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See no evil, hear no evil, speak no evil: Tanzania’s struggles with the HIV epidemic

Nestled on the south-eastern slopes of Mt Kilimanjaro in Northern Tanzania, the sprawling village of Machame emerges from the surrounding rainforest. This village is home to the Machame Hospital, where I was fortunate enough to undertake a month-long elective before commencing my final year of medical school. This elective was a challenging, yet enriching experience, and helped me gain a glimpse into some of the major public health issues affecting the country.

The century-old Machame Hospital is a 120-bed facility that provides essential healthcare to over 150,000 people from the surrounding area. Although severely under-resourced, the hospital was a bustling hive of activity that provided me with a taste of Tanzanian medical, surgical and obstetric services. The locals were exceptionally friendly and welcoming and I was able to get involved in all aspects of hospital functioning including attending clinics, contributing to ward rounds, assisting in surgery and conducting outreach clinics in the community.

Throughout my time there it quickly became apparent that the gravest problem facing the community of Machame, as with much of Tanzania, is that of HIV/AIDS. Indeed, the most recent epidemiological data estimate the national adult prevalence to be 5.7%. [1] This figure, however, is likely to be an underestimation given the prevailing social stigma associated with being HIV-positive and the resultant reluctance of people to come forward for testing.

In Tanzania, HIV is a dirty word. Many of the doctors and health workers were loath to refer to it by name (virusi vya ukimwi or VVU in Swahili), especially around patients. It was often alluded to by euphemisms, becoming the great unspoken problem. Many Tanzanians have a very poor understanding of its natural history or transmission and this engenders great fear, especially as many have witnessed the devastating effects of the disease firsthand. [2,3] When it comes to HIV, unfortunately many Tanzanians really do ‘see no evil, hear no evil, and speak no evil.’

Machame Hospital’s HIV clinic was housed in a little hut ten metres from the main hospital complex itself – an apt demonstration of the social segregation of AIDS sufferers. Accommodating patients with HIV within the main facility may discourage others from presenting for fear of contracting the condition while in hospital. The locals were also worried about being sighted at known HIV treatment or testing locations for fear of social repercussions. The building was instead known as the Centre for Disease Control, a deliberately ambiguous name that enabled patients to attend appointments without fear of being stigmatised as a carrier.

During my elective I also had the opportunity to assist with HIV screening using finger-prick antibody testing. Under the auspices of a general clinic, we would travel to different locations around the village and set up a consulting area. It almost seemed that an unspoken agreement existed between the patients and medical staff to ensure HIV testing was conducted surreptitiously, with the testing area tucked away up the back and never mentioned by name. This made the process all very secretive, ensuring that full, informed consent was often overlooked. Despite this, many seemed to know what was going on and, fortunately, people from the village willingly came forward to be tested.

I met numerous patients during my elective but the most confronting case I saw was that of a two-year-old boy infected with HIV. The child’s mother had already died from complications of AIDS and the grandmother, distraught and surfeited, had brought him in asking for an ‘injection to kill her baby’ because she could no longer bear to see him so sick. He had already lost 30% of his 10kg body weight within the last month and cried throughout the whole consultation. Apart from being deeply tragic on a human level, seeing patients such as this made me frustrated as this situation might have been prevented. Perhaps the greatest tragedy of medicine in the developing world is when medical knowledge exists to provide a solution, but is not implemented due to a lack of financial or educational resources.

Fortunately, there were also many uplifting cases that did highlight the tangible benefits of effective medical therapy. One 38-year-old presented to the hospital with a paltry CD4 count of 1 (the normal adult range being between 500 and 1,300 cells per microlitre [4]). He was commenced on anti-retroviral therapy and is now doing well, able to again provide for his wife and son.

There are certainly many challenges that Tanzanian health authorities continue to face in the fight against HIV/AIDS.

Firstly, the lack of health resources in the country limits the capacity for investigations. For example, in Machame it was not possible to measure HIV viral loads, a test routinely performed in Australia to monitor disease progress. CD4 counts alone stand as the only available measure of treatment efficacy. Secondly, patients perceive little incentive to continue taking anti-retroviral medication if they do not feel that it is improving their well-being, as the notions of prevention and maintenance therapy are generally poorly understood. This generates significant compliance challenges that undermine the delivery of treatment.

For its part, the government provides all HIV medication free of charge. Although this is an excellent initiative, it makes the reluctance of people to get tested and treated harder to fathom, especially considering the effectiveness of pharmacotherapy. For example, the rate of vertical transmission from untreated mother to child is 25-35%, but this can be reduced by up to two-thirds with Highly Active Anti-Retroviral Therapy during pregnancy and six months of breastfeeding. [5]

Thirdly, the considerable social stigma and widespread reluctance to discuss HIV act as a significant barrier to primary and secondary prevention strategies. Public education about HIV/AIDS is severely limited and it is difficult to counsel patients about preventing transmission of the illness when sex remains a taboo subject. Many people are tragically unaware of the role of unprotected heterosexual intercourse in spreading infection, in spite of it being the most common mode of transmission. [1]

There is also an issue of protection for health care workers. I noticed a marked contrast in attitudes towards personal safety and infection control between my time in both the Australian and Tanzanian systems. In Australia, additional precautions are taken for patients with diseases like HIV. Such measures include isolating infectious or immunodeficient patients, collection and incineration of contaminated medical waste, use of personal protective equipment and safe handling of sharps. None of these methods were routinely observed to be practiced during my time in Tanzania and it raised concerns about the rate of potentially preventable transmission amongst hospital staff. Indeed, a recent study of two other Tanzanian hospitals found that nearly half of all healthcare workers experienced at least one occupational injury, such as a needle-stick injury, over a twelve-month period. [6] Clearly, efforts need to be made to improve safety procedures and staff awareness.

Overall, reducing the impact of HIV will depend on multiple approaches with a focus on adherence to treatment, early testing and mitigation of high-risk behaviours. Such improvement can only be achieved through education and good public health initiatives.

My time in Tanzania as an elective medical student proved to be a humbling and eye-opening exposure to global health, with a particular focus on HIV/AIDS. By far the most incredible words I have ever learnt to say are hakuna shida, as this was the Swahili phrase I used to inform patients that their HIV test was negative. People were so pleased to hear this that several patients cried with joy or hugged me upon learning the good news. In a beautiful moment of symmetry to my previous HIV clinic, I saw another lady accompanying her grandchild who had lost his mother to AIDS. This time the boy was negative and, upon hearing this, the grandmother burst into joyous tears. These experiences have helped change my perspective on medicine and what I take for granted in Australia. I look forward to potentially returning in the future and to help get people talking about HIV.

Acknowledgements

I would like to thank the Insight Global Health Group for providing financial support for this elective through the Insight Development Grant.

Conflict of interest

None declared.

I especially want to acknowledge the significant contribution of colleague Justin Mencel, who undertook the elective with me and helped organise it. Additionally, I would like to recognise the warmth and generosity with which we were welcomed by the whole community, in particular by Hospital Patron Mr Edward Mushi.

Correspondence

M Weightman: michael.weightman@student.adelaide.edu.au

References

[1] Tanzania Commission for AIDS, Zanzibar AIDS Commission, National Bureau of Statistics (Tanzania), Office of the Chief Government Statistician, Macro International Inc. Tanzania HIV/AIDS and malaria indicator survey 2007-08. Dar es Salaam, Tanzania: Macro International Inc; 2008.

[2] Amuri M, Mitchell S, Cockcroft A, Andersson N. Socio-economic status and HIV/AIDS stigma in Tanzania. AIDS Care 2011;23(3):378-82.

[3] Ostermann J, Reddy E, Shorter M, Muiruri C, Mtalo A, Itemba D et al. Who tests, who doesn’t, and why? Uptake of mobile HIV counseling and testing in the Kilimanjaro Region of Tanzania. PLoS One 2011;6(1):e16488.

[4] Coffey S, editor. Guide for HIV/AIDS Clinical Care. Rockville, MD, USA: US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2011.

