitly mentioned in the Declaration, but may be included under the umbrella of voluntary family planning in certain bilateral projects [5].

As outlined, the scope of the Muskoka initiative is quite large and inclusive of a wide range of critical interventions for MNCH. However, the scale of the initiative is much less ambitious.

In their statement, G8 leaders noted that over the next five years the estimated impact of the $7.3 billion in new funding would include the prevention of 1.3 million deaths of children under five years of age, the prevention of 64 000 maternal deaths, and the provision of modern family planning methods to 12 million couples in need [5]. These improvements will only slightly diminish the global discrepancies in MNCH. Per year, the Initiative will save the lives of an estimated 260,000 under-five children and 12 800 mothers – relatively small figures compared to the millions of lives lost each year due to the lack of funding for healthcare services and providers.

Thus, in terms of value and potential impact, the Muskoka Initiative was largely underwhelming as the signature focus of the 2010 G8 Summit. The money mobilized for the Initiative was significantly less than what many were predicting. It was also significantly less than pledges that had been made in the past. When compared to the $20 billion pledge towards food security made at the 2009 L’Aquila Summit – $6.5 billion of which has already been delivered over the past year – the G8 commitment of $5 billion over five years towards maternal and children’s health is much less ambitious [5].

In the G8 Muskoka declaration, the leaders emphasized that support from the G8 is “catalytic” and that commitments are made “with the objective of generating a greater collective effort by bilateral and multilateral donors, developing countries and other stakeholders” [5]. As previously noted, some non-G8 countries and foundations have already pledged $2.3 billion towards the Muskoka Initiative. However, it is unknown whether this trend will continue after the initial momentum.

Even so, it is unlikely that any additional contribution to the Muskoka Initiative made by a non-G8 country, foundation, or multilateral organization will exceed the $5 billion commitment made by the G8, the primary source of funding for most global health initiatives. It is also very improbable that an additional $22.7 billion – the gap between the Muskoka Initiative funds and the estimated $30 billion needed to accelerate progress on MDGs 4 and 5 – will be generated before 2015.

Improving MNCH is critical for achieving better global health. It will be impossible to reach the MDGs if major improvements are not made. Having MNCH as the signature focus of the 2010 Muskoka Summit was an important and positive first step taken by G8 leaders. Unfortunately, the final G8 commitments towards the Muskoka Initiative were not enough to truly accelerate the progress necessary on MDGs 4 and 5 to significantly reduce maternal, newborn and child mortality.

For real, sustainable improvements to take place in MNCH, momentum behind the Muskoka Initiative must continue. This will be the true challenge for the international community over the next five years.

Robin Lennox
University of Toronto

robin.lennox.2(a)gmail.com

References

1. G8 Research Group. Policy Brief: Maternal, Newborn, and Child Health at the G8. G8 Information Centre website 2010 [cited 11 Jun 2010]. Available from: http://www.g8.utoronto.ca/briefs/index.html.

2. The Partnership for Maternal, Newborn and Child Health. Consensus for Maternal, Newborn and Child Health. WHO website 2010 [cited 25 Jun 2010]. Available from: http://www.who.int/pmnch/topics/part_publications/2009_mnchconsensus/en/index.html.

3. Hogan MC, et al. Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 May 8; 375(9726): 1609-1623.

4. Rajaratnam JK, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970—2010: a systematic analysis of progress towards Millennium Development Goal 4. The Lancet. 2010 Jun 5; 375(9730): 1988-2008.

5. G8 Muskoka Declaration Recovery and New Beginnings. Government of Canada Muskoka 2010 G-8 website 2010 [cited 27 Jun 2010]. Available from: http://g8.gc.ca/g8-summit/summit-documents/g8-muskoka-declaration-recovery-and-new-beginnings/.

Bibliography

G8 Muskoka Declaration Recovery and New Beginnings. Government of Canada Muskoka 2010 G-8 website 2010 [cited 27 Jun 2010]. Available from: http://g8.gc.ca/g8-summit/summit-documents/g8-muskoka-declaration-recovery-and-new-beginnings/.

