Better Health For All

As a paediatric registrar I saw a 10 year old girl exsanguinate. She had been in a high speed road crash in which both her parents had been killed. She was sitting in the back wearing a lap belt. It had ruptured her spleen and liver. She was fully conscious but deathly pale and my job was to look after her airway. She asked, ‘will I be alright?’ and I said, ‘yes – but we need to do an operation to stop the bleeding in your tummy’. I gave her an anaesthetic and took her up to theatre but she died on the table. Her death hit me like a hammer and her memory has lived with me ever since.  

About 20 years later, working with doctors world-wide, we eventually found a safe and effective treatment for acute traumatic bleeding. It might have saved her life. The CRASH-2 trial showed that early administration of the anti-fibrinolytic drug tranexamic acid – usually known as TXA – reduces bleeding deaths by one third. Globally, this cheap generic drug could save over 100,000 lives each year.  

But how do we get this result into practice?  

Because this was the first time we had found a treatment that actually worked in trauma patients, we had never done this before. We had to learn fast. Thankfully I work with some very able and committed people – Professor Haleema Shakur-Still who co-directs the LSHTM (London School of Hygiene and Tropical Medicine) Clinical Trials Unit with me in particular.  We worked with victim organisations, the media, clinicians and policy makers (the Chief Medical Officer, National Clinical Director, NHS Trusts, World Health Organisation). We got tranexamic acid on the WHO List of Essential Medicines. The British Army put TXA into combat care protocols and in 2012, the US Army reviewed the evidence from the CRASH-2 trial and included TXA into its treatment protocols.  

We worked with the road traffic victim’s organisation RoadPeace to monitor the implementation of TXA across the NHS. RoadPeace sent Freedom of Information requests to all NHS trusts on an annual basis asking about TXA use. We lobbied the BBC to include TXA in emergency care soaps such as Holby City and Casualty. We worked with the National Clinical Director for trauma to include TXA in the standard contract for trauma services and with Ambulance Trusts on pre-hospital TXA use (TXA was later included in Ambulance guidelines). Slowly TXA use in the NHS started rising.  

Recent trauma audit data show that TXA use in NHS trauma has increased from zero in 2010 to over 75% in 2016. But there is lots more to do. One major new challenge is to increase the use of tranexamic acid in women with post-partum haemorrhage (PPH) in low and middle income countries. Our second global trial in acute severe bleeding was the WOMAN trial which enrolled 20,000 women with PPH from over 20 countries world-wide. Again we found that tranexamic acid reduces bleeding deaths by one third. Getting research into practice in high income countries is a lot easier than in low and middle income countries where there is poor health service infrastructure but no mother should die for the lack of a drug that costs less than a dollar.  

Winning the Bazalgette Professorship – Champion of Evidence Award – is a real shot in the arm. I had always revered Bazalgette’s contribution to public health and often talk about him to the students. I hope that this award will somehow help us to get TXA to every patient who needs it.  

Written by Ian Roberts, professor of epidemiology and public health, and co-director of the Clinical Trials Unit at LSHTM. Professor Roberts is the first person to be awarded the FPH Bazalgette Professorship Champion of Evidence Award. The Award, presented in collaboration with the Alliance for Useful Evidence, recognises a Fellow of FPH for major contributions to public health policy and/or practice through research translation for the benefit of UK population health.