H5N1

Cuban embassy advises municipal health councils doctors will leave Brazil at year's end

Via globo.com G1: Cuban embassy advises municipal health councils doctors will leave Brazil at year's end. Excerpt from the Google translation, and then a comment:

The National Council of Municipal Health Secretaries (Conasems) reported on Thursday (15) that it has been advised by the Cuban embassy that all Cuban doctors will leave Brazil by the end of the year.

 

On Wednesday (14), President-elect Jair Bolsonaro reported that the Cuban government has decided to leave the More Doctors program in a disagreement about qualification tests.

 

The Cuban Ministry of Public Health, however, reported having taken the decision because of "threatening and derogatory statements" from Bolsonaro.

 

In August, while still campaigning, Bolsonaro declared that he would "expel" Cuban doctors from Brazil, for example.

 

Cuba has sent professionals to Brazil since 2013. In the More Doctors program, just over half of the professionals - 8,470 of the more than 16,000 professionals - come from Cuba, according to data obtained by the G1.

 

28 million will be affected

 

According to the National Confederation of Municipalities, the departure of Cuban doctors will affect more than 28 million people who live in municipalities where they are the only doctors in the country.

 

"The value of the More Doctors Program, echoed in the various corners of Brazil, has proven to be one of the main achievements of the municipalist movement in the face of the difficulty of delivering primary care and placing medical professionals in regions where there is a shortage or absence of these professionals," the CNM said in a statement.

This is indeed politics as medicine on a large scale, and Bolsonaro won't even be president until New Year's Day. It's going to be a very bad 2019 in Brazil.

Papua New Guinea is rich in resources but poor in health

Via The New York Times: Papua New Guinea Is Rich in Resources but Poor in Health. Excerpt:

PORT MORESBY, Papua New Guinea — Polio was vanquished by the Pacific nation of Papua New Guinea 18 years ago. Now, as world leaders gather there for the Asia-Pacific Economic Cooperation summit meeting this week, polio has returned — on top of raging drug-resistant epidemics of tuberculosis, malaria and H.I.V., and deadly flash points of preventable diseases like whooping cough and measles.  

All over the country, there are symptoms of a profound public health emergency; young and old are getting sick and dying unnecessarily, while facilities lack basic medicines and equipment. 

Doctors and experts say the unfolding crisis is the realization of their worst fears after years of deterioration and neglect.  

“We were expecting something like this,” Dr. Anup Gurung, a public health specialist with the World Health Organization, said of the polio outbreak at a news conference in the capital, Port Moresby, in September. 

He pointed to the erosion of vaccination rates, which are down to 30 percent in some parts of the country. “It’s like someone lit a paper castle where everything is on fire,” he said. 

Officials in Papua New Guinea hope that hosting the Asia-Pacific Economic Cooperation, or APEC, meeting in Port Moresby will elevate the country’s international profile, but the health crisis has become an embarrassment for a nation with an abundance of gold, copper, silver, oil and gas. 

Public frustration with the summit spending has already led to two national strikes. The collapse of health services has been a focus of the protests. 

The return of polio is a clear indicator of the failures, with Papua New Guinea accounting for 21 of 109 cases found globally this year. 

The Papua New Guinea outbreak is vaccine-derived, which means that weakened live virus excreted by vaccinated children has mutated and escaped into the rapidly increasing unprotected population. Dr. Gurung blamed “the steady breakdown of the health system” for the country’s polio emergency.  

Local and international experts point to three interlinked causes of the country’s health crisis: the collapse of the medical supply chain; changing relations with the country’s biggest aid donor, Australia; and rampant corruption. 

Getting medicines, equipment and other supplies around Papua New Guinea has always been challenging. The country has few roads, formidable geography and a widely dispersed population, with about 80 percent living in rural and remote locations.  

That improved with assistance from Australia, but the Australian government withdrew from the arrangement in protest in 2013 after Papua New Guinea awarded the national medicine supply contract to a local company that Julie Bishop, then the Australian foreign minister, said had no accreditation and “a history of supplying substandard drugs.” 