[5] Siegfried N, van der Merwe L, Brocklehurst P, Sint T. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev 2011;2011(7):1-122.

[6] Mashoto K, Mubyazi G, Mohamed H, Malebo H. Self-reported occupational exposure to HIV and factors influencing its management practice: a study of healthcare workers in Tumbi and Dodoma Hospitals, Tanzania. BMC Health Serv Res 2013;13(1):276.

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Reproductive Healthcare in Latin America: Perspectives from a Guatemalan Elective

If medicine is to fulfill her great task, then she must enter the political and social life.

—Rudolf Virchow, founder of modern pathology

An overseas elective is a time to experience medicine in another setting, and it is as much about the setting as it is about the medicine. While gunshot wounds in Johannesburg, and tropical diseases in East Timor, are the often the draw cards when we are planning an elective, it is witnessing the social conditions that lead to those health problems that really change our outlook. Rudolph Virchow was right about many things, but this dictum seems to go unheeded in much of our medical education. Perhaps that is best; there doesn’t seem to be much space in the curriculum for a quick course on East Asian history, Latin American politics or economic development. It does mean, however, that for many of us, our elective becomes a crash course on the political and social life we aren’t taught about in medical school.

After some deliberation, I decided on a women’s health elective in Guatemala. It seemed like a good chance to spend some time learning about a single public health issue in more depth, and at the time I was interested in how cervical cancer, a disease so preventable in our own country, could be such a significant killer of women in the developing world. Some quick research led me to believe Guatemala was no different. Once I arrived, however, I discovered that most of the women in that area of Guatemala, Antigua, a wealthy area popular with tourists, were already engaged by cervical cancer screening programs. While the hospital I was working at openly encouraged women to be screened for cervical cancer, there was an issue that no one seemed to be talking about. An issue that inextricably links medicine to the political and social lives of women. Contraception.

In the first week I went out on a few visits with the social worker to the villages surrounding Antigua where most of the patients lived. As we walked farther from the edge of town the roads diminished to dirt tracks, the cinder block houses became tin shacks. We spoke mostly to women and many of their stories were similar; they worried when their husbands would next get regular work, whether there would be enough money for food, whether they could continue to afford to send their children to school. It also seemed as if every family had upwards of five or six children, many of them only a year or two apart. The doctors at the hospital had said they did not discuss family planning with the women because it was a cultural issue, and they did not want to alienate the community. Although the hospital was run by a Christian non-profit based in the United States (US), the director stated the practices at the hospital were not guided by religious belief. The doctors and health workers at the hospital would not raise the issue of contraception with patients. If women requested contraception the hospital would refer them to another US-based non-governmental organization (NGO), WINGS, that dealt with family planning amongst other reproductive health issues, and had limited funding and scope. Walking through those tin shacks and dirt lanes family planning seemed much more than a cultural issue, it seemed to be about gender, politics, economics, education, religion and history too.

Guatemala has one of the highest fertility rates in Latin America of four children per woman. [1] Amongst Indigenous women that rate is 6.8, and in some rural areas is reported to be as high as 10 per woman. Indeed the Indigenous population, mostly Maya, make up approximately 50% of Guatemala’s population, of which 80% live rurally. [2] As is true almost universally for Indigenous populations, they suffer from significantly poorer health parameters, which can be traced back to a brutal colonial history followed by a 36-year civil war, and the ongoing economic and educational disparities related to this.

On a quest to find out more about contraceptive use, I decided to spend the remainder of my elective with another NGO, Maya Gift, doing village clinics in the Lago de Atitlan region of the Guatemalan highlands, where the population is largely Indigenous and the fertility rates are highest. Maternal mortality rate (MMR) in this region is up to 534 per 100 000, compared to 120 per 100 000 in Guatemala as a whole, or 7 per 100 000 in Australia. [3] Most births are not attended by a skilled midwife, but by a comadrona, a traditional birth attendant. In Guatemala, 59% of births are attended by a traditional birth attendant only, in rural areas this percentage is thought to be much higher. [4] The high fertility rates, combined with high maternal mortality rates, result in a 1 in 20 lifetime chance of dying in childbirth in the highlands surrounding Atitlan. [5] That is significantly higher than the 1 in 190 lifetime risk in Guatemala as a whole, or the 1 in 8100 lifetime risk of dying in childbirth in Australia. [3]

Given the incredible impact of pregnancy on women’s lives in this part of the world it seemed strange for health organizations to not actively discuss the issue, or to consider it as purely cultural. It seemed like these women were missing out on a basic element of healthcare, but were they really? What does contraceptive use mean to the individual and the society they live in.

A revolutionary pill

Family planning may date back to the fertility goddesses of ancient Egypt, but modern family planning methods started in the 1960s with the contraceptive pill. The availability of effective contraception had far reaching consequences for role of women in society, particularly in terms of marriage and the workforce. [6]

It was not long before family planning entered the domain of public health. Amid concerns about rapid population growth, international family planning programs in the 1960s and 70s were framed with population policies, with the focus on reaching demographic and fertility targets. In this context some nations adopted coercive population control policies that violated human rights and often targeted sections of the population based on race and socioeconomic status. [7] This sort of practice is completely at odds with the family planning efforts of the majority of governments and public health organizations today.

Family planning in 2012

The marked shift in the basis of family planning policy from population control to human rights was clearly demarcated in 1994 by the Program of Action of International Conference on Population and Development in Cairo. [8] Here, 179 countries signed on to a Program of Action that framed family planning as a women’s health issue rather than a purely demographic issue. For the first time, universal access to contraceptives was set as the goal, rather than the population targets set in the past. From this conference onwards the focus has been on autonomy, choice and improving access.

With this approach in mind, the benefits of family planning programs in developing countries have been marked. In development terms family planning provides one of the best returns for investment of any public health measure. [9] When women are given access to modern family planning methods they have fewer children and those children go on to be better educated and healthier, suffering significantly less from malnutrition. The most well known cases are perhaps in South East Asia, where countries like Thailand dropped their fertility rate from 6.3 in 1967 to 1.7 in 2003. [10] In this setting the decrease in fertility was associated with an explosion in economic growth, leading to a phenomenon known as the ‘demographic dividend’. [11] This phenomenon occurs in countries with high fertility rates, where an increased investment in family planning results in a significant fertility drop across one generation. [12] As a greater proportion of the population are at working age relative to dependants, there may be more funds to spend on health and education. This raises the ‘human capital’ of the population, as those children who have grown up an environment with increased access to health and education become more economically productive than their predecessors.

Despite the knowledge of the profound effect of family planning on economic development, funding for programs was slowly eroded from the 1980s onwards. [13] This was in part due to the redirection of funds to fight the AIDS epidemic, and in part due to the political rise of the Christian right in US politics. The Christian right lobbied to block US funding to the United Nations Population Fund (UNFPA), a key reproductive health body, and prevented the United States Agency for International Development (USAID) funding any organisations that were linked with abortion. Many of those organisations were also key providers of less controversial aspects of family planning, including the contraceptive pill and injectable contraceptives. [14]

In 2012, however, family planning was placed back on top of the development agenda, when Melinda Gates, of the Bill and Melinda Gates Foundation, the largest philanthropic organization in the world, decided to make family planning her signature issue, investing several billion dollars in the cause. Gates highlighted the key issues in her first public speech on the topic: accessibility, education and above all, removing the taboo surrounding contraception. [15] At the landmark London Summit on Family Planning in July 2012, organized by the Gates Foundation, world leaders gathered to orchestrate a plan to address the enormous unmet need for contraceptives. It is estimated that 222 million women who would like to use contraception do not have access to it. Of the 210 million pregnancies each year, 80 million are estimated to be unintended. Furthermore, there are 22 million unsafe abortions occurring each year, resulting in 47,000 deaths. [13]

There is, of course, another reason family planning has been put back on the agenda: climate change. Uncontrolled population growth has been touted as one of the most significant contributors to carbon emissions. [16] A 2011 UN report on the predicted population of the world in 2050 outlined the variability in our global future. [17] The report released three variants of estimated population, a smaller, medium and large variant, 8.1 billion, 9.3 billion and 10.6 billion, respectively. The medium variant, largely held to be the most likely, relies on fertility rates in high fertility countries dropping from an average of 4.9 children per woman to 2.8. Family planning services in high fertility countries in Africa and Asia will need to be expanded if they are to meet this need. Alarmingly, Africa, which struggles to provide food and water to its inhabitants today, could see its population more than triple, from 1 billion today to 3.6 billion by 2100. [18]

The global, the local

For the women of the Lago de Atitlan region of Guatemala these global issues are largely esoteric. The inaccessibility of contraception at the local level is made up of a different set of factors, albeit related to these global issues. After talking with these women for a few weeks it seemed that the barriers to contraceptive use could be broadly broken down into economic, educational, cultural, historical and geographical obstacles.

