Isobel Braithwaite shares her thoughts on the recent launch event of the Turning the World Upside Down online platform.
A couple of weeks back, I attended the launch event of the new Turning the World Upside Down (TTWUD) website, which was hosted by Nigel Crisp, ex-chief executive of the UK’s National Health Service and author of a great book of the same name, and organised by Medsin’s director, Jonny Meldrum. It was a very thought-provoking event, and the site itself is already full of various interesting and unusual case studies from across the world.
Near the start of the launch, Paul Farmer (a physician and medical anthropologist who is also the Chair of Harvard’s Department of Global Health, a founding director of the international non-profit Partners In Health, and an all-round inspirational person) made the simple point that global health is basically all about equity. It’s an often made point, but it can’t be repeated enough. It’s why I care about global health, and why I first became involved in the student global health network Medsin, focusing mainly on the topic of climate change and health. Health equity is also under siege right on our doorstep here in the UK, with the current erosion of various safety nets and what sometimes looks rather like wholesale abandonment of the goal of health equity.
Improving global health is also about using and sharing knowledge on what works and to that end, TTWUD seeks to facilitate ‘co-development’ – as Nigel Crisp eloquently puts it – through mutual teaching and learning, by global health professionals and stakeholders from high, low and middle income countries alike.
To illustrate this point, the first of the many case study examples presented to the panel was that of Brazil’s very young system of primary healthcare and community health workers (CHWs). Each of the 250,000-strong army of CHWs has personal responsibility to visit each of ~150 households at least once per month, and is responsible for a wide range of preventative and integrated healthcare and environmental health roles. What’s particularly amazing about it is not only its success and cost-effectiveness, but also that there are plans afoot to pilot the system in North Wales. The system and plans for reverse innovation to Wales are described further in the full case study.
Given his influential role as Chairman of the National Association of Primary Care and of the NHS Clinical Commissioners, Charles Alessi’s evident enthusiasm for another pilot in England was an encouraging sign. At the same time, his metaphor for the NHS establishment (‘dinosaurs sitting on two separate drainpipes’), and the editor of the British Medical Journal Fiona Godlee’s comments about the difference in patients’ expectations in the UK, perhaps hint at the extent of the challenges in translating such eminently sensible, cost-effective schemes to higher-income contexts such as the UK.
Wales somehow seems to be better than England at piloting new ways of doing things in general: they’ve also achieved impressive results from the National Exercise Referral Scheme that they’ve implemented nation-wide, which was evaluated thoroughly by academics from Cardiff University and demonstrated an average cost per QALY gained of £12,111, with a marginal cost saving for those who adhere fully; far more cost-effective than most new drugs that are approved.
Three particular themes that came up in discussion were the value of disruption in the face of what I’ll call ‘establishment inertia’; of creative, cost-effective changes to practice often resulting from necessity or adversity; and – linked to the first point and one which reflected the strong student contingent in the audience – the importance of youth in this agenda. All three resonated strongly with me, the last perhaps unsurprisingly, as did many of the more specific points, such as that about the importance of clear organisational direction which was made in a speech by the head of the African Health Policy Network.
One other recurrent theme was that of personalised care and patient empowerment as the next revolution in healthcare, in the wake of evidence-based medicine. There was a lot of talk about the value of context-specific approaches to healthcare service improvement, which recognise the importance of local culture and context in how health systems work and develop, and – at the clinical scale – systems which make it possible to treat the patient as a unique whole, not a set of biological components. At its core, perhaps that’s what good healthcare is all about. It probably doesn’t hurt that it’s often better value and more resource efficient too.
Sustainability in a broad sense, and what it means for healthcare, is something I’m particularly interested in, in part because I’ve previously been involved in some work on the subject at the Centre for Sustainable Healthcare in Oxford. I was reminded of thoughts I’d had then – whilst searching the literature on self-care, patient empowerment and environmental sustainability in healthcare (very scarce!) – by a comment that Paul Farmer made at one point. He spoke about the ‘fetishisation of the quantifiable’, both in public health and peer-reviewed journals more broadly, and as a consequence of this, a missed opportunity in public and global health because we too often fail to appreciate what disciplines like sociology and anthropology can bring to the table.
This is not to imply that there aren’t journals making inroads here – some of PLOS’s publications are a case in point, as are various others – but I could thoroughly relate to his point. I’m studying public health at the moment, and although I recognise the importance of quantitative evidence, I do think that certain genres of problem and intervention – especially policy-based interventions that seek to improve the determinants of health upstream – are inherently much harder both to implement and to evaluate fully in a quantitative way. I also think they can easily be put at a disadvantage by this bias, even though they may in fact be the most effective and sustainable ways to respond to complex problems like obesity.