The company, Borneo Pacific, won the contract — worth 32 million Australian dollars, or $23 million — despite its bid being millions of dollars higher than those of reputable international organizations. At the time, the Medical Society of Papua New Guinea said the deal would “lead to the deaths of many Papua New Guineans.”  

Reports from health facilities across the country indicate those fears have been borne out. (Borneo Pacific did not respond to requests for comment.)

Lessons from the Ebola front lines

Thanks to Mary Marshall for sending the link to this book review by Nahid Bhadelia in Nature: Lessons from the Ebola front lines. Excerpt:

Outbreak Culture: The Ebola Crisis and the Next Epidemic. Pardis Sabeti and Lara Salahi Harvard University Press (2018)  

When you work inside a system that you believe in, yet recognize as dysfunctional, it can be hard to offer a balanced critique. And the stakes are high when the system in question is the response to a humanitarian emergency, where public opinion determines crucial funding. Outbreak Culture, on the Ebola crisis of 2013–16, strikes this delicate balance expertly. 

The central theme of the book, by geneticist Pardis Sabeti and journalist Lara Salahi, is that common threads of dysfunction run through responses to epidemics. These emerge from the underlying architecture of societies (resulting from history, politics and culture), the competition between international organizations and (sometimes) the self-serving motivations of individuals in high-stress situations. We fracture along lines of existing weaknesses. 

Sabeti — who was part of the Ebola response effort — and Salahi show that the world is doomed to repeat the same mistakes with every new epidemic unless outbreak response shifts to a “mode that favors collaboration instead of competition, and readiness instead of reaction”. My experience leads me to concur. I was a clinical responder in Sierra Leone during the Ebola epidemic in both 2014 and 2015; I now work in Uganda, across the border from the current outbreak in the Democratic Republic of the Congo. (Full disclosure: I appear briefly in the book.)  

Outbreak Culture is based on the cumulative accounts of more than 200 people who worked on the West African response, from clinicians and researchers to public-health workers and administrators. By bringing in these voices, the work distinguishes itself from recent individual accounts. Yet it maintains a personal tone. It also incorporates the post-epidemic analyses by international organizations and governments, such as the internal and external World Health Organization reviews, and independent reports by the US National Academy of Medicine and other academic collaboratives. And it puts a human face on the challenges by telling the stories of researchers, clinicians and patients, including Sabeti and members of her lab.  

Today, every new outbreak demands the re-creation of administrative structures. Negotiations for access and operations are made in real time. Sabeti and Salahi argue that the dearth of dependable administrative structures and oversight in West Africa created a space in which competing incentives and personal ambitions wreaked havoc. They highlight the dark underbelly of on‑the-ground interactions that slow down and ultimately stymie the response itself, and which many reports have previously shied away from. 

The authors interviewed numerous people and sent out an e-mail survey; 132 people answered. This was anonymous, because otherwise most of us (I took the survey) would have baulked at answering the hard questions it featured about competition, corruption and waste. About 27% of respondents said that they had experienced illegal tactics during the epidemic. Another 37% noted that they had experienced intimidation, for instance by personally facing, witnessing, hearing about or perpetuating it.  

Sabeti and Salahi share stories of how data and samples that could have helped were hoarded by researchers and organizations, including individuals within several international public-health bodies. They give an unflinching account of how corruption at all levels siphoned resources away from communities in need. 

For example, the International Federation of Red Cross and Red Crescent Societies confirmed that almost US$6 million of its Ebola funds were misappropriated in West Africa. The authors also highlight concrete examples of how organizational politics, cultural differences and mistrust led to ineffective communication at crucial points during the epidemic. 

Despite these revelations, the book ends on a positive note. It links failures during the epidemic to specific underlying gaps in governance (for example, the ways in which aid is distributed and reported allowed for individuals to siphon off funds). It identifies core processes required for reform. These include streamlining communication systems between outbreak-response partners, and establishing a central research-governance structure composed of experts without conflicts of interest.