In this area of Guatemala, generally only the males worked for a paid wage, which for a campesino (rural labourer) was US$150 per month. [19] Speaking with the campesinos who came to the clinic, it seemed this wage would often need to support families with six or more children and dependant grandparents. An average workday involved 12 hours of backbreaking labour, carrying 60kg sacks of coffee back and forth. Speaking with the women it was clear they worked just as hard: labouring, preparing meals and selling food in the bigger towns. In this environment it seemed there was rarely a free morning, or spare funds, to go and get an injection of depot contraceptive at the clinic in the next town. Contraception would have to be cheaper, or free, and more accessible if they were to use it consistently.

Inextricably linked to the economic disadvantage of rural Guatemala was the educational disadvantage. Many families could not afford to send their children to school, which although free, required purchasing shoes, uniforms, books and supplies. The average amount of schooling is 4.28 years per person. [20] Illiteracy rates are amongst the highest in Latin America; 21.8% for men and 39.8% for women. [21] It is estimated that two million children of school age are not attending school. The majority of these are Indigenous girls living in rural areas, the very demographic that go on to experience poor reproductive health and the highest fertility rates. [22] These educational disparities are apparent in every aspect of health and particularly in reproductive health. Myths of contraceptive side effects abound in such an environment. Some I commonly heard were that contraceptives can give you cancer, can cause irreversible infertility, or can cause menstrual blood to collect in the uterus and make a woman sick.

Perhaps the most commonly referred to barriers to contraception are culture and religion. In fact, it was the reason the doctors in Antigua gave me for not discussing contraception with their patients. Certainly the Guatemalans are very religious people, 55-60% are Catholic and 40% are Evangelical Christian. [23] There is also a strong machismo culture, as in much of Latin America, and virility is associated with manhood. Culture, however, has proven to be exquisitely sensitive to change when it comes to contraception. In historically strong Catholic countries like Ireland and Italy contraceptive use rates have grown to mirror other developed countries. In 2010, 94% of sexually active adults trying to avoid pregnancy in Ireland had used contraception in the previous year. [24] Similarly, 85% of Catholics in the United States no longer believe that the use of contraception is immoral. I think this signifies that when people are educated and have access to contraception, they are willing to integrate different forms of knowledge into their own belief systems and practices. Attributing the low rate of contraceptive use as religious in origin seems overly simplistic, given members of the same religion in another cultural and economic environment make different decisions.

Lastly, nothing can be discussed in relation to Guatemala without mentioning history and geography. The Indigenous Guatemalans bore the brunt of a brutal 36-year civil war, which only ended in 1996. Assumed to have sided with the left wing guerrillas, who supported more populist policies, the Indigenous were targeted by the right wing military government. [25] Some of the towns in the Lago de Atitlan region were the sites of acts of genocide by the government. It goes without saying that public health, and family planning, for these people was not a priority for the Government. Aside from small NGOs that carried out work in the Atitlan region throughout the violence, the health system of the region has been developed from scratch since 1996 and remains grossly underfunded. The Atitlan region remains one of the poorest in a country with one of the most unequal distributions of wealth in the world. Contributing further to the disadvantaged health status of these people is the difficulty of accessing services in larger towns. Seemingly regular natural disasters have severely damaged what little infrastructure there was connecting small mountain villages. Even the shortest of distances can take hours to travel, and poor roads and lack of transport are yet another barrier to delivering effective healthcare.

Xocomil: wind of change

Despite all these barriers to accessing contraception, it seems there is real hope. Many of the Guatemalans I met believed the end of the Mayan calendar on winter solstice 2012 would bring change, a new world, and an end to the old world of inequality and injustice. Thinking of the immense change contraception brought to many countries, and the very real possibility that this will soon be available to women in developing countries, I found myself sharing in the optimism.

But optimism should never breed complacence, and the struggle to make contraception universally available to women continues. Continued progress towards this goal raises new obstacles. After all, it was only recently in the United States, where contraception has been available since the 1960s, that there was a push to remove the requirement for health insurers to cover contraception from the Affordable Care Act.  We cannot afford to forget Virchow’s words now. In order to fulfil our tasks as future medical professionals, we must not forget the political and social life of the world we live in.

The Xocomil is the midday wind that crosses Lake Atitlan. The local Mayan people believe the wind carries away sin and the souls of lives lost in the lake. It is famous in the region and is a symbol of change and vitality.

Acknowledgements

Lyle and Andree at Maya Gift for giving me the opportunity to travel to villages as part of my elective.

Conflict of interest

None declared.

Correspondence

C McHugh: catemchugh@icloud.com

References

[1] UNICEF. At a glance: Guatemala. 2012; Available from: http://www.unicef.org/infobycountry/guatemala_statistics.html.

[2] Metz B. Politics, population and family planning in Guatemala: Ch’orti’ Maya experiences. Human Organization. 2001;60(3).

[3] Organization WH, UNICEF, UNFPA, Bank TW. Trends in maternal mortality: 1990 to 2010 2012.

[4] Walsh L. Beliefs and Rituals in Traditional Birth Attendant Practice in Guatemala. Journal of Transcultural Nursing. 2006;17(2):148-54.

[5] Pfeiffer E. Guatemala. Minnesota Curamericas Guatemala; 2010 [cited 2013]; Available from: www.curamericas.org/our-work/guatemala.

[6] Goldin C, Katz L. The Power of the Pill: Oral Contraceptives and Women’s Career and Marriage Decisions. Journal of Political Economy. 2002;110(4):730-70.

[7] Santhya K. Changing Family Planning in India: An Overview of Recent Evidence. New Delhi: Population Council, 2003.

[8] Greene M, Joshi O, Robles O. By Choice, Not By Chance: Family Planning, Human Rights and Development. New York: 2012.

[9] Singh S, Darroch JE. Adding It Up: Costs and Benefits of Contraceptive Services. Estimates for 2012. New York: Guttmacher Institute; 2012 [cited 2013 July 6]; Available from: www.guttmacher.org/pubs/AIU-2012-estimates.pdf.

[10]  SEARO. Thailand and Family Planning: An Overview. New Delhi: World Health Organization; 2003.

[11] Atinc TM. Realizing the Demographic Dividend: Challenges and Opportunities for Ministers of Finance and Development. Word Bank Live2011 Available from: http://live.worldbank.org/realizing-demographic-dividend-challenges-and-opportunities-ministers-finance-and-development.

[12] Bloom DE, Canning D, Sevilla J. The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change. RAND Corporation 2003.

[13] Family Planning: An Overview. The Bill and Melinda Gates Foundation; 2012; Available from: http://www.gatesfoundation.org/familyplanning/Pages/overview.aspx.

[14] Douglas E. USAID Halts Supply of Contraceptives to Marie Stopes in Six African Countries. RH Reality Check. 2008.

[15] Gates M. Let’s put birth control back on the agenda: TED; 2012.

[16] Simmons A. 7 challenges for 7 billion. ABC News; 2011 [cited July 6 2013]; Available from: www.abc.net.au/news/2011-11-02/7-issues-facing-7-billion-people/3610318.

[17] World Population Prospects: The 2010 Revision, Highlights and 2011.

