Archive for July, 2018

AmritaFor me, the journey as a public health registrar began with an exploration away from clinical medicine in 2010. I first started to contemplate a career in public health when I was still at medical school, inspired by a friend who was thinking about going into the specialty herself after she had done her ‘elective’ in Sierra Leone. (Somehow she ended up becoming a breast surgeon but never mind!)

After that conversation I reflected on my own elective in India, and my friend’s sentiments resonated with my experience too – the seedlings of a career in public health had been planted in my mind.

Despite this, I knew I wanted to get some clinical work under my belt first and paediatrics was the obvious choice as my passion for child health started when I was a sixth-former and worked as a regular volunteer in a respite home for children with severe learning difficulties.

Fast forward five years, and I had completed 3 years of specialty training, membership exams and borne witness to the fairly extreme highs and lows of paediatrics, seeing children die being an experience which really stays with you forever. I had also worked rotas involving 1 in 2 weekends for 24 months, rotas which were constantly over-stretched and under-staffed.

But often the most frustrating aspect for me was that things could be done differently. Being so busy I rarely had chance to use the toilet let alone sit down for lunch, I wondered if the 2 week-old baby with prolonged jaundice (likely due to breast milk), really needed to be seen in the same setting as all the acutely unwell children. Or if the kids referred by GPs with diarrhoea and vomiting could have their fluid challenge at home rather than in hospital. Or if something could have been done to prevent the babies born 12 weeks prematurely from being preterm in the first place. Many of these babies made it, some didn’t but all of them experienced countless interventions along the way.

Public health was definitely the career choice for me but it was with a heavy heart that I left paediatrics and I will never forget the Training Programme Director’s parting words: “It’s a revolving door, you can always return”. But I was pregnant and glad to be doing a job that was stimulating, proactive and afforded me a better work-life balance than I’d ever experienced before.

Through public health training, I have learned so much and passionately enjoyed my work. All that I now understand about wider determinants, health inequalities, access, care pathways, integrated/person-centred care, wellbeing, prevention and social prescribing have helped me to make sense of my 5 years on the frontline.

However, those clinical years are now some time ago and things move on. In addition I have felt increasingly that the public health ask of frontline staff can sometimes seem overwhelming and yet I recognise that there are golden opportunities to make those crucial contacts really count.

To reconcile this, to see how things have moved on and because I missed it, after 8 years I have recently returned to the frontline as a specialty doctor in community paediatrics, undertaking a clinic per week alongside my training in public health.

It’s early days. There have been some ‘typical’ issues to do with IT etc., but I am very fortunate to be supported by lovely colleagues who have known me for a decade or more.

The patients, and their families, are fascinating. There is a richness to each story – often shared with me via an interpreter. The social determinants of health are illustrated in every story – both the resilience that comes from strong, loving supportive relationships and the consequences of isolation, poor housing and poverty. And as far as putting public health into practice goes, for each family there may be multiple issues. But often at a given point in time, there is one issue which is most pressing – and this may be a felt need, an expressed need or a normative one. The art of public health on the frontline is to work out and try to address that particular need.

Written by Dr Amrita Jesurasa

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The eyes of a mother who has suffered the loss of a child can destroy the soul of anyone who gazes upon them. More souls become casualties of war than physical bodies.

Suzy Kassem, Rise Up and Salute the Sun: The Writings of Suzy Kassem

Medicine, in its entirety, is a one of the most noble, worthy and charitable professions. It is very close to human beings’ existence in alleviating pain and curing disease. Even in the worst conditions, in conflict stricken areas, healthcare workers continue to save lives. This was translated as a fundamental principle of the International Humanitarian Law to protect healthcare workers and health facilities in conflict zones.

Over the years conflicted parties have swapped locations of health care workers and facilities and agreed to keep them secure during conflict. Unfortunately it is not always possible to do so and targeting healthcare workers has been documented in many situations.