North Kivu: Free healthcare concerns all diseases until healing

Via Radio Moto Butembo-Beni: Health: Free healthcare concerns all diseases until healing. The purpose, of course, is to keep people coming for non-Ebola treatment, and the story says something about the state of the local healthcare system. The Google translation, lightly edited:

How can we understand free care? 

The representative of the provincial health division indicated that free care covers all diseases without exception. Dr. Hyppolite SANGALA said that throughout the patient's contact with the caregiver until the cure, the patient will not pay a penny. 

Dr. Hyppolite SANGALA reminded that no one can be excluded from this free care. He added that routine consultations such as NPC and cases of surgical operations of diseases are also supported. 

It must be said that a warning has been issued to all caregivers who might ask for money from patients in selected health facilities.

‘This Is Going to Hurt’: A grossly funny memoir of a burned out doctor

I'm becoming increasingly concerned about occupational health and safety as a public health issue, and a new book has put the focus squarely on healthcare workers' health and safety. The Tyee has published my review of ‘This Is Going to Hurt’: A Grossly Funny Memoir of a Burned Out Doctor. After discussing the book (which is indeed very funny) and the problems in the UK's NHS, I continue:

Canadian and American healthcare systems are unindicted co-conspirators, exploiting their workers in the name of serving patients at a politically affordable price. Search the website of the New England Journal of Medicine for the term “physician burnout” and you’ll get 72 hits. The problem starts in medical school and takes many forms thereafter, from stigma to scheduling to sexual harassment and violence. It means physicians and other healthcare workers must deal with their own depression, emotional exhaustion, and suicidal thoughts while also trying to care for their patients. 

Chief cause of death for young physicians: suicide  

OMA Insurance, a program run by the Ontario Medical Association, says Canadian physicians face problems as serious as their American and British colleagues:  

“The overall physician suicide rate cited by most studies is two to four times higher than the general population. In the United States, this translates to an equivalent of one to two average-sized medical school graduating classes needed every year just to replace the number of physicians who commit suicide… Moreover, studies have also concluded that suicide is the most common cause of death for young physicians (26% of deaths). Male physicians commit suicide at a rate about 1.4 times greater than the general population, whereas female physicians have suicide rates about 3 times higher than the general population. Unlike the general population, where males complete suicide four times more often than females, male and female physicians have approximately equal suicide rates.” 

Ironically, the Canadian Medical Association Journal says Ontario doctors who seek counselling through OMA insurance may receive only $350 for counselling, and get nothing for counselling or medication if they have a pre-existing condition of mental health concerns.  

A recent article in CMAJ sums up the North American problem: “One in four Canadian physicians reports high levels of burnout and one in three screens positive for depression. South of the border, more than half of physicians in the United States have symptoms of burnout. One in five is thinking about reducing their hours and 1 in 50 is considering early retirement, despite mounting physician shortages. Meanwhile, some 400 physicians and 100 medical students die by suicide each year.”

Life expectancy is rising in Finland – unlike in the UK. What’s going right?

Yet again the Finns kick our collective butt. Via The Guardian, an opinion piece: Life expectancy is rising in Finland – unlike in the UK. What’s going right? Excerpt:

Earlier this week, a new report from the Royal College of Paediatrics and Child Health warned that infant mortality in the UK could be 140% higher by 2030 than in comparatively wealthy countries if current trends continue. Infant mortality rates are already twice as high as in Finland. There are also big gaps between the UK and Finland on rising life expectancy. Life expectancy has stopped rising in the UK, and is now actually falling across much of the country. 

In stark contrast, Office for National Statistics figures show that out of 20 comparator countries, Finland has experienced the largest increase in improvements in life expectancy for men since 2010, and Finnish women’s life expectancy has also consistently risen.

What is it about Finland? And what’s wrong with the UK? We know that Finland has some of the best education in Europe. Homelessness rates are falling. And now we learn that the Finns have just experienced the fastest health improvements recorded among 20 affluent countries. In contrast, since 2010 the UK has had the second worst record of the 20 countries, with only the US doing worse.  