This is particularly true when it comes to more abstract concepts such as patient engagement, self-care, social capital, sustainability and resilience. They are difficult to pin down on a neat, one-dimensional scale, but – in the face of rising costs due to ageing populations, a massive epidemic of non-communicable diseases, globalisation, climate change, energy insecurity and resource scarcity – if we wish to improve our health systems and prepare them for future challenges, they are now perhaps some of the most important dimensions of innovation.
In one of the presented case studies – the scaling up of a USAID-funded pilot which had aimed to improve care in 3 specific areas (hypertension, pregnancy induced hypertension (PIH) and neonatal respiratory distress syndrome (NRDS)) - it was actually thanks to further funding not being awarded that scaling up and spreading’ happened effectively, resulting in markedly better health outcomes (see also http://www.hciproject.org/node/3563 for more on this).
After a great presentation on the effectiveness of an integrated and home-based palliative care scheme in India by ex-Medsin presidents Felicity Jones and Dan Knights, the Royal Society of Medicine (RSM)’s Lead for Global Health, Mr. B Sethia, and Prof. Parveen Kumar – ex-president of the RSM and co-author of the medical school core textbook Kumar and Clarke; it’s always strange to find out that your textbooks were written by real people somehow! – pitched their idea. Their proposed way to turn the world upside down involved medical student electives and – to sum up a much longer explanation – they want to make them into a two-way exchange, seeing this as an opportunity both to build capacity, to share ideas and to create long-term partnerships.
Profs Kumar and Sethia also made the case for such a scheme to be funded through aid given the newly announced increase in aid to 0.7% of GDP, quoting figures on the percentage of this which may not be spent effectively at present. In response to a (rather leading) question about support for the idea, one person in the room had the courage to express his qualms publicly, and this was because of the proposed source of funds. I felt the same; although broadly speaking I liked the idea, at least in principle, I can think of many things I would spend aid money on before paying for medical elective exchanges.
For example, I couldn’t help but wonder whether it might not be better perhaps to invest in scaling up schemes like the small-scale scheme MedicToMedic, which specifically invests in training health workers from rural backgrounds and poorer groups who have been found to be much more likely to practice in or near their communities when they graduate than the urban middle class who are often the only students’ whose parents can afford medical student fees.
Or in making the most of technology in order to share experiences and build capacity without even needing to fly, as exemplified by a real-time clinical education website (described here) which was created by Alexander Finlayson and others. There are other issues needing consideration here too, especially given the current problems of medical migration away from resource-poor countries to where the pay is higher and the reasonable possibility of such a scheme even exacerbating this issue.
Paul Farmer’s response to the idea centred on the need to be cognisant of the immense disparities in wealth between rich and poor settings, but he clearly recognised that this question won’t have a simple answer. Also relevant is his point that wealth is very much a relative concept: Brazil is lower income than the UK or US, but to a country like Rwanda it looks like a colossal economic powerhouse, whose primary care strategy would be very difficult – if not impossible – to emulate on financial grounds regardless of its cost-effectiveness.
On the other hand, this article of Paul Farmer’s, quoted by Fiona Godlee at the start, illustrates how health status in Rwanda has, in this very different context, improved by strides since the end of the genocide in 1994, thanks in large part to enlightened policy with an emphasis on integrated care at the level of the patient and on health system strengthening.
One of the key points I took away from the whole event is that exporting the way of delivering healthcare which has become the norm in the UK or the US to developing countries is rarely what is needed or appropriate: although we also have things to teach, the often tacit assumption that ‘our way’ is the best way is both unhelpful and flawed. What the discussion made clear to me is how much the West has to learn from lower income contexts, who often achieve very good – and sometimes better – health outcomes with much less. Increasingly over the decades to come, we will also have to learn to do more with less, for both economic and environmental reasons. The challenge lies in how to build mutual trust based on equity and respect, in order to learn together, from one another, in such immensely different contexts.
Now seems as good a time as any for us to start turning the world upside down – and, with your contributions, I think that TTWUD.org can be a great vehicle to help make that happen.
Isobel is a medical student taking a year away from medicine to study Public Health at LSHTM. She coordinates the Medsin-affiliated activity Healthy Planet, and can (sometimes!) be found on twitter at @izzybraithwaite.