[18] Gillis J, Dugger C. UN forecasts 10.1 billion by Century’s End. 2011 [cited 2013 July 6]; Available from: www.nytimes.com/2011/05/04/world/04population.html?_r=0.

[19] Schieber B. Guatemala: 60 percent of workers earn less than minimum wage. The Guatemala Times. 2011 Wednesday 16th November

[20] Edwards J. Education and Poverty in Guatemala. World Bank, 2002.

[21] Literacy: Guatemala. 2012 [cited 2013 July 6]; Available from: www.cia.gov/library/publications/the-world-factbook/fields/2103.html.

[22] Hallman K, Peracca S. Indigenous Girls in Guatemala: Poverty and Location. In: Lewis M, Lockheed M, editors. Exclusion, Gender and Education: Case Studies from the Developing World. Washington: Centre for Global Development; 2007.

[23] International Religious Freedom Report: Guatemala. Washington US Department of State; 2006 [cited July 6 2013]; Available from: www.state.gov/j/drl/rls/irf/.

[24] McBride O, Morgan K, McGee H. Irish Contraception and Crisis Pregnancy Study. Health Service Executive, 2010.

[25] Manz B. Refugees of a Hidden War: The Aftermath of the Counterinsurgency in Guatemala. Albany, New York: State University of New York; 1988.

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Probiotics: A New Recommendation with Proton Pump Inhibitors?

Introduction

Clostridium difficile-Associated Diarrhoea (CDAD) is becoming a worldwide epidemic with significant patient morbidity and mortality, as well as increasing the costs to health care systems. Although CDAD is generally associated with antibiotic use, there are multiple studies demonstrating that proton pump inhibitors (PPIs) may also be linked with CDAD. This is particularly worrisome for physicians in general practice, where PPIs are among the most frequently prescribed drugs. [1]

Clostridium difficile is a gram-positive, spore-forming, anaerobic bacillus that may cause gastrointestinal infections with poor patient outcomes and significant medical costs. [2,3] In one study, 3% of C. difficile infections resulted in death or admission to an Intensive Care Unit. [4] In 2002, another study demonstrated a mortality rate of 15.7% due to C. difficile colitis. [5] Although there is no complete cost analysis done in Australia, the figures emerging from the United States are staggering, with the average C. difficile infection cost ranging between $10,970-$29,000 per patient [6,7] and the estimated annual cost of $55 million in the state of New York alone. [7]

The mechanism of infestation and standard treatment

C. difficile enters the human body by spores which are ingested orally. Five percent of the population carries C. difficile asymptomatically due to growth-regulation by gastrointestinal flora. [8] In the presence of antibiotics, normal flora may be reduced, allowing an over-colonization of C. difficile. Typically, C. difficile is treated with a 10-day course of metronidazole for less severe infections, or with vancomycin for severe infections, with recurrence rates as high as 25%. [9]

PPIs and the link with C. difficile

PPIs are a class of drugs frequently prescribed in the general practice setting for Gastro-Oesophageal-Reflux-Disease (GORD), [10] peptic ulcer disease [11] and related conditions. [12] PPIs inhibit the hydrogen-potassium ATPase of parietal cells in the stomach, decreasing gastric acid production, thereby settling acid-related gastric symptoms. General practitioners are prescribing PPIs with increasing frequency. This is not surprising, as between 3% and 7% of the population suffer from GORD. [13] The mechanism by which PPIs may lead to C. difficile colitis is unclear; it may be that reduced stomach acidity allows more of the bacterial spores to survive, thereby increasing bacterial load in the gastrointestinal system. [14]

There are multiple studies demonstrating a link between C. difficile and PPIs. [15-18] In one meta-analysis of case-control and cohort studies, it was shown that PPIs imparted a relative risk of 1.69 for the development of C. difficile infection. [19] Another meta-analysis published by Kwok et al. (2012)  suggested a 70% increase in risk of this infection. [20] Given the considerable risk of developing CDAD in association with PPIs, and the morbidity and mortality associated with CDAD, it is recommended that general practitioners use caution when prescribing these medications, observe patients for secondary diarrhoea and investigate with C. difficile cytotoxin assays.

A multi-center case control trial from the Netherlands identified that the greatest risk for development of C. difficile infection was within the first three months after initiation of antibiotics, with the risk peaking at one month and declining between one and three months. [21] According to this study, third-generation cephalosporins and carbapenems were associated with the greatest risk of CDAD.[21] Other risk factors for CDAD include living in long term care facilities, major bowel diseases such as Inflammatory Bowel Disease (IBD), colorectal cancer, radiation and chemotherapy, and age, with highest risk beyond the age of 65 years. [22] It is yet to be determined if similar risk factors are involved in the development of PPI-associated diarrhoea.

It should be noted that the meta-analytic link between PPIs and CDAD is criticized, as there are multiple methodological problems with many of the studies involved. [23] One criticism is that duration and dose of PPI exposure were not variables considered in the meta-analyses; therefore, the exposure-dependent and dose-dependent relationship cannot be established. [23] Further research is required to determine whether there is a causal relationship between PPI use and CDAD.

What can physicians do in the meantime while the link is investigated?

There may be a role for probiotics in the prevention of PPI related CDAD. Probiotics are broadly defined as live microorganisms that exert beneficial effect on the host. [24-26] The mechanism for this is unclear, but may involve the suppression of pathogenic bacteria and/or suppression of inflammation in the gut. [27] There are a wide range of probiotics marketed today to improve immune function including Bifidobacterium lactis, Lactobacillus reuteri, Lactobacillus rhamnosus and others for diarrhoea including Saccharomyces boulardii, Lactobacillus casei, Lactobacilus acidophilus and others. Lactobacillus, bifidobacteria and certain yeasts (eg: Saccharomyces) are the most common microbes used in commercial probiotics. These can be consumed as part of fermented foods, such as yogurt, or directly as supplements. Recommendation of the probiotic S. boulardii with antibiotics has shown a significant reduction in the incidence of antibiotic-associated-diarrhoea in two separate double-blind placebo controlled studies. [28,29] A meta-analysis reveals nine studies have shown use for both S. boulardii and lactobacilli in the prevention but not the treatment of CDAD. [30]

At this point there is no research examining the effects of probiotics regarding the prevention of PPI associated CDAD; however, it is reasonable to presume there may be a role for S. boulardii and lactobacilli in balancing the gastrointestinal tract flora whether the disruption of its microenvironment is secondary to antibiotics or PPIs. If future research demonstrates a similar reduction in PPI-related CDAD, as has been documented with antibiotic-related CDAD, there may be grounds for adjustment of future clinical recommendations to include probiotics with PPIs in the general practice setting.

In general practice, deciding whether to prescribe any medication requires evaluation of risks and benefits to the patient. As minimal risks have been reported in healthy individuals with probiotic use, [31] and given the potential benefit to reduce the incidence of CDAD, research needs to be done to determine whether there is benefit to prophylactically recommending S. boulardii with PPIs. It would be logistically difficult to ensure compliance and no use of alternate anti-acid medication in a randomly controlled longitudinal trial in the development of C. difficile infection. However, a well controlled prospective cohort study may minimize confounding factors and suggest causality by examining patients with limited comorbidities.

The risks of recommending probiotics

There are no systematic reviews demonstrating risk of probiotics; however, general practitioners should be aware that multiple case studies indicate there may be a risk of recommending probiotics in immunocompromised patients. These include cases of hepatic abscesses and pneumonia, [32] probiotic sepsis [33,34] and S. boulardii fungaemia. [35,36] There are no cases of such probiotic sepsis or fungaemia in healthy individuals.

Conclusion

Probiotics have been recommended in the prevention but not the treatment of C. difficile infection associated with antibiotics. While the pathogenesis of PPI-related CDAD is unknown, it presumably involves the disruption of gastrointestinal flora, which is potentially amenable to probiotic supplementation. Given minimal documented risks of probiotics in immunocompetent individuals, research needs to determine whether there are direct benefits of the use of probiotics in the prevention of PPI-related CDAD. Such recommendation on the part of the general practitioner may reduce morbidity and mortality associated with CDAD and reduce costs to the health care system.