Finland and its Scandinavian neighbours excel in preventive measures. These are not the measures we are used to talking about in the UK, where you tell people to try harder, eat better, smoke less, and exercise more – implying it is all down to the individual. Finland excels in the provision of healthy, free school meals for all. It takes the eradication of childhood poverty seriously and its politicians are criticised over any apparent lack of action. The Finns spend more than we do on public services and social care.  

Unlike the patronising public health information doled out by Public Health England, real preventive measures include genuinely affordable housing for all, so that people can afford good food rather than paying much of their income on astronomical private sector rents. In contrast, the results of a lack of proper prevention services in the UK are shocking. A baby is almost 50% more likely to be stillborn in England and Wales. And the country offers much better maternity packages and paternity and parental leave. 

According to the OECD, Finland spends a slightly lower proportion of its GDP (9.5%) on health than does the UK (9.7%). Finland can do far more with that money partly because doctors don’t need to be paid as much as they are in the UK, since housing costs are lower. For every 10,000 people in Finland, there are 32 doctors employed, compared to 28 in the UK, and there are 40 hospital beds for every 10,000 Finns, compared to 26 in the UK. 

Amazingly, there is now a movement in Finland to introduce more private sector providers across healthcare. If the proposals for reforms are passed these reforms will begin in Finland in January 2021. Perhaps the National Coalition party MPs should come and visit the UK first?

WHO: Chikungunya – Sudan

WHO has published Chikungunya – Sudan.  Excerpt and then a comment: 

On 31 May 2018, the State Ministry of Health (SMOH) of the Red Sea State in Sudan reported four suspected cases of chikungunya fever from Swakin locality, in Red Sea State. Among the signs and symptoms were sudden onset of fever, headache, joint pain and swelling, muscle pain and/or inability to walk.  

The first suspected case of chikungunya in the neighboring Kassala State was reported on 8 August 2018, in a male travelling from the Red Sea State. Since then cases have been reported in three localities of the State (Kassala, West Kassala and Rural Kassala). On 10 August, among 24 collected blood samples, 22 samples tested positive for chikungunya by PCR and ELISA at the National Public Health Laboratory (NPHL) in Khartoum. On 9 September, an additional 100 samples were collected and pooled in batches of ten: 50% of pools tested positive for mixed chikungunya and dengue viruses, and all pools were positive for chikungunya virus.  

From 31 May through 2 October 2018, seven States (Kassala, Red Sea, Al Gadaref, River Nile, Northern State, South Darfur, and Khartoum) have been affected with a total of 13 978 cases of chikungunya, 95% of which are from Kassala State. No hospital admission or death has been officially reported. Approximately 7% of the reported cases were children less than 5 years of age and 60% were females.  

Public health response 

• Federal Ministry of Health (FMOH) and the Health Cluster organized an ad-hoc Health Cluster Coordination meeting to engage health cluster partners in addressing the current outbreak. 

• FMOH in collaboration with WHO and partners prepared an accelerated response plan to scale up vector control and health education campaigns. 

• Volunteers were mobilized to conduct house-to-house visits, inspection and targeted health education campaigns. 

• WHO technically and financially supported the surveillance system and case management. 

• WHO and partners provided logistical and financial support to the response operation (case management, surveillance, vector control, health education and risk communication) in affected localities in Kassala, Gadaref and Red Sea States. 

• WHO mobilized funds to support the scaled up operations by the FMOH including deployment of various staff at both the Federal and State level. 

WHO risk assessment 

The overall risk of chikungunya at the national level is very high because of the following: presence of Aedes aegypti in most parts of the country, availability of breeding sites in houses and uncoordinated community involvement in vector control aggravated by the ongoing rainy season which favours the proliferation of the vector and spread of the outbreak to other states in the country. 

