Category Archives: Public Health

In my mind, it is a subset of Global Health, often more locally focused.

Play with Big Tobacco and you will be tarred

Philip Morris International (PMI), profits by selling the world’s leading cause of preventable death — tobacco. The Foundation for a Smoke-Free World (FSFW) recently handed PMI a public relations coup by accepting a $1 Billion donation. Who now could credibly work with FSFW?

PMI is the world’s largest, international tobacco company. It is quite explicitly not interested in a tobacco-free world and it works hard and secretly to subvert tobacco control. Its raison d’être is the sale of tobacco products, and the “smoke-free world” cover provided by FSFW looks like a Big Tobacco tactic in a long line of them.

There is little doubt that FSFW as an organisation has placed itself in moral jeopardy by accepting PMI’s money: “Moral jeopardy occurs when a person or an organisation attempts to do good using resources from a source that involves harm.” And here is the rub. One of FSFW’s stated goals is to support global research through the support of “Centers of Excellence”. Any research group, however, that accepts FSFW money is exposing itself to moral jeopardy. And like other health and medical research outputs from conflicted industry sources, the results cannot be trusted — no matter how genuine the researchers are in their belief of independence.

PMI’s money laundering scheme for researchers may provide a scent of freshness, but the tobacco tar will stick.

Does global health need a ‘red team’?

Looking at population health, time-series data it is easy to imagine that everything is getting better and better. What is more, as your eye tracks the line into some imaginary future, it is easy to believe that things will continue to get better and better. It is a soothing balm to the more insidious thought, that doom awaits us around every corner. In the world of stock pickers and equities experts, the balm is the Ying of the bull to the Yang of the bear. Hope versus despair.

The late Hans Rosling has done more to ground people in that hopeful view of the future than any other person. The gapminder website, his creation, provides clear, firm evidence of global improvements in health and well-being across a wide range of outcomes. As you follow the motion picture trends, countries improve. Some occasionally collapse, horribly. Then they recover. And on average, all improve. Poverty, life expectancy, education, the infant mortality rate — it does not matter what you focus on, the world has been getting better and better

Figure 1 is a quick snapshot of this improvement in life expectancy from 1915 and 2015. In both years, higher national wealth was associated with better life expectancy. In 1915, a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 30 years. In 2015 a country with a GDP/capita (adjusted for inflation and price) of $1,000 had a life expectancy of 60 years.

Figure 1. The left and right panels show the countries’ life expectancy in relationship to the GDP/capita (adjusted for inflation and price) 100 years apart. In 1915 a country with a GDP/capita of $1000 had a life expectancy around 30 years. In 2015 it was around 60 years — a difference of about 30 years. Source: Gapminder

In contrast, in the middle of the 18th Century, life expectancy was similar across all countries, without regard to national wealth. Little had changed by the middle of the 19th Century. Sixty years later (1915), there was a strong association between national wealth and life expectancy; and over the next 100 years, things became much better for everyone.

Will this continue?

Let’s hope that it will. There are however significant threats visible on the horizon — and I would argue that Global Health needs a strong Red Team to make plain that dreadful prospect, often and forcefully. And as the Red Team argues their side we should hope fervently that they are utterly and comprehensively wrong! We should nonetheless listen to the arguments and not glaze over or dismiss them as we would Cassandra.

Red Teams arose in the US military and intelligence communities. They were there to argue against self-satisfied complacency. If the majority view was purple, they argued orange, if Winter, then Summer. Their purpose was to find the weaknesses in the status quo. One of the most extraordinary examples of the power of a contrarian view was the Millenium Challenge 2002, in which Paul van Riper showed that a demonstrably weaker force (the Red Team) could be devastatingly effective against the powerful (Blue Team) when they were prepared to play outside the constrained paradigm of accepted norms.

In Global Health the situation is, of course, entirely different — we do not battle each other, but we do struggle with (and against) nature and the environment. What is not different between Intelligence agencies and Global Health agencies is that views become entrenched. The Philosopher of Science, Thomas Kuhn, described the entrenchment of scientific ideas in terms of normal science: “the regular work of scientists theorizing, observing, and experimenting within a settled paradigm or explanatory framework”. These “settled paradigms” can permit significant new developments, but they brook no serious opposition (only tinkering at the margins). They are the VHS manufacturer to the plucky Betamax.

“Beta what?”, I hear you ask, and the point is made.