By its very nature, armed conflict is a dirty business and a risky place to be yet there are selfless people who put their lives at risk in the front line saving others’ lives. This is the ultimate generosity and beyond description. To target them is a war crime to say the least.

The consequences of such attacks are significant. Even one attack on a healthcare worker is too many! Each loss of life of a healthcare worker or healthcare facility is not just the loss of a life, which in itself is momentous. It is also the loss of many years of investment, the loss of a community’s social asset, the loss of a body of knowledge, the rupturing of the arterial mesh work of society, the very pulse of humanity and the theft and destruction of something sacred.

To statisticians, the sad story of the 21 year old nurse who was recently killed by the Israeli army while on duty saving lives is yet another number but can we make her life count?

This statistic is part of an increasingly worrying trend: the indiscriminate killing of healthcare workers and targeting of healthcare facilities in areas of conflict.
Razan An-Najjar was a 21-year-old female volunteering as a first responder, while carrying out her humanitarian duties with the Palestinian Medical Relief Society (PMRS). Her death has once again questioned the sanctity of human life, the right to healthcare and the poorly observed International Humanitarian Law that assure this safety.

“Healthcare workers must be allowed to perform their duties without fear of death or injury,” said the Humanitarian Coordinator, Mr. Jamie McGoldrick. “The killing of a clearly-identified medical staffer by security forces during a demonstration is particularly reprehensible”.

The WHO uses the Surveillance System of Attacks on Healthcare (SSA), a global standardized and systemic approach to collecting data of attacks on health care facilities and workers. In the first quarter of this year (2018) alone there have been 149 attacks on healthcare workers, 221 deaths and 261 injuries across 13 countries and territories. This is a huge underestimate of the scale of loss due to global violence.

All casualties of war are avoidable. Razan was a civilian, was unarmed, wearing her white paramedic coat and tending to the injured when she was shot in the back. What protection do healthcare workers get, what international or national laws governing their safety and amnesty can we hold people, ideologies, states and countries to account against?

When will the international community wake up and enforce stricter penalties for those who infringe the law, what will it take to regain humanity? If the white dove is a symbol of peace and the white flag is used as an international symbol of surrender or being unarmed then why can’t we make the white coat a symbol of #NotATarget? Healthcare professionals all around the world should raise this issue with their governing bodies, with their governments, with the public, at each World Humanitarian Day and at every opportunity.

We reiterate the British Medical Association’s demand to respect medical neutrality and call upon adversaries to secure the safety of healthcare workers and health facilities in the affected areas. Further considering the significant number of British healthcare workers who volunteer to work in conflict zones it is prudent as healthcare workers we highlight these issues and raise our concerns to ensure their safety is maintained whilst on duty.

“Never think that war, no matter how necessary, nor how justified, is not a crime.”

Ernest Hemingway, Ernest Hemingway: A Literary

Written by Dr Samia Latif, Consultant Communicable Disease Control and member of FPH’s Global Violence Prevention Special Interest Group (SIG), and Dr Bayad Nozad, co-chair of FPH’s Global Violence Prevention SIG.

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This is the first in a series of blogs written in appreciation of Dr Julian Tudor Hart who died on 1 July 2018. To read the post written by John Wyn Owen, click here.

Dr Julian Tudor Hart

Dr Julian Tudor Hart (Image: Wikimedia Commons)

Julian Tudor Hart was a visionary leader who combined advocacy for equitable primary care and social justice, trenchant critiques of market influences in health care and innovative research showing how whole population approaches to improving health could transform primary care. Amongst his seminal works his paper ‘The Inverse Care Law’ published in The Lancet in 1971 is perhaps the best known and still widely quoted. It documented how those who most need high quality health care are least likely to receive it and how privately funded and delivered health care undermined high quality universal coverage. He observed that the removal of market forces from the provision of primary care with the advent of the NHS had resulted in improved access for disadvantaged populations, concluding that ‘a national health service can run quite well without the profit motive, and that the motivation of the work itself can be more powerful in a de-commercialised setting’.

