Science without borders, numbers with intent

Preeminent sword-swallowing toxico-nutritional neuro-epidemiologist Hans Rosling just leapt on the table.

Gymnastics in service of illustrating a point (and charming the crowd) during his keynote speech at the Médecins Sans Frontieres (MSF) Scientific Day in London last Friday, and he’s waving his arms enthusiastically.

Intelligent data can do that  – draw insight and outrage from dense statistics, and make you want to stand 10 feet tall so people can see what you see.

For instance a better view of the impossible equation facing the ministry of health in Vietnam today, which Hans challenged the audience to balance: a disease panel equivalent to America in the 1980s divided by the resources of the U.S. economy in the 1960s, multiplied by popular demand for 21^st century technology.*

Answers on a very large postcard.  Please.

Or the view from Lagos State, Nigeria, where the maternal mortality ratio is 545/100,000 live births (one of the highest in the world, compared with 8.2 in the U.K., 16.7 in the U.S.). That’s bad, but sub-regional data focuses the binoculars, and  it gets much worse: MSF research has shown that in two of Lagos’ urban slums, the ratio is nearly double – a sinkhole of a crisis unseen except by those who are falling in.

Responsive and responsible statistics can give vulnerable populations a table to stand on, and global health workers a more effective place to begin.  They can help allocate resources and advocate for change.

In other words – heck, in Bill Gates’ words! – measurement matters.

So say the professionals – so says Lifebox - and so says MSF, whose Manson Unit aims to use medicine, lab work and epidemiology to identify developments in the management of medical issues and help MSF field projects to put these changes into practice.

“What is the most important next step in improving research IMPACT in MSF?”

And our audience survey says:

Make sure all MSF research is freely accessible to everyone, by publising in open access journals (39%)

MSF has been presenting research findings at its yearly scientific conference since 2004 (holy archives!) and seems to aspire to a central message: to make a useful impact in global health, we have to listen.

Listen to patterns, listen to colleagues, and most obviously listen to the needs of those groups we are trying to support against a vastly unequal setup.

“Do we actually know the people in the refugee camps?  Do we know their needs?” asked Philipp du Cros, head of the Manson Unit.

For MSF, this has most recently meant investigating reports of excessive deaths in young children in Zamfara State, Nigeria, and joining a multi-agency response to treat the lead poisoning caused by small-scale gold mining; implementing a voluntary reporting system for medical errors in its projects to improve systems (such as increased use of the WHO Surgical Safety Checklist) without allocating blame; following up on reports of death due to ‘yellow eye’ in South Sudan and acting to address the Hepatitis E outbreak (often first identified by acute jaundice), in real time.

Open access was a happy feature of the day, with support from PLOS (the Public Library of Science), dynamic Twitterlogue, and all presentations available online here.

Even more boundless was the audience that followed online, joining in the conversation via live streaming from 92 countries wordwide.

The boundaries between research, advocacy and resources are blurry, and objectivity requires a stance that doesn’t leave much room for compromise.  So there was criticism on Friday, too, but that wasn’t our takeaway message.

The primary concern of any global health initiative needs to be a constantly renewed understanding of the reality of the situation, so that we have a chance of successfully addressing it.  If we don’t ask, regard, review, how do we know?

There are a lot of people listening.  Let’s ask them.

- – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - -

*See Hans Rosling’s 2006 TED Talk, ‘Stats that reshape your worldview’.  And his curated 5 TED Talks on global issues here.  And his conversation with Partners in Health.  In fact, why don’t you go for a Rosling ramble – good for your circulation, and we’ll be right here when you get back.

Bright as yellow

If Rotarians lit up yellow on a map wherever they traveled, Yorkshire would have been a lot sunnier mid-April.

Despite the rain and the general drear, hundreds of members of their vast network gathered for three days at the Harrogate International Centre for the 88^th Rotary International in Great Britain and Ireland Annual Conference.