Global Health has large, powerful groups that are in danger of playing a form of technocratic hegemony — Global Health, normal science. It’s incremental, unabrasive, and potentially wrong or ineffectual. Some of the possible threats to global health are well known, and if we focus only on those related to climate change and population growth the following is a reasonable starting list:

The global expansion of humans over the past 10,000 years was made possible by the growth of agriculture, which in turn was made possible by a stabilisation in the climate about … 10,000 years ago. Our current success is again a product of agricultural developments. Paul Ehrlich, in his 1968 book The Population Bomb wrote a Malthusian tale of global starvation. His prediction failed to take account of Norman Borlaug’s green revolution, and the development of semidwarf wheat, which saw grain yields triple in the 1960s and 1970s. The predicted cycle of devastating starvation was averted.

Success in the past, unfortunately, does not tell us anything about the future. Timely science then does not predict timely science now. Although Borlaug’s work saw Ehrlich’s predicted threats displaced in time, towards the end of his Nobel Prize acceptance speech, Borlaug said:

Malthus signaled the danger a century and a half ago. But he emphasized principally the danger that population would increase faster than food supplies. In his time he could not foresee the tremendous increase in man’s food production potential. Nor could he have foreseen the disturbing and destructive physical and mental consequences of the grotesque concentration of human beings into the poisoned and clangorous environment of pathologically hypertrophied megalopoles. Can human beings endure the strain? Abnormal stresses and strains tend to accentuate man’s animal instincts and provoke irrational and socially disruptive behavior among the less stable individuals in the maddening crowd.

We must recognize the fact that adequate food is only the first requisite for life. For a decent and humane life we must also provide an opportunity for good education, remunerative employment, comfortable housing, good clothing, and effective and compassionate medical care. Unless we can do this, man may degenerate sooner from environmental diseases than from hunger.

So far, the international, multilateral approach to a possibly gloomy future is to seek hope — it does, after all, spring eternal. We will reduce greenhouse gas emissions, tackle global poverty through economic growth, and increase food production. We will not need to tackle population growth, nor will we have to make do with less. We write about planetary health, but we do not develop strategies for a planet that is less human-friendly tomorrow than it is today.

I hope that global health and well-being will improve well into the future, well past my life and I hope well past that of my children, (and their children, …). In case it does not, I would like to think that there is a Global Health Red Team that does not just echo gloomy news in the halls of power, but argues for and develops strategies suitable for the world in which we are all worse off. What should our goal be in that worse off world? Is it a global goal, an equitable goal of mutual pain, or is it a “My Country First”, Shakespearean tragedy of the commons?

There is an ironic twist to the use of Red Teams in the US military that may have some bearing on their use in Global Health. In the Millenium Challenge 2002 when the Red Team devastated the Blue Team in the first few days of a fortnight-long exercise, the judges reset the clock. They hamstrung the Red Team, and then let everything play out in a way that would ensure that normal (military) science came out unscathed.

Global Health needs to be intellectually braver.

Would you give knee surgery to the FAT MAN?

I do understand your plight, Mr Smith. An arthritic knee can be extremely painful. And you say it’s so bad you can’t even walk from the living room to the kitchen. That’s actually very good news! Yes, yes … awful … but terribly good news. If you can’t walk to the kitchen, you can’t eat. If you can’t eat you’ll lose weight. And the faster you lose weight, the sooner we’ll schedule your knee surgery.

On 15 March 2017, Dr David Black, NHS England’s medical director for Yorkshire and the Humber, sent a letter of praise to the Rotherham Clinical Commissioning Group (RCCG). The RCCG had decided to restrict the access to smokers and “dangerously overweight patients” of hip and knee surgery. The letter was leaked, and it has triggered, according to the Guardian, “a storm of protest.”

The title of this blog is a play on David Edmond’s book, Would you kill the fat man, an exploration of moral philosophy and difficult choices about the valuation of human life. The RCCG’s decision intrigued me. It was essentially a decision about rationing a finite commodity — healthcare. In a world of plenty, rationing healthcare is a non-question. In the real world, however, in a world of shrinking healthcare budgets and a squeezed NHS, resources must be allocated in a way that means some people will receive less healthcare or no healthcare. Fairness requires that the rules of allocation are transparent and reasonable.

While you ponder, whether you would give knee surgery to the FAT MAN, I have a follow-up question. Would you want to see a doctor who would deny you knee surgery because of some characteristic of yours unrelated to whether you would benefit from knee surgery?

I am sorry Mrs Smith, today we decided not to offer clinical services to women, people under 5’7″, or carpenters. We need to cut the costs of our clinical services, and by excluding those groups, we can save an absolute bundle.