Also, in the absence of a good surveillance system to clearly define the dynamics of the outbreak, it is a big challenge to target the public health actions to control the outbreak. The lack of financial and technical resources to respond to needs, if not addressed immediately and properly, may lead to further escalation of the number of cases and eventually overwhelm the already over-stretched capacities of the country. 

The risk at the regional level is considered moderate. WHO Regional Office is already mobilizing its resources to support the ongoing outbreak and is prepared to support other neighbouring countries if the outbreak spreads outside Sudan. The overall risk at the global level is low.

Note the absence of "officially reported" hemorrhagic cases or deaths. This should be welcome news, but given the nature of the regime, it's not entirely trustworthy. 

Reading between the lines of WHO's very bland prose, I see some exasperation at the lack of "a good surveillance system" and "already over-stretched capacities of the country," much as WHO implicitly criticizes the Saudis for their chronic lack of hospital infection control.

 

I doubt very much that the Sudan FMOH will get the support, personnel, and training it needs to deal with chikungunya or anything else it may be dealing with.

Hospitals pummeled by Hurricane Michael scramble to evacuate patients

Via The New York Times: Hospitals Pummeled by Hurricane Michael Scramble to Evacuate Patients. Excerpt:

PANAMA CITY, Fla. — Bay Medical Center, a 300-bed hospital in the center of town, was a tumultuous mess. Staff members were frantically working on Thursday to evacuate patients just as new ones showed up at the door.  

Hurricane Michael had strafed the place, blowing out windows and stripping some of the buildings in the sprawling complex down to their metal girders. Signage was strewn in the streets. Doctors, nurses and workers wandered outside, some crying, some looking for cell service. 

The governor had announced that all of the patients in the hospital were to be evacuated. But by midmorning Thursday, at least 100 patients remained inside. And other residents of the ravaged city were still showing up asking for medical care only to be turned away. A man named Wain Hall, 23, was standing with his bicycle, screaming at a security guard by the boarded-up entrance to the emergency room.  

“I got a busted head, and so you refuse me medical attention here?” he said. He lifted his ball cap to reveal matted, blood-soaked hair. “I have lost everything and everyone keeps turning us away,” he said.

As Michael bore down and then passed, some hospitals in the region closed entirely, and others evacuated their patients, but kept staff in place to run overwhelmed emergency rooms. In Florida, four hospitals and 11 nursing facilities were closed, according to the Federal Emergency Management Agency. Panama City has five hospitals, according to the Florida Health Association. Bay Medical, with 323 beds, and Gulf Coast Regional Medical Center, with 238, are the biggest. 

Florida officials also said food and supplies were being dropped in by air to the state’s mental hospital in Chattahoochee, which is cut off by land. The mental hospital has a section that houses the criminally insane, but the facility itself has not been breached, officials said. 

Gov. Nathan Deal of Georgia said 35 hospitals or nursing homes in that state were without electricity and operating with generators. 

Federal health officials said they were moving approximately 400 medical and public health responders into affected areas, including six disaster teams that can set up medical operations outdoors. Some were heading to an overwhelmed emergency department in Tallahassee. Other federal medical personnel were being assigned to search-and-rescue teams to triage people who were rescued.

Increasing mortality and declining health status in the USA: Where is public health?

In the Harvard Health Policy Review, Dr. Stephen Bezruchka of the School of Public at the University of Washington writes: Increasing Mortality and Declining Health Status in the USA: Where is Public Health? Excerpt:

Mortality increases at the national level are very rare phenomena this century. In the 1900s, mortality only increased in countries greatly affected by World War I and II, and in the 1990s in Sub-Saharan nations with high AIDS prevalence as well as after the collapse of the Soviet Union in 1991. 

Beginning this century, mortality is now increasing in the United States. The National Center for Health Statistics reports that life expectancy is declining, and infant mortality is increasing. The reported life expectancy decline is for the period 2014 to 2016 and will continue through 2017. This three-year decline is unprecedented in the U.S. All-cause death rates are similarly increasing except for those over age 65. For adults, aged 24 to 65, mortality has increased for all race-ethnicity groups. This includes all-cause mortality, as well as cause-specific mortality that includes hypertensive, alcoholic liver, and respiratory diseases, drug overdoses, as well as suicides and homicides.  