Our oximeter sits quite close to Rotary, at least on the Pantone spectrum, and so we set out to join them!

In between the business meetings and the voting and the Young Citizen Awards, Rotarians made purposeful turns around the exhibition hall, packed with so many good organizations (and good whiskies) that it was hard not to feel dispirited and elated at the same time – so much imbalance, and so many people working to redress it.

A snapshot of Rotary initiatives worldwide

Rotarians support practical projects – barrels, straws, boxes – and  they like to roll up their sleeves for results.

From 1009 healthy babies born to mothers diagnosed with HIV in Uganda, to  250 reported cases of polio in 2012 down from 350,000 in 1985, they count in real numbers, and set out to see a job through.

So we’re delighted that Rotary clubs around the world are starting to get involved with Lifebox, helping ups to count down and close the 77,000-strong global pulse oximetry gap.

Over the last year they have nominated to direct oximeters to particular countries – like members of the Portishead Rotary Club who donated oximeters and spare probes to Kivunge Hospital hospital in Zanzibar, to complement the support a neighbouring club gives to Makunduchi Hospital, nearby on the island.

Dr Carl Heidelmyer of the Portishead Rotary Club models a pulse oximeter at the ESA conference in Paris last year.

Others have elected to meet the need on our growing waiting list – like the Ilkley Wharfdale Rotary Club, whose members hosted an Indian Evening to raise funds for pulse oximeters.

Clubs in target countries have supported their own colleagues – like the Dili Rotary Club in East Timor, which funded 16 oximeters and double the number of spare probes for the St John of God Hospital neonatal unit.

Clubs have even clubbed together, cross-continent, to support entire countries – as with the ‘Benin Saturation 100%’ projects developing between Rotarians in Benin and Belgium.

In short – or long, and hopefully longer – Rotary Clubs around the world are making surgery safer!

Rotarians from the Edinburgh area demonstrate healthy oxygen saturation levels!

Every oximeter that we send safeguards thousands of patients a year.  Because the equipment is specially designed for low-resource settings, they’ll last a long time – and because training and follow-up is such an essential part of what we do, we’ll be around to make sure of it.

We had such a good time at the conference, meeting Rotarians from all over the country, taking their oxygen saturation levels and hearing more about the various projects they’re involved with – and we hope they had fun meeting us too.

The sun didn’t come out, but the days did seem a little brighter.

Raising the dough

Thank you for visiting the Lifebox Foundation blog.

Please check as appropriate:

          1. I like eating cake

          2. I like making cake*

          3. I believe that no patient should die from unsafe surgery

If any of these statements apply then – hi there! – we’ve got an idea for you.**

On behalf of our co-founder the AAGBI, Lifebox is proud to introduce…

The Great Anaesthesia Bake!

The AAGBI is challenging anaesthesia departments around the UK to get in the kitchen, get baking, get – er, out of the kitchen again, and host a hospital bake sale to raise funds for Lifebox.

Today in more than 70,000 operating rooms worldwide, surgery is taking place without any monitoring beyond a blood pressure cuff or a finger on the pulse.

Life-saving operations – emergency c-sections for mothers locked in obstructed labour, trauma care for children struck down in road traffic accidents – become life-threatening ones, because vital safety checks aren’t carried out, and essential equipment isn’t available.

Download this handy pack and make a difference.

Just £160 will enable Lifebox to send a pulse oximeter directly to the door of any hospital in a low-resource country where surgery is taking place without pulse oximetry monitoring.

Your cake making/buying/eating will help us to host training workshops for anaesthesia providers in pulse oximetry and the WHO Surgical Safety Checklist.

If you attended the GAT conference in Oxford a couple of weeks ago you’ll know that the Great Anaesthesia Bake is already underway!