Conflict of interest

None declared.

Correspondence

C Oitment: colby.oitment@uqconnect.edu.au

References

[1] Ahrens D, Behrens G, Himmel W, Kochen M, Chenot JF. Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care.  Int J Clin Prac. 2012; 66(8):767-773. DOI: 10.1111/j.1742-1241.2012.02973.x

[2] Miller M, Gravel D , Mulvey M, Taylor G, Boyd D, Simor A, et al. Health care-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis. 2010; 50: 194-200.

[3] Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short- and long-term attributable costs of Clostridium difficile-associated disease in nonsurgical inpatients. Clin Infect Dis. 2008; 46: 497-504.

[4] Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum. 1995; 38(4): 350-354.

[5] Morris AM, Jobe BA, Stoney M, Sheppard BC, Deveney CW, Deveney KE. Clostridium difficile colitis: an increasingly aggressive iatrogenic disease? Arch Surg. 2002; 137(10): 1096-1100.

[6] McFarland LV, Surawicz CM, Rubin M, Fekety R, Elmer GW, Greenberg RN. Recurrent Clostridium difficile disease: epidemiology and clinical characteristics. Infect Cont Hosp Epidemiol. 1999; 20(1): 43-50.

[7] Lipp MJ, Nero DC, Callahan MA. The impact of hospital-acquired Clostridium difficile. J Gastroenterol Hepatol. 2012; 27(11): 1733-1737.

[8] Bartlett JG. Clostridium difficile: clinical considerations. Rev Infect Dis. 1990;12 (2):243-251.

[9] Bricker E, Garg R, Nelson R, Loza A, Novak T, Hansen J. Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults. Cochrane Database of Syst Rev. 2007; (3): CD004610.

[10] McKeage K, Blick SK, Croxfall JD, Lyseng-Williamson KA, Keating GM. Esomeprazole: a review of its use in the management of gastric-acid related diseases in adults. Drugs. 2008; 68: 1571-1607.

[11] Saha SK, Saha SK, Masud H, Islam N, Ralhan AS, Roy PK, Hasan M. To compare the efficacy of triple therapy with furazolidone amoxicillin and omeprazole for two weeks and three weeks in the eradication of Helicobacter pylori in Bangladeshi duodenal ulcer patients. Bangladesh Med Res Counc Bull. 2011; 37(3): 83-87.

[12] Gerson LB, Mitra S, Blecker WF, Yeung P. Control of intra-esophageal pH in patients with Barrett’s esophagus on omeprazole sodium bicarbonate therapy. Ailment Pharmacol Ther; 2012; 35(7): 803-809.

[13] Digestive diseases in the United States: Epidemiology and Impact. NIH. 1994; 94-1447.

[14] Stevens V, Dumyati G, Brown J, Wijgaarden E. Differential risk of Clostridium difficile infection with proton pump inhibitor use by level of antibiotic exposure. Pharmacoepidemiol Drug Saf. 2011; 20(10): 1035-1042.

[15] Rotamel A, Poritz LS, Messaris E, Berg A, Stewart DB. PPI Therapy and Albumin are Better Predictors of Recurrent Clostridium difficile Colitis than Choice of Antibiotics. J Gastrointest Surg. 2012; 16(12): 2267-2273.

[16] Leonard AD, Ho KM, Flexman J. Proton pump inhibitors and diarrhoea related to Clostridium difficile infection in hospitalized patients: a case-control study. Intern Med J. 2012; 42(5): 591-594.

[17] Keuhn BM. Reflux drugs linked to C. difficle-related diarrhea. JAMA. 2012; 307(10): 1014.

[18] Kim YG, Graham DY, Jang BI. Proton pump inibitor use and recurrent Clostridium difficile-associated disease: a case-control analysis matched by propensity score. J Clin Gastroenterol. 2012; 46(5): 397-400.

[19] Janarthanan S , Ditah I , Adler DG, Ehrinpreis MN. Clostridium difficile associated

diarrhea and proton pump inhibitor therapy – a meta-analysis. Am J Gastroenterol. 2012; 107:1001-1010.

[20] Kwok CS , Arthur AK , Anibueze CI, Singh S, Cavallazzi R, Loke YK. Risk of Clostridium difficile infection with acid suppression agents and antibiotics: meta-analysis. Am J Gastroenterol. 2012; 107:1011-1019.

[21] Grigorios I, Leontiadis I, Miller M, Howden C. How Much Do PPIs Contribute to C. difficile Infections? The Am J Gastroenterol. 2012;107:1020-1021.

[22] Pillai A, Nelson RL. Probiotics for the treatment of Clostridium difficile-associated colitis in adults. The Cochrane Library. 2008; 3: 1-18.

[23] Hensgens MPM, Goorhuis A, Dekkers OM, Kuijper EJ. Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. J Antimicrob Chemother. 2011; 1-7

[24] Bartlett JG, Gerding DN. Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Disease 2008; 46: s12-s18

[25] Dinleyici EC, Eren M, Ozen M, Yargic ZA, Vandenplas Y. Effectiveness and Safety of Saccharomyces boulardii for Acute Infectious Diarrhea. Expert op on boil therapy. 2012: 12(4); 395-410.

[26] Vitetta L. Probiotics, prebiotics and gastrointestinal health. Medicine Today. 2008;9(9): 65-70.

[27] Avadhani A, Miley H. Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults–a meta-analysis. J Am Acad Nurse Pract. 2011;23(6):269-274.

[28] Surawicz CM, Elmer GW, Speelman P, McFarland L, Chinn J, van Belle G. Prevention of antibiotic-associated diarrhoea by Saccharomyces boulardii: a prospective study. Gastro. 1989; 96: 981-988.

[29] McFarland LV, Surawicz CM, Greenberg RN, Elmer GW, Moyer KA, Melcher SA, et al. Prevention of B-lactam-associated diarrhoea by Saccharomyces boulardii compared with placebo. Am J Gastroenterol 1995; 90: 439-448.

[30] D’Souza AL, Rajkumar C, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhea: meta-analysis. BMJ. 2002. 8; 324(7350): 1361

[31] Das RR, Naik SS, Singh M. Probiotics as additives on therapy in allergic airway diseases: a systematic review of benefits and risks. Biomed Res Int. 2013; Vol 2013, Article ID 231979, 10 pages. DOI: 10.1155/2013/231979.

[32] Kunz AN, Noel JM, Fairchok MP. Two cases of Lactobacillus bacteremia during probiotic treatment of short gut syndrome. J Pediatr Gastroenterol Nutr 2004;38:457-458.

[33] De Groote MA, Frank DN, Dowell E, Glode MP, Pace NR. Lactobacillus rhamnosus GG bacteremia associated with probiotic use in a child with short gut syndrome. Pediatr Infect Dis J. 2005;24:278-280.

[34] Hennequin C, Kauffmann-Lacroix C, Jobert A, Vlard JP, Ricour C, Jacquemin JL, et al. Possible role of catheters in Saccharomyces boulardii fungemia. Eur J Clin Microbiol Infect Dis. 2000;19:16-20.

[35] Bassetti S, Frei R, Zimmerli W. Fungemia with Saccharomyces cerevisiae after treatment with Saccharomyces boulardii. Am J Med 1998;105:71-72.

[36] Niault M, Thomas F, Prost J, Ansari FH, Kalfon P. Fungemia due to Saccharomyces species in a patient treated with enteral Saccharomyces boulardii. Clin Infect Dis. 1999; 28: 930.

 

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Feature Articles Articles

Evidence based practice; keep it simple stupid

Learning and implementing evidence based practice is an expected component of good medical practice. Synthesising evidence in an effective and timely manner is a skill that is growing in importance and relevance. Evidence based practice is widely included in medical school curricula, and information literacy skills are known to be difficult to acquire. We provide a fresh look at a streamlined approach to evidence based practice, using a ‘real world’ case study.