Relative declines in U.S. life expectancy compared to other nations have been observed for half a century. That is, while mortality had been decreasing in the U.S., the improvements were better in many other nations. Life expectancy in the USA lags 4.5 years behind Japan. If we eradicated our leading killer, heart disease, we still wouldn't bridge the gap. If health were an Olympic event, our performance would be falling behind 35 to 60 other nations depending on the mortality indicator chosen. 

This represents a marked change compared to the early 1950s when our mortality rates were among the lowest in international comparisons. The relative decline has been more marked in women. Huge expectations are placed on women in the US without much support from government in comparison to other nations. A 2013 report from the Institute of Medicine documenting this has received little attention or response by our federal institutions responsible for our health status.  

Public health agencies at the federal, state and local level have not drawn attention to this most mortal of all perils. Why? There are almost no public surveys of our health status as a nation. A population-based survey of medical students carried out in 2002 found that a third of medical students thought the United States led the world in the highest life expectancy and lowest infant mortality. No attention is devoted to our health as a nation, in comparison to other nations, in our health care schools. The same is true for schools of public health. 

Medical care is about diagnosing and treating illness and injury, which focuses on individuals and their issues. The United States spends more on health care than the rest of the world combined. Logically, medical care cannot be responsible for our health decline. Even with the advent of the Affordable Care Act, it is difficult to demonstrate related health improvements. The same was true after the adoption of Medicare. 

The public doesn't distinguish health from health care. We access health, we pay for health, we invest in health, we get health and so on, but those statements are all about health care. The question that should be asked is whether we want health or health care. Ideally we should have both. We do not.

Venezuela: Hospitals see more dengue than measles cases, says Epidemiology Society

Via Efecto Cocuyo: Llegan más casos de dengue que sarampión a hospitales, según Sociedad de Infectología [Hospitals see more dengue than measles cases, says Epidemiology Society]. Excerpt, with my translation:

Los casos de dengue aumentan en Venezuela. Al ser un país tropical, el clima favorece la reproducción de mosquitos que transmiten esta enfermedad, pero sumado a la falta de políticas para  su prevención, se genera el escenario ideal para su fácil proliferación, según la Sociedad Venezolana de Infectología (SVI). 

Cases of dengue are increasing in Venezuela. As tropical country, the climate favours reproduction of the mosquitos that transmit the disease, but combined with the lack of policies to prevent it, conditions are ideal for its easy spread, according to the Venezuelan Society of Epidemiology.

“Las principales consultas que se atienden actualmente en las emergencias de los hospitales son por dengue. En algunos casos está desplazando al sarampión. El dengue lo tenemos presente desde hace años”, expresó María Graciela López, presidenta de la SVI. 

"Dengue cases are currently seen most in hospital emergency department," said María Graciela López, president of the society. "In some cases they're displacing measles. We've had dengue for years."

López aseguró que a pesar de que existe una evidente alza de los casos, aún no manejan cifras. Informó que esta organización se encuentra elaborando un informe respecto al estado de la enfermedad y en detalle el aumento de casos. 

López said that although there's an evident rise in cases, they still have no number. She said her organization is developing a report on the state of the disease with details on the rise in cases.

Indicó que la falta de información oficial limita la capacidad de atender la enfermedad. Desde finales de 2016 no reciben el Boletín Epidemiológico por parte del Ministerio de Salud. “Si hubiera una información fluida por parte del Ministerio, tendríamos cómo orientarnos para trabajar eficazmente”, manifestó López.

She said the lack of official information limits the capacity to respond to the disease. Since late 2016 they haven't received the Epidemiological Bulletin from the Ministry of Health. "If there had been a flow of information from the Ministry, we'd know how to organize ourselves to work efficiently," she said.