Great Anaesthesia Bake judge Dr Daniele Bryden and AAGBI president Dr William Harrop-Griffiths smile for the cakes and the cameras

Committee members prepared (and even more impressively, traveled long distances with) a first class array of treats to be judged by anaesthesia and the BBC’s own consultant Dr Daniele Bryden.

(Although not before our pulse oximeter found time to style and shoot in its own Pirelli calendar…)

The camera

doesn’t add ten pounds

it’s only the cake

We even spotted a very presidential-looking entry, a sturdy, signed Victoria sponge celebrating the AAGBI’s last great fundraising venture for Lifebox.

AAGBI council members cycled from London to the 2012 Annual Congress in Bournemouth to raise funds for Lifebox

At 3 in the afternoon Dr Bryden paced the table, cutting scientific (but elegant) slices from each entry.  After a short confab, she announced the winner:

Majestic! (And demolished five minutes later)

Elaine Yip’s cardamom cake with pistachio and orange icing was pronounced “unusual and distinctive”.  The CT2 found her cake in a Hugh Fearnley-Whittingstall receipt, but the stickily delicious icing was her own paired invention.

Judges agreed that the propofol molecule dusted on top was a particularly special touch.  (Stay tuned for an interview with the baker herself!)

Judging from the scene 15 minutes later, it looked like GAT attendees agreed with the choice – and all the other cakes too.   They razed the table to crumbs, and raised £48 for Lifebox in the process!

Congratulations Elaine!

The Great Anaesthesia Bake is running until the end of August (at the AAGBI annual congress), so you have plenty of time to get your own inspiration and  your department on board.

Over the next few weeks we’ll be tweeting updates at #greatanaesthesiabake, sharing photos cakes, receipts and all the baking secrets we can get our hands on – as well as updating you on the difference you’re making to anaesthesia providers and patients worldwide.

This is a delicious, flagrantly non-nutritious way to help your colleagues on the frontline of the surgical safety crisis.  Please join us – and remember (click the photo):

- – - – - – - – - - – - – - – - – - - – - – - – - – - - – - – - – - – - - – - – - – - – - - – - – - – - – -

* option 2b) I like making cake and often bring baked goods in to the department, but never make people pay for them, and it’s about time that I do

** Or all three?  There must be a reason this was @safersurgery’s most popular Tweet ever:

A medico-maritime life for me

If it looks like a ship and it sails like a ship and makes sounds like a ship…it’s probably a floating hospital.  At least if it’s the one that belongs to the charity Mercy Ships, currently docked in the Port of Conakry in Guinea, West Africa.

Bon jour! (The port approach is a lot wetter than starboard entrance)

The MV Africa Mercy is the largest charitable hospital ship in the world, providing free surgical services (primarily facial reconstruction, benign tumor excision, cataract removal and child orthopaedics) to the African countries Mercy Ships visits on a rotating basis.

Pre-Very Useful Bridge

A repurposed Danish passenger ferry, she took to the seas in 2007 after a very useful bridge built between coasts en route, put the 16,500-ton vessel on the job line.

About 400 long-term staff, 200 local day workers and a rotating crew of volunteers – surgeons, anaesthesiologists, nurses, radiographers, technicians, engineers, administrators, cleaners, cooks, carers, families, officers and of course a captain – are paid up members of this unique medico-maritime community.

(Actually staff pay their own way on board – although the volunteer-staffed Starbucks is generously subsidized by the mermaid herself.*)

This week, by gracious invitation, Lifebox is finding our sea legs too!

We’ve joined the faculty of the Anaesthesia Care Team (ACT), led by Mercy Ships international board member Dr Keith Thomson (who, alongside his team, delivered our pulse oximeters to Togo last summer), for a three-day training course at Donka Hospital – one of two national facilities, both in Conakry, and the largest hospital in Guinea.

We’re ready to join about 60 anaesthesia providers and midwives for two days of lectures, workshops, quizzes and dancing (possibly we’re not 100% ready for the dancing? But you should be!) in essential anaesthesia and midwifery techniques, followed by a day of the WHO Surgical Safety Checklist and pulse oximetry.