Introduction

The importance of evidence based practice (EBP) is ever increasing. [1,2] However, the complexities of collecting, interpreting and synthesising information may be time consuming and laborious. [3] Information literacy skills are known to be difficult to learn. [4] In an effort to condense the process, a variety of models have been designed for evidence retrieval, including the 4S, [5] the 5S, [6] and more recently the 6S pyramid (Fig. 1). [7] In this article we will focus on the 6S pyramid and its application to a clinical case.

The technology explosion of the last decade has increased access to information for clinicians in almost all settings. The rapid development of handheld electronic devices, paired with the licenses to evidence based databases being held by many universities and institutions, results in information being easier to access. The problem then arises of how to find the best information for a clinical scenario in the swiftest manner. The 6S pyramid is useful as it provides a guide showing where to look first; additionally, it tracks the integration of research into clinical practice, with a decision support system at the pinnacle. An example of this is the ‘PrimaryCare Sidebar’ [8] integrating evidence based guidelines into the clinical data already in the patient record. Although the tip of the pyramid is not always readily available, as we step down the pyramid there are a variety of other evidence based tools available, including Dynamed, [9] BMJ Clinical Evidence, [10] and the Therapeutic Guidelines. [11] Further down the pyramid are reliable resources such as PubMed [12] and the Cochrane Database of Systematic Reviews, [13] which are freely available online.

This article presents a streamlined approach to EBP, demonstrating the multistep process via a clinical case. One of the most difficult aspects of evidence based practice, translating medical jargon and statistics into ‘layman’s terms’ with the goal of empowering the patient to make an informed decision, is demonstrated. Our aim is to demystify EBP and its application for medical students and practitioners, thereby encouraging a wider application in day-to-day clinical work.

Case Details

Mrs SJ is a 62yo Caucasian female who is fairly new to the practice; she presents to discuss the topic of her back pain. SJ reports a three year history of bilateral lumbar radiculopathy; MRI showed degenerative spinal canal stenosis at L5/S1 and nerve conduction studies confirmed neural involvement. Failing a period of conservative measures and continuing to report severe pain, SJ underwent an L5/S1 laminectomy and posterior fusion.

Postoperatively, SJ reported minor relief of her symptoms; she continues to have 6/10 bilateral leg pain on a daily basis. The surgeon advised SJ there was no role for further operative procedures and SJ confirmed she did not want to even consider another procedure. Following the surgery she trialled gabapentin, with minimal effect. Since then she has been attempting to manage her pain with paracetamol, which has only had a partial effect.

Although not under any major financial stress, SJ felt the benefit of the gabapentin did not justify the cost, contributing to cessation of the medication. As an adjunct to pharmacotherapy, SJ had five sessions of physiotherapy addressing postural correction and stretching. She felt there was no benefit from this treatment.

SJ has an otherwise unremarkable medical history, is not on any regular medication and has no allergies. She lives with her husband, who is well. Friends have mentioned other drugs that they found effective for their pain, and she asks why she shouldn’t use them.

Determining a specific, targeted question

Before we seek our answers, we need to define the question/s. [14] This will lead us to a more precise, relevant answer, and save time sifting through irrelevant information.

In patients with chronic lumbar neuropathic pain (radiculopathy), what are the pharmacological options? This question is really what the patient has asked; however, our clinical problem is: what are the pain management options (pharmacological and non-pharmacological) in a patient with radiculopathy who has failed surgical therapy. In practice, we may choose to enquire about the pharmacotherapy about which Mrs SJ has asked; however, a holistic approach to the longterm management of this patient would involve a review of all options, including those that are non-pharmacological. In order to stay focused on the purpose of this article, which is the process of EBP and not the best practice treatment for lumbar radiculopathy, we will focus on pharmacotherapy only.

PICO:

  • Population: Chronic radiculopathy, unsuccessful lumbar surgery, menopausal women
  • Intervention: Medication, not gabapentin
  • Comparator: No medication, paracetamol
  • Outcome: Pain reduction and quality of life improvement. [15]

Collecting the evidence

In order to approach this therapy question, we started as high up the pyramid as possible. When creating a search we used keywords that were defined during the formulation of our targeted (PICO) question. Boolean operators (AND, OR, NOT) are also useful and function well in most search engines. Dynamed contained a topic entitled ‘Lumbar spinal stenosis,’ and the treatment section covered some information about medications, but this was not complete. Using BMJ Clinical Evidence (a clinical guideline tool) we searched ‘chronic pain.’ That search led us to the topic ‘chronic pain syndromes,’ and, although there wasn’t a direct answer to our question, under the treatment section we found an international guideline dated 2007.

Now that we knew guidelines existed on the topic, we searched Medline for a more recent version. This led us to three international guidelines. We used the 2010 paper ‘Recommendations for the pharmacological management of neuropathic pain: an overview and literature update’ by Dworkin et al as the primary paper. [16] Unfortunately, as is often the case, evidence specific to our patient was not available.

Determining levels of evidence and strength of recommendation in order to deliver appropriate advice

In order to give valid advice we need to know the strength of the evidence it is based upon, and the size of effect in our population of interest. Various guides exist in order to systemise this process and various methods are commonly used in the literature. The Oxford Centre for Evidence-based Medicine [17] is a well established resource. More recently, The Grading of Recommendations Assessment, Development and Evaluation (GRADE) [18] has been developed with the aim of providing a comprehensive system for grading quality of evidence and strength of recommendations. The resources above provide quality instruction on how to perform the vital step of appraising evidence. Fortunately, this has often already been done for us by others who have summarised the literature, in guidelines or systematic reviews, but it is good to be familiar with the process.

Breaking down the evidence in a real world scenario

Evidence comes from a variety of communities worldwide, and as such, a patient’s specific situation always needs to be taken into account. [22] Various approaches for communicating evidence [23] and mediums for doing so have been evaluated. [24] The way we communicate with patients about risk and effectiveness of treatments can affect their perception and understanding of illness. Communicating with the aid of numerical data, absolute risk (instead of relative risk), both negative and positive perspectives, and with visual aids, all help to improve understanding. [25] Closed loop communication can be used in order to verify understanding. We need to start by translating the evidence into dialogue that would take place between two human beings. This can be helpful in conceptualising the information retrieved. Let’s try…

Doctor: Let’s start by talking about the type of pain you have.

The pain you have is a nerve pain, often called neuropathic pain. This can be due to a lesion or disease. In your case, structures in your lower back are directly irritating nerves. In a simple world you remove the ‘lesion or disease’ and the pain would go away.

Unfortunately, after chronic stimulation the pain message continues to be ‘switched on’ even without a stimulus. This pain can be treated with medications but is often more difficult to manage.

Patient: I totally agree, this pain has been really difficult to manage, and has been getting on top of me for a long time.

Doctor: So your friends have mentioned medications?

Patient: Yes, they have mentioned a few different ones. I’m not sure of the names.

Doctor: There’s a lot of research about medications for the treatment of neuropathic pain, [16] but not a lot have looked at your particular scenario. [26] Of the few medications that have been tested, the evidence suggests only a small amount of benefit. There are some medications that have a lack of efficacy and we should avoid these.

Patient: I am really interested in trying another medication, even if the improvement is only small. Anything that would help me get through the day would be positive.

Doctor: Studies have shown that there are a few main groups of medications that are considered first choice; gabapentin (the one you tried) was one of them. Alternatives include opioids and some antidepressants. We use the antidepressants not because we think you are depressed, but because they have good pain relieving properties for this type of pain. You should know that research found these medications gave meaningful pain relief to around 50 percent of the patients. [23] So, effectively one in two patients. Although this gives us an idea of what to expect, it doesn’t mean it will work for you.

Because of the unclear nature of the evidence, we need to approach the choice of medication carefully, considering your situation. [16]

Patient: So…what are the side effects and how much do these medications cost?