G8 Research Group. Policy Brief: Maternal, Newborn, and Child Health at the G8. G8 Information Centre website 2010 [cited 11 Jun 2010]. Available from: http://www.g8.utoronto.ca/briefs/index.html.

Hogan MC, et al. Maternal mortality for 181 countries, 1980—2008: a systematic analysis of progress towards Millennium Development Goal 5. The Lancet. 2010 May 8; 375(9726): 1609-1623.

Rajaratnam JK, et al. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970—2010: a systematic analysis of progress towards Millennium Development Goal 4. The Lancet. 2010 Jun 5; 375(9730): 1988-2008.
The Partnership for Maternal, Newborn and Child Health. Consensus for Maternal, Newborn and Child Health. WHO website 2010 [cited 25 Jun 2010]. Available from:http://www.who.int/pmnch/topics/part_publications/2009_mnchconsensus/en/index.html.

Weston Park Hospital

I did my elective in clinical oncology at the Weston Park Hospital in Sheffield, which is one of three specialist cancer hospitals in the UK.  My aim was to confront what I felt was the most difficult part of medicine: end of life care. I wanted to find the elusive balance between being empathetic, without feeling emotionally drained, but neither neglect patients’ emotion needs. Furthermore, I wanted to know whether or not I could cope with death, a topic I had avoided for too long.

Two patients I will always remember. The first was an urgent admission of a patient with new onset amnesia caused by brain tumour. The patient was unaware of his change, but the spouse’s tears emphasised the severity of the amnesia that had eroded his identity.  I did not know what to do or say and my nightmare was becoming a reality. No longer could I hide behind medical facts and I needed to provide emotional support, but how? Thankfully the oncologist intervened by pacing his succinct information in relation to their emotions and concerns.

This patient underwent emergency neurosurgery but treatment was not curative. I felt sad, but this was actually sympathy since the treatment bought the patient time to compress his most important life experiences into the limited time frame and still feel fulfilled. Now I understood why I would not engage emotionally with palliative care patients as this always made me question my own mortality. However, death no longer bothers me, as I have seen how people can adapt by accomplishing achievements they would have otherwise postponed or abandoned altogether.

The second patient was pregnant and had delayed her cancer treatment till after childbirth. This might avoid the risk of harm to her child related to the treatment, but this might also raise the likelihood of a worse prognosis for her. Initially, it felt odd to provide treatment that was not curative, but allowing symptom control so that she could arrange plans for her child’s care, made me feel satisfied and privileged in supporting her. No longer did oncology appear to be concerned with death, but about preserving patients’ options, opportunities and hope.

Overall, oncology is useful for revision because it is a multi-system specialty that involves all age groups in addition to its many social issues and so this encourages students to be more holistic in their management plans. Furthermore, this elective helped me broaden my understanding of palliative care, chemotherapy and radiotherapy planning which showed me how to apply anatomy to clinical situations. There are many opportunities to practise and develop your own communication style with patients, as well as when liaising with colleagues in medical and surgical specialties. Also, the doctor-patient relationships are more personal and humane due to frequent outpatient follow-up, which is uncommon in most other specialties. This hospital also offers a variety of lab based and clinical research projects to pursue since your timetable will be flexible and can be tailored to your needs.

The advantages of staying in the UK for your elective is that what you learn will be fully applicable to your future practice and it will provide you useful networks that could be invaluable for securing later training posts. Also you will know more about the workplace and area to help you decide whether or not the post is suitable for you.

Finally, my patients have led me to re-think what is most important to me and to not leave things until later, as unlike my oncology patients, I do not know how much time I have left.

William Lee

william_22_lee(a)hotmail.co.uk

Also, scroll down to read the news update from our regional advisor in Pakistan on the recent floods in the country!

Source: Polar

Risk factors, commonly used in epidemiology, are variables that are associated with an increased risk of pathology. These are important measures, as knowing individuals who are at risk enables health professionals to design programmes to prevent the onset of disease or prevent further problems if the disease has already presented.

There are several risk factors, both modifiable and non-modifiable, that currently exist for cardiac diseases. Age, gender, and family history are the main non-modifiable risk factors. The major modifiable risk factors include smoking