And we’re very excited for the donation of French-language pulse oximeters to outfit the six hospitals represented at the course, donated with the proceeds from Dr Keith’s recent half marathon adventures!

The Africa Mercy usually spends ten months in each country it visits, wending along the West African coast and ducking back to the Canary Islands in between for repairs.  This is her first trip to Guinea but the charity’s third, following two prior visits from the MV Anastasis (nee Victoria).  She arrived in August, with six operating rooms and nearly 80 patient beds to house the patients eligible for surgery.  Many thousands have shown up for screening, and the lists will stay full until the ship pulls out of port this spring.

Guinea is a low-resource country, but isn’t resource-poor: as the world’s top exporter of bauxite, a key component of aluminium, it sends mini-mountain ranges out of the port regularly.

The islands are lush and the sea is fish-blue.

But the post-colonial legacy and ongoing conflict has been disastrous for most of the 10 million people who live here now, heightened by refugees and tensions from neighbours including  Sierra Leone and Mali.  Guinea most recently ranked 178 out of 187 on the UN’s Human Development Index, with just 1.6 mean years of school for adults and a life expectancy of 54.5 years.

There are only four medical anaesthetists in the entire country, and no standardized programme for anaesthesia training whatsoever.  The doctors here have studied in France, in Moscow; the technicians have learned on the job. There isn’t a single working pulse oximeter in the main operating block in Donka.

The unmet surgical need is vast.

An operating room at Donka Hospital

Over the next few weeks we’ll be sharing stories from the ship, from the dedicated crew, from the fabulous ACT team – and from the patients.  They are still queuing up in the hot sun on the dock for screening, often alone and from far up country, in the hope of a life-changing operation they’ll not find anywhere else, from a ship that – with the best will in the world – was built to sail away to another port in need.

 

Women in the workplace

Over breakfast at the SAFE course/Lifebox training in Rwanda a few weeks ago – bread, boiled eggs, thick black coffee and milky African tea –

It’s always nice to see what people have for breakfast

– a male guest at the Dereva Hotel was heard to inquire:

“Tell me, why it is that women dominate anaesthesia?”

Was that a glint in his eye or not?  Either way, he had a point – to a point.

There’s limited evidence of female domination in the higher echelons of the healthcare profession, i.e. medical anaesthesia.  The road through medical school to specialization is male-dominated, and although there are two female residents in the current first year cohort of the anaesthesia programme at CHUK no women have graduated since it launched in 2006.

Professor Angela Enright with the two female trainees at the CHUK anaesthesia programme

But the anaesthesia technician profession is different.

All techs graduate from the same three-year programme at the Kigali Health Institute (KHI), which was set up in direct response to the crisis-point shortage of healthcare workers in Rwanda.

They are trained in the practicalities of anaesthesia, and only the essentials of physiology necessary for the job at hand. KHI has trained about 30 anaesthesia technicians a year since the programme began in 1996, and there are now about 160 working in Rwanda.  Although the medical anaesthesia programme is no longer nascent, techs far outstrip the number of medical graduates at present.

Practicing patient resuscitation at the SAFE course

So their responsibilities are vast. Techs look after the operating rooms; they do emergency resuscitation (trauma, shock, cardiac arrest).  In rural areas, they can end up with cases even more complicated than a medical anaesthetist at a teaching hospital would be faced with, alone.

And because applicants must have completed a science qualification to be eligible for the programme, with the majority coming from nursing, demographics mean that a high proportion of techs are women.

“I had to work all hours!” explained Jeanette Kayitesi, an anaesthesia tech in Kigali, reminiscing about her first job in a small city hospital where she was the only anaesthesia technician.  “They always came to get me.  They came to get me in the middle of the night.  They came to get me on maternity leave…”

Domination?  Maybe not.  But it’s certainly a dramatic change from the position of women in Rwanda a generation ago.