Doctor: Antidepressants, particularly an older group called ‘TCAs’ (tricyclic antidepressants) have been shown to be effective. We don’t fully understand how they work for pain, but do know they provide pain relief in patients who aren’t depressed. [28] On the positive side, they are cheap, are taken once a day and can help with sleep. On the negative side, there are some side effects including dry mouth and constipation. These are not harmful, but annoying, and often resolve with a change in dosage. Rarely, these drugs can cause disturbance to the heart rhythm, and an overdose of these medications is very dangerous to children, so they need to be kept out of reach at all times. Newer antidepressants called SNRIs have shown fewer side effects, but haven’t been studied as thoroughly. [16]

Patient: Besides the heart thing these sound pretty good. I don’t have children at home so that shouldn’t be an issue. Is there anything else on offer?

Doctor: Another group of medications work by slowing down pain impulses; gabapentin is one of these. Although they have proven effectiveness, side effects include dizziness and sedation. As you have mentioned, this is an expensive choice and hasn’t worked for you, so it’s probably not the best option for us at the moment.

Patient: Agreed!

Doctor: Finally, the opioid-like medications are an option. However, I would prefer if we could avoid these. Generally, individuals build tolerance to them and they can be addictive.

Patient: I don’t want to have to rely on it all the time, or have to keep using more of the medication. It sounds like the first option, the antidepressants, is the best, particularly if they are going to help me sleep.

Doctor: Yes, assisting with sleep is a great attribute of TCAs, but it takes a while for full effect, so let’s trial a medication called amitriptyline for six weeks and reassess after that. The medication will cost around A$30 a month. I would like to do an ECG to get an idea of your baseline heart rhythm, and for you to complete two questionnaires in order for us to keep track of your progress: the McGill pain questionnaire [29] and the Short form 36. [30]

Please come back and see me sooner if you have any concerns or develop the side effects we talked about. Also, I would like you to consider other ways this pain can be managed. There are many alternative approaches we should explore, most of which do not include medications.

Conclusion

So, that wasn’t too hard, was it? We defined the question, used a top down approach to the evidence pyramid, and accessed a synthesis of the best literature to answer our question. We made an assessment of the quality of the information available, and attempted to translate ‘doctor speak’ into lay terms. Implementation of the evidence will inevitably lead to further questions. The ongoing process of EBP is illustrated as a cycle (Fig. 2).

Gathering evidence based information should no longer be a chore. Using evidence at any level of the pyramid needs thoughtful consideration, requiring close scrutiny of the methods of evidence generation and the method of appraisal. Due to the increasing amount of evidence being published, synthesis and weighing of existing evidence can serve to provide a more comprehensive and relevant source of evidence based recommendations. The streamlined pyramid approach can be skimmed during consultations or scrutinised for assignments.

So the next time a patient (or an examiner!) throws you a curveball, use EBP to find the comprehensive answer they deserve.

Acknowledgements

The authors would like to thank Dr Morris Aziz for his contribution on the topic.

Conflict of interest

None declared.

Correspondence

J Dannaway: jdan9820@uni.sydney.edu.au

References

[1] Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, et al. Sicily statement on evidence-based practice. BMC Medical Education. 2005; 5(1):1.

[2] Sackett DL, Rosenberg WMC. On the need for evidence-based medicine. Journal of Public Health. 1995; 17(3):330 –334.

[3] Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. BMJ. 1998 Jul 25;317(7153):273–6.

[4] Hofer AR, Townsend L, Brunetti K. Troublesome Concepts and Information Literacy: Investigating Threshold Concepts for IL Instruction. Portal: Libraries and the Academy. 2012; 12(4):387–405.

[5] Haynes RB. Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence. ACP J. Club. 2001 Apr;134(2):A11–13.

[6] Haynes RB. Of studies, syntheses, synopses, summaries, and systems: the “5S” evolution of information services for evidence-based healthcare decisions. Evidence Based Medicine. 2006; 11(6):162–4.

[7] DiCenso A, Bayley L, Haynes RB. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evidence based nursing. 2009; 12(4):99–101.

[8] PrimaryCare Sidebar. [Accessed 2013 Aug 26]. Available from: http://www.racgpoxygen.com.au/products/

[9] Dynamed. [Accessed 2011 Dec 19]. Available from: http://dynamed.ebscohost.com/

[10] BMJ Clinical Evidence. [Accessed 2011 Dec 19]. Available from: http://clinicalevidence.bmj.com/ceweb/index.jsp

[11] Therapeutic Guidelines. [Accessed 2011 Dec 19]. Available from: http://www.tg.org.au/

[12] PubMed. [Accessed 2011 Dec 19]. Available from:http://www.ncbi.nlm.nih.gov/pubmed/

[13] The Cochrane Collaboration. Cochrane Reviews. [Accessed 2011 Dec 19]. Available from: http://www.cochrane.org/cochrane-reviews

[14] Centre for Evidence Based Medicine. Asking focused questions. [Accessed 2011 Dec 19]. Available from: http://www.cebm.net/index.aspx?o=1036

[15] Salisbury J, Glasziou P, Del Mar C, Salisbury J. Evidence-based practice workbook. Oxford: Blackwell; 2007.

[16] Dworkin RH, O’Connor AB, Audette J, Baron R, Gourlay GK, Haanpää ML, et al. Recommendations for the pharmacological management of neuropathic pain: an overview and literature update. Mayo Clinic Proceedings. 2010. p. S3.

[17] CEBM (Centre for Evidence-Based Medicine). [Accessed 2011 Dec 19]. Available from: http://www.cebm.net/index.aspx?o=1001

[18] The grading of recommendations assessment, development and evaluation (GRADE). [Accessed 2012 Dec 19]. Available from: http://www.gradeworkinggroup.org/index.htm

[19] Tran DQH, Duong S, Finlayson RJ. Lumbar spinal stenosis: a brief review of the nonsurgical management. Can J Anaesth. 2010 Jul;57(7):694–703.

[20] Baron R, Freynhagen R, Tölle TR, Cloutier C, Leon T, Murphy TK, et al. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. Pain. 2010 Sep;150(3):420–7.

[21] Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. European Journal of Neurology. 2010; 17(9):1113–e88.

[22] Centre for Evidence Based Medicine. Making a decision. [Accessed 2011 Dec 19]. Available from: http://www.cebm.net/index.aspx?o=1854

[23] Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA: The Journal of the American Medical Association. 2004; 291(19):2359.

[24] Trevena LJ, Barratt A, Butow P, Caldwell P. A systematic review on communicating with patients about evidence. Journal of Evaluation in Clinical Practice. 2006; 12(1):13–23.

[25] Paling J. Strategies to help patients understand risks. BMJ. 2003; 327(7417):745–8.

[26] Attal N, Martinez V. Recent Developments in the Pharmacological Management of Neuropathic Pain. European Neurological Journal. 2010

[27] OʼConnor AB. Neuropathic Pain: Quality-of-Life Impact, Costs and Cost Effectiveness of Therapy. PharmacoEconomics. 2009;27(2):95–112.

[28] Max MB, Culnane M, Schafer SC, Gracely RH, Walther DJ, Smoller B, et al. Amitriptyline relieves diabetic neuropathy pain in patients with normal or depressed mood. Neurology. 1987 Apr;37(4):589–96.

[29] Melzack R, Katz J. The McGill Pain Questionnaire: appraisal and current status. Guilford Press; 2001.

[30] Ware Jr JE. SF-36 health survey update. Spine. 2000;25(24):3130–9.

Categories
Feature Articles Articles

Improving medication adherence amongst Aboriginal and Torres Strait Islander peoples

Introduction

Aboriginal and Torres Strait Islander peoples represent a minority population in Australia, comprising approximately 2.5% of the total Australian population in 2011. [1] There are a number of challenges faced by Aboriginal and Torres Strait Islander peoples, due to social, economic and health differentials as a consequence of the history of marginalisation. [3] Despite improvement in detection and management of chronic disease, Aboriginal and Torres Strait Islander peoples continue to have higher incidences of chronic diseases such as cardiovascular disease and diabetes mellitus. [2,4]

A contributing factor to this gap in health statistics is a low rate of adherence to medication amongst Aboriginal and Torres Strait Islander peoples. [5] While this problem is not unique to this population, there is global evidence that the rates of adherence to medication are lower amongst marginalised groups. [6] In order to help reduce the burden of disease amongst this group, it is important to explore some reasons for non-adherence that are unique to Aboriginal and Torres Strait Islander peoples. In particular, this article will focus on the impact of cultural insensitivity and problems with access to healthcare and medications amongst this population. It will suggest how adherence can be improved through improving cultural sensitivity and access to healthcare, in order to reduce the gap in health statistics between Aboriginal and Torres Strait Islander peoples and non-Aboriginal and Torres Strait Islander peoples.

