A couple of weeks back, I attended the launch event of the new Turning the World Upside Down (TTWUD) website. It was a thought-provoking event, and the site itself is full of interesting and unusual case studies from across the world, so after the event I decided to write up some parts of the discussion and a few reflections for a student global health network called Medsin; here Ive just adapted it slightly for the CSH.
Near the start of the event, Paul Farmer (co-founder of Partners In Health and all-round inspirational person) made the simple point - often made, but one that probably can't be repeated enough - that global health is basically all about equity. It's why I care about global health and why I first became involved in the UK student charity Medsin-UK. And its something thats increasingly 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. 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 Brazils 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. Whats 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 Alessis evident enthusiasm for another pilot in England was very encouraging. At the same time, his thoughts about dinosaurs sitting on two separate drainpipes as a metaphor for the NHS establishment, and BMJ editor Fiona Godlees comments about patients expectations in the UK, perhaps hint at the extent of the challenge in translating such eminently sensible, cost-effective schemes to higher-income contexts such as the UK. Wales seems to be much better at piloting new ways of doing things somehow; they've also achieved impressive and good-value results from the joined-up National Exercise Referral Scheme that they've implemented, which was evaluated pretty thoroughly by academics from Cardiff University and demonstrated a cost per QALY of 12,111, with a marginal cost saving for those who adhere fully.
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, and many of the more specific points also struck a chord, such as that about the importance of clear organisational direction 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, that's what good healthcare is all about. I guess it doesnt hurt that its often better value and more resource efficient too.
Sustainability in a broad sense, and what it means for healthcare, is something Im particularly interested in, in part because I've previously been involved in some work on the subject at the CSH. 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 it the opportunity that disciplines like sociology and anthropology bring to the table, which we too often miss in public and global health.
I could thoroughly relate to this point; Im 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 upstream, policy-based interventions - are inherently much harder to evaluate fully or effectively 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 some more abstract concepts such as patient engagement, self care, social capital, sustainability and resilience. They are difficult to pin down on a neat or simple scale, but - in the face of rising costs due to ageing populations, an enormous NCD epidemic, climate change, energy insecurity and increasing resource scarcity - they are now perhaps some of the most important dimensions of innovation in improving our healthcare and health systems.
In one of the examples - 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 info).
After a great presentation on an integrated and home-based palliative care scheme in India by ex-Medsin presidents Felicity Jones and Dan Knights, Prof. Parveen Kumar (always strange to find out your textbooks were written by real people somehow...!) and the RSMs B Sethia 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 why. 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 couldnt help wonder whether it might not be better perhaps to invest in scaling up schemes like the small-scale scheme MedicToMedic, which specifically invest 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 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 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 wont 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. Yet 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 of 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 did make clear 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 to start turning the world upside down - and, with your contributions, I think that TTWUD.org could be a great vehicle to help make that happen.
Please log in or sign up to comment.