At a time when the sources of funding for the NHS are being reviewed it is instructive to see that such debates have been an enduring feature of the political landscape. In his paper Julian noted that even at that time some politicians believed that the ceiling for tax-based funding of health services had been reached and that additional funds should be raised by out-of-pocket payments. This perception proved incorrect and expenditure on health care from taxation subsequently increased, thus avoiding the regressive effects of charging for health care at the point of use.

Unusually, Julian Tudor Hart combined authorship of classic papers with many years of clinical practice in primary care focusing on disadvantaged populations, driven by his political commitment to socialism. Following a period as a general practitioner in a practice caring for a deprived community in Notting Hill, West London he worked for 30 years as a general practitioner in Glyncorrwg, a former mining village in the Afan Valley, South Wales. Influenced by luminaries such as Archie Cochrane and Richard Doll, he was a pioneering exponent of combining an epidemiological population approach with clinical practice. He articulated a whole population approach to the control of high blood pressure using the opportunity presented by patient contacts with primary care services to measure blood pressure and other key cardiovascular risk factors and showing that, through such ‘anticipatory care’, virtually 100% coverage could be achieved. His practice was the first to be designed as a research practice by the Medical Research Council and undertook a range innovative studies, mostly based on Julian Tudor Hart’s own work. He provided an unparalleled opportunity for young researchers and general practitioners in training (including myself) to learn from his unstinting commitment to rigorous research and high quality clinical care in a well-defined but socially disadvantaged community.

A paper in the BMJ with many of his research fellows in 1993 described more than 20 years follow up of screen-detected hypertension in people under 40 years of age. Several important papers on salt intake and hypertension contributed substantially to understanding of the relationship, including providing evidence against the hypothesis that people with a family history of high blood pressure show greater sensitivity in their blood pressure response to dietary sodium compared to those without a family history (Lancet 1983). He also had the courage to put his own clinical practice under the spotlight in a paper describing the results of an audit of 500 consecutive deaths (BMJ 1987).

Julian Tudor Hart also had strong views about medical education and the prerequisites for effective practice in primary care. He was an early advocate for departments of academic general practice in medical schools – an aim which still remains unfulfilled in many countries . His visionary book ’ A New Kind of Doctor’ was written for ‘students, doctors, other health workers, and non-medical people interested in the National Health Service (NHS), regardless of their political affiliations’. In it he examines the social context in which health care is delivered and articulates a vision for professionalism which encompasses working with patients as active partners to co-create health, addressing health and disease in many cases as a continuum requiring whole population approaches, and widening the recruitment of doctors so that they become more representative of the population they serve. Although his own commitment to Socialism was made clear and exemplified by his Presidency of the Socialist Health Association, his outstanding communication skills and clarity of thought meant that his ideas were often well received by those from a range of political perspectives. The 40th anniversary of the Alma Ata declaration in 2018 reminds us that the central message from ‘The Inverse Care Law’ and his outstanding body of writing and research about the central importance of universal primary health care to a civilised society is as relevant as ever.

Written by Prof Sir Andy Haines

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#futureofpublichealth: this is the second in a series of blogs that aims to champion the prevention delivered in NHS settings as part of the NHS at 70 celebrations and FPH’s public health funding campaign

Sarfo-Annin Jason PG

The success in the decreasing prevalence of smokers in the UK is largely due to programmes and actions taken out of the hospital. Since 1999 the public has had access to free Stop Smoking Services; patients can be directed to a local smoking cessation service where trained staff can prescribe medications and give support to people attempting to quit. Other levers that have worked to reduce smoking include public policy initiatives – the introduction of smoking bans, restrictions on advertising and packaging and increased taxation on cigarettes. No single department of government is responsible for these policies, showing that prevention works best when there is joined up or complementary policy across the different domains of government.