La DOMINATION at the SAFE course

“In the past, they didn’t like it when a married woman kept working,” explained Mediatrice Usabye, an education director from southern Rwanda, who was in Rwamagana for a conference.

“People saw a woman as someone to marry, to raise children; if a family had a boy and a girl, the boy was the one who went to school.

“But after the genocide the government realized there was a disparity between male/female education, and a gender imbalance in all domains.  Now things are changing.  They’re working to close the gap.  Women have paid maternity leave (one month in the private sector; three months in the public sector).”

Today, the rector of KHI is a woman.

Dr Chantal Kabagabo, Rector of the Kigali Health Institute

So is the anaesthesia department head at the National University of Rwanda.

So is the Minister of Health.

Dr Agnes Binagwaho, Minister of Health

That doesn’t change the fact that the reason women appear to ‘dominate’ in anaesthesia, sir, is partly because they are encouraged to train as nurses, not doctors.

“You may ask me why that is,” said Mediatrice, imposingly.  “It’s because so many books are written in Rwanda, especially in primary studies…they show pictures.  Pictures of women as nurses and teachers.”

Anaesthesia providers pose outside the operating theatres at CHUK

But Rwandan women are writing their own stories long after they finish primary school.  Take Jeanette.  She recently finished her Masters in Public Health (MPH), and wouldn’t be satisfied, she explained, if she didn’t keep learning and working.  She likes her job as an anaesthesia tech because her day is never the same twice.

She also has five children, aged between 12 and three.

At first her husband nagged when she carried on working after they were married, after their children were born.  Why did she have to take further studies?  Why couldn’t she stay home with the kids?

And now?

The magnificent Jeanette

“He’s so proud. Now when we’re out, I hear him on the other side of the room, telling strangers about my job.  Well, he says, my wife…”

Happy International Women’s Day!

 

 

The World We Want 2015

It’s a magnificent proposition.  Go on: design the world you want your children to grow up in.

Just remember that you can’t choose their sex, their race, their long- or latitude.  And you don’t know their characters, their ideas, their – well, you don’t know anything about what they really want, do you?  You just need to know that, wherever and whoever they are, they’ve got the best shot at a life and let living.

Back in 2000, eight priority areas and associated targets were identified to take a generation closer to this fair start: the Millennium Development Goals (MDGs).

(c) US Mission Geneva

With just 2.85 years (and counting) to go until these targets expire, the penalty for missing the mark will be paid by those who they were intended to support.

So we better get the next plan underway.

Lifebox is proud to have submitted a paper to “The World We Want 2015,” a joint platform between the United Nations and Civil Society (that’s you!  And us!) conceived as a forum – or even a movement – for “people all over the world contributing their vision towards an overall plan to build a just and sustainable world free from poverty.”

Our concern is, of course, health; and more specifically, the essential but neglected role that surgery plays in healthcare.

An estimated 56 million people require surgery in Africa alone, resulting in 25 million disability-adjusted life years (DALYs).  There’s no devil’s advocacy in pointing out the fact that this is close to double the number of people infected with HIV worldwide (33 million), a health crisis that has long and rightly been recognized as such. Our paper aims to draw similar attention to the crisis of unmet surgical need in low-resource settings.

Back in 2000, surgery was bundled with the “other diseases” of MDG 6, when in actual fact it’s a tool that can be used to achieve certain targets.

MDG5, for example, maternal health, for example, is a gospel priority, with great improvements made over the last decade.  “But levels are far from the 2015 target.”

One of the barriers is surely a numbers game, with the odds stacked: the recommended c-section rate is 5-15 percent of deliveries, but rates from low-resource countries are drastically lower than this – just 0.6 percent in Ethiopia.  Without broader access to safe surgery, maternal health targets will never be met.