I have heard it said of the doctor, academic and human rights advocate, Paul Farmer, that he would regularly re-allocate hospital resources from Boston to his very needy patients in Haiti. He used to raid the drug stocks of a Boston hospital, stuff them in his suitcase and fly them back to his patients in Haiti. I have no idea if the story is true or not. It does mark, however, one of the great traditions of medicine. The role of a doctor is to advocate vigorously for the health (and often social) needs of the patient. The patient actually in front of them. The one in need. Because, if your doctor will not advocate for your health needs, who will? This is why all the great TV hospital dramas show a clash between the doctor and the hospital administrator. Administrators ration. Doctors treat. The doctor goes all out to save little Jenny, against all odds. The surly hospital administrator stands in front of the operating room, hand outstretched and declares (Pythonesque): “None shall pass.”

Under the current NHS system of clinical commissioning groups, there are family doctors who are simultaneously trying to make rational decisions about the allocation of limited resources to a population, and trying to be the best health advocates for the patient in front of them. That screams conflict of interest. If you live in the catchment area of the RCCG and want my advice, check out which doctors are part of the RCCG. If your doctor is one of them, change doctor immediately. Treating you, advocating for your health interests is what you need and should want. Unfortunately, if she is part of the RCCG when she is treating you, you are not her principal concern. Run(!) assuming of course that you don’t need knee surgery.

Should smokers and overweight people receive knee surgery? Let’s start with smokers. Why would you not want to treat a smoker? It is difficult to come up with arguments that are not so outrageous that they are embarrassing to make. But I won’t let personal embarrassment get in the way of stating the top two silly arguments that came to mind:

Smoking is a disgusting habit and anyone who smokes deserves all the pain they get?
Smokers won’t live as long as non-smokers, so the investment in surgery to reduce pain and improve mobility in smokers will not have the net benefits to society as the same investment in non-smokers.

The arguments for restricting the surgery to people who are not overweight are similarly cringe-worthy. There are also clinical reasons for prioritising the overweight. The load on joints resulting from increased weight creates greater wear-and-tear and, the broader inflammatory processes that obesity triggers also seem to increase the risks of osteoarthritis — affecting hands as well as knees. [See for example, here and here].

I can’t find the RCCG’s arguments for restricting access to knee surgery for smokers and people who are overweight, but prima facie it looks a lot like a variant of victim blaming.

Full disclosure. I am all for the rational allocation of resources. I think smoking is a disgusting habit. I am overweight and trying to do something about it. I also think that the arguments for resource allocation need to be more explicit about the social values upon which they are often implicitly based.

Babies have less than a 1 in 3 chance of recovery from a poor 1 minute Apgar score

We recently completed a study of 272,472 live, singleton, term births without congenital anomalies recorded in the Malaysian National Obstetrics Registry (NOR). We wanted to know what proportion of births had a poor 1 minute Apgar score (<4); and the likelihood that they would recover (Apgar score ≥7) by 5 minutes.

As we noted in the paper:

While the Apgar score at 5 minutes is a better predictor of later outcomes than the Apgar score at 1 minute, there is a necessary temporal process involved, and a neonate must pass through the first minute of life to reach the fifth. Understanding the factors associated with the transition from intrauterine to extrauterine life, particularly for neonates with 1 min Apgar scores <4, has the potential to improve care.

Surprisingly, to me at least, we could find no research looking at that 1 minute to 5 minute transition. Ours was a first.

From the 270,000+ births, you can see (Figure 1) that the probability of a 5 minute Apgar score ≥7 rises dramatically as the 1 minute Apgar score increases. There is an almost straight line relationship between a 1 minute Apgar score of 1, a 1 minute Apgar score of 6, and the chance of a 5 minute Apgar score ≥7.

Fig 1: The probability (with 95% CI) of an Apgar score at 5 min (≥7) given any Apgar score at 1 minute

A 1 minute Apgar of 6 almost guarantees a 5 minute Apgar score ≥7; in contrast a 1 minute Apgar of 3 has only a 50% chance of recovery, and a 1 minute Apgar of 1 has only less than a 10% chance of recovery.

Fortunately, only 0.6% of births had poor Apgar scores (<4). The type of delivery (Caesarean section, or vaginal delivery) and the staff conducting the delivery (Doctor or Midwife) were both significantly associated with the chance of recovery. The challenge is working out the causal order. Do certain kinds of delivery cause poor recovery, or are babies likely to have poor recovery delivered in particular ways? Does the training of Doctors or Midwives exacerbate/improve the risks of poor recovery, or are babies likely to have poor recovery delivered by particular personnel?

Our study cannot answer the questions, but it does raise interesting points for future studies of actual labor room practice — questions not easily answered with registry type data.