It is easy to see how preventing disease is a challenge for health care professionals based in hospitals – so much of the work of prevention is implemented and paid for by local authorities and is best managed beyond hospital walls. That said, people working in a variety of NHS settings play a huge role in promoting and delivering prevention-based services to patients. In my current post working in obstetrics & gynaecology, some of my work in prevention involves encouraging pregnant women to stop smoking. Smoking in pregnancy increases the risk of complications in pregnancy such as premature birth and miscarriage. Parental smoking also increases the risk of sudden infant death syndrome and children developing health conditions, such as asthma, later in life. These dangers have led to many hospitals employing smoking in pregnancy specialist midwives. These midwives can be based at a hospital seeing pregnant women in clinics, in the community seeing women at home – or a mixture of both. They play a vital role in making sure that new mums get the support they need during pregnancy, from signposting to mental health services to breastfeeding advice.

There are many other hospital-based prevention schemes. For example, specialist staff in drug and alcohol addiction or multi-disciplinary teams working in strength conditioning in the elderly to prevent falls. All of them take advantage of both a captive audience when in hospital, and the close relationships between patients and staff. Unfortunately, there are problems on the horizon where the hospital-based models of preventative care described will not be enough.

Multi-morbidity, i.e. having more than one disease, is the great challenge for my generation of doctors and indeed all hospital-based health care staff. Many medical problems that we see in our patients, such as heart attacks, stroke and diabetes are connected to preventable conditions, like obesity. There are no easy solutions to the obesity epidemic, but what is clear, is that reminding patients of the recommended daily calorie intake or the recommended weekly amount of exercise and then signposting to local weight loss programmes alone isn’t going to solve the problem.

As the number of obese people grows, the NHS is seeing a rising demand for bariatric surgery and services. Whilst such operations are important and ‘preventative’ in that they contribute to tackling obesity-related diseases, the aim should be to avoid performing surgery in the first place. Obesity is a more complex problem than smoking. It touches upon many important areas of life – local government, education, transport, housing and planning, health and social care, food standards and so on. Therefore, like smoking, action at the population level is needed to address the growing epidemic.

Doctors working in the NHS have an important role to play in preventing disease in patients. However preventative medicine isn’t the primary role of a gastroenterologist, breast surgeon or a general practitioner. Furthermore health care is not the major contributor to the health of individuals. So, a future approach to delivering prevention must include, in addition to the health care system, broader public health activity in the community. Programmes are needed that focus on the wider determinants of health, such as socio-economic status or housing. Public health professionals are trained and best equipped for this field – not hospital doctors. Preventative interventions created and delivered by the NHS need to be supported with the work of public health professionals in developing and contributing to public policy and delivering effective programmes and support in communities.

Joined up thinking across national and local government is a pre-requisite and I do not believe we currently have a robust system to deliver this. I’d propose a ‘Cabinet of Public Health’ formed of senior public health professionals whereby cabinet members and their teams would work within and as part of government departments assessing the health impact of proposed policy. Regular meetings would aim to develop ways of joining up policy to tackle complex issues like obesity or poverty and the impact these have on health. There would need to be a role for contributions from primary and secondary care in such a system. This could be input from Royal Medical Colleges or by recruiting clinicians as National Medical Directors for various medical specialties or chronic conditions.

NHS clinicians that deliver prevention, as well as cure, will be important contributors to improving the health of the population and creating a sustainable health care system. However, it would be folly to think the NHS or the health and social care system can deliver prevention alone. Smart and connected public policy with the accompanying funding to enact it, must reflect this reality.

Written by Jason Sarfo-Annin, GP Registrar and Academic Clinical Fellow in Primary Care. You can follow Jason on Twitter @Dr_JSA.

Note from FPH: As we celebrate the NHS at 70, many in the health community are taking this moment to ask some big questions about the kind of future we envision for our health system and the level of funding support necessary to realise it. We believe that public health and prevention must be central in this national debate about the future of NHS funding and we’d like your support to help us make that case. If you’re an FPH member or work in the NHS delivering prevention, please consider joining our ‘sounding board’ of members and clinicians who are helping us develop policy on this issue. For more info, please email policy@fph.org.uk.

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