(c) Amber Lucero-Dwyer/Lifebox Foundation

So it’s certainly a big step forward to see the words “surgical capacity” appearing twice in the draft report, released this month as the next stage in the WWW2015 online consultation on health.  This is in reference to the infrastructure required to build national health systems and the “needed services” to meet the goal of Universal Health Coverage (UCH).

And then comes the call for comment.

We strongly echo the response from Jaymie Henry  on behalf of the International Collaboration for Essential Surgery (ICES), which calls for a higher-level of attention to surgery as a primary care component, and the emphasis on training this requires.

We strongly echo the rationale from Kathleen Casey, founding director of Operation Giving Back, who wrote last year in JAMA that  “greater provision of quality surgical care averts lifelong disability, prevents death and ameliorates the conditions of poverty.”

We strongly state that infrastructure and improving access to safe anaesthesia is an essential component of safe surgery, and that this is a universal right.

The back-story behind the development of the first round of MDGs, without denigrating their impact, is rather more back-of-a-napkin than might be expected. (Positives: agile.  Negatives: last-minute corridor dash to include the environment on the list.)

Sequels are usually a more scrutinized story, and this time the consultation is on a massive and laborious scale.  (Negatives: massive and laborious.  Positives: this conversation affects all of us, and we need to fling open the doors.)

We’ll be watching closely, and joining in where we can.  And we’ll continue to distribute pulse oximeters and training in oximetry and the World Health Organization’s Surgical Safety Checklist, and strive to close the global pulse oximetry gap.  The numerous organizations that have submitted comments to the thematic consultation will likewise continue the work that made them passionate enough about global health to comment in the first place.

Because there’s a long way to go in closing the gap between the world we want and the world we’ve got; we can talk while we work.

Thank you

They say that the recession is affecting charitable giving.

We say, have you met the readers of the British Medical Journal.

Over the last two months, a stationer’s rainbow of envelopes has greeted our mornings and a rush of online donations have cheered our afternoons (sometimes we actually cheered!)

Generous readers have raised more than £26,000 for Lifebox.

That’s more than 160 pulse oximeters for hospitals in low-resource settings currently delivering surgery without this essential monitoring.  That’s spare probes to extend the life-saving lifespan of the oximeters, and training for anaesthesia providers to ensure that the equipment is used to its fullest, essential function.

We are enormously grateful to everyone who gave – familiar friends from the previous year’s campaign, new names we are delighted to get to know, and every modest Anonymous in between, to whom we are immodestly thankful.

We’re equally grateful to the BMJ for this opportunity.  We’ve worked hard with staff at the journal to show you why your contribution is needed, and what your generosity allows us to do.

You’ve helped us effectively turn the lights on for anaesthesia providers in Togo, with a donation of 113 oximeters – enough for every operating theatre in the country:

“Before he had a pulse oximeter he felt like an airplane pilot without a radar,” our colleague explained of one of the nurse anaesthetists.  “Now he has an oximeter he has a radar; now he can see where he is going.”

You’ve helped strengthen communities, given medical anaesthetists in El Salvador the opportunity to practically support their technician colleagues across the country, making anaesthesia safer for everyone.

In the last two months we’ve explored a rationale for pulse oximetry that spans decades, from “another preventable perioperative death in a hospital in central Africa in 1986” without monitoring, to an operation in the same country more than 20 years later where a pulse oximeter from Lifebox directly saved a life.

Experts have taken us behind the scenes to the frustratingly full-and-wrongly-stocked store cupboards at low-resource setting hospitals, and donors and recipients have taken us cross-continents, showing how directly and immediately your donation can make a difference.

Every single feature, podcast and blog from the campaign is available here on our website.  We hope you’ll take a moment to browse, and join us in marveling at how widespread and complex the surgical safety crisis can be, and at how many incredible individuals are fighting to make a difference.

We hope you’ll stay tuned this year to see what happens next!

With sincere thanks from everyone at Lifebox.