Impact of non-adherence

The World Health Organisation (WHO) estimates that, in developed countries, 50% of patients fail to comply with advice given by medical practitioners, including both medication and lifestyle advice. [6] Non-adherence with medication is a complex problem that is multi-factorial, and can contribute both to the failure of treatment [5] and increased costs to the healthcare system. [7] Often, this lack of adherence is intentional due to side effects, perceived drug effectiveness, and cost. [8] The implications of these barriers to adherence for Aboriginal and Torres Strait Islander peoples will be discussed below, with an emphasis on cultural barriers preventing adherence. [9]

Chronic diseases require adherence to medications and lifestyle modifications, in order to slow disease progression and prevent complications. [10] Therefore, non-adherence to either form of treatment can contribute to the perpetuation of this gap in health statistics. For example, in general, Aboriginal and Torres Strait Islander peoples have higher rates of cardiovascular disease than non-Aboriginal and Torres Strait Islander peoples. [3] Given that medication and lifestyle modifications reduce risk factors of cardiovascular disease and improve mortality, failure to comply with these treatments can result in exacerbation of disease rates. [3] Similarly, diabetes mellitus is a condition that is more prevalent amongst the Aboriginal and Torres Strait Islander population, and its morbidity and mortality are also disproportionately higher amongst this population. [10] Poorly controlled diabetes mellitus, through lack of adequate pharmacological management, can have serious vascular complications. This perpetuation of health inequality would in turn have a negative impact on national health expenditure, leading to increased costs to the health system. [9]

Barriers to adherence

According to the WHO, there are five dimensions that can impair a patient’s adherence with medication. [6] These are the healthcare team or system, socioeconomic factors, the nature of the therapy, the patient and the medical condition. [6] The first four dimensions are especially relevant to Aboriginal and Torres Strait Islander peoples in both rural and urban settings, and will be discussed below.

Socioeconomic factors

First, as stated by the WHO, socioeconomic factors play an important role in the low rates of adherence amongst Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples have a lower income status than non-Aboriginal and Torres Strait Islander peoples, and also have a higher unemployment rate. [11] This may therefore affect adherence to long-term, expensive medical treatment. Geographic location has previously been a barrier to accessing medications for some Aboriginal and Torres Strait Islander communities [3] and is within the WHO’s healthcare system dimension. However, the Australian Government has, in recent years, initiated national programs and legislated to improve access to prescription medications for Aboriginal and Torres Strait Islander peoples. This will be discussed below.

Cultural insensitivity

Of the Aboriginal and Torres Strait Islander peoples who do live in urban centres, many report cultural insensitivity as being the main barrier to receiving care from services that do not specialise in Aboriginal and Torres Strait Islander health. [12] This in turn can influence medication uptake and adherence. In particular, the non-Aboriginal and Torres Strait Islander healthcare system can be seen as unwelcoming. [11] This is a barrier under WHO’s healthcare team dimension. For example, one Aboriginal and Torres Strait Islander patient was unhappy because he was told to go to an Aboriginal and Torres Strait Islander health service, when he presented to a service that does not specialise in Aboriginal and Torres Strait Islander health. [12] This attitude often fosters a poor relationship between the clinician and the individual. [11]

Miscommunication between health practitioner and patient contributes to a lack of adherence to medications. For example, the services outside the Aboriginal and Torres Strait Islander system often do not provide enough support for people who only speak traditional languages within communities. [5] Cass et al. (2002) demonstrated that communication by healthcare service providers to Aboriginal and Torres Strait Islander peoples who preferred to communicate in languages other than English was often poor. [13]

Other causes of miscommunication were the health practitioner failing to share control in the consultation with the patient, failing to overcoming language barriers by not using interpreters, and using too much biomedical language during the consultation. [13] When the patient does not feel involved in decision-making, he or she is less motivated to adhere to treatment advice. [5] Furthermore, miscommunication is often unrecognised by the health practitioner, meaning that concepts are never clarified. [13] While most Aboriginal and Torres Strait Islander peoples are fluent in English, such miscommunication can have a negative impact on adherence to treatment for many people, leading in turn to adverse health outcomes. [13]

Furthermore, services that do not specialise in Aboriginal and Torres Strait Islander health sometimes do not accommodate Aboriginal and Torres Strait Islander cultural practices, which may hinder medication adherence. In some Aboriginal and Torres Strait Islander communities, traditional healers can be the first point of call for health problems. [14] Only when the traditional healers are unable to provide a solution does an individual from such a community approach the Western health system. [14] As a consequence, Aboriginal and Torres Strait Islander peoples may be less likely to comply with prescriptions due to unfamiliarity with Western medicine. [13] Furthermore, the concept of prophylactic medication does not exist in some Aboriginal and Torres Strait Islander cultures, so some community members may be reluctant to take medications that are not for the treatment of acute conditions. [15]

The family plays an important role in many Aboriginal and Torres Strait Islander people’s health. [5] Therefore, the family itself can act as a barrier to medication adherence in a number of ways. [5] First, there can be a culture of sharing medications in some communities. [5] This can result in under-treatment of the person who was prescribed the medication. Secondly, some families can influence a person’s decision to adhere to medication, by failing to support the person to adhere to medication, or by encouraging the notion that medication adherence is not cultural.[5] Therefore, educating the community and seeking familial support is important to improve adherence rates to therapies amongst some Aboriginal and Torres Strait Islander peoples. [5]

Healthcare practitioners’ role

There are a number of issues with adherence due to healthcare practitioner behaviours. First, due to cultural differences, a lack of flexibility when prescribing medication has been identified as contributing to non-adherence amongst some groups. [12] For example, health service providers are not always using long-acting medication preparations where possible, nor appropriate combination medications, to reduce the number of tablets that the patient has to take. [15] This falls under the WHO dimension of the nature of the therapy, and is something that health service providers should be aware of when engaging in culturally sensitive medical practice.

Similarly, medical practitioners themselves can be non-adherent to clinical practice guidelines when providing treatment to some Aboriginal and Torres Strait Islander peoples. [16] The study by Fürthauer et al. (2013) showed that medical practitioners may deliberately deviate from a clinical guideline for a particular patient, if they feel that the patient may not adhere to the treatment in the long-term, due to cultural practices or socioeconomic background. [16] This comes under the WHO healthcare team dimension, and is an important cause of non-adherence that needs to be examined closely in the Australian context.

The WHO states that patients should be supported, not blamed, for a lack of adherence. [6] Therefore, practitioners should take an active role to ensure that the healthcare environment supports adherence to medication. [6] For example, practitioners should work with patients to create a therapy regime that fits the patient’s lifestyle. [6] It has been shown that a shift in attitude amongst healthcare practitioners to a more empathetic, collaborative approach with their patients achieves better adherence rates. [6] This includes the practitioner taking the socio-demographic characteristics of the patient into account. [6]

History of marginalisation

In addition, some Aboriginal and Torres Strait Islander peoples feel that health services should recognise the history surrounding racism and discrimination against Aboriginal and Torres Strait Islander peoples, in order to facilitate trust and improve service uptake. [12] This issue is within WHO’s patient-specific dimension, and may eliminate any feelings of ‘cultural shame’ for accessing Western medication due to the history of marginalisation of Aboriginal and Torres Strait Islander peoples. [3] This indicates that more research needs to be undertaken on the psychological impact of marginalisation on Aboriginal and Torres Strait Islander and its link to non-adherence.

Minimising non-adherence

There are a two main ways to improve adherence rates amongst Aboriginal and Torres Strait Islander peoples. One is by improving cultural sensitivity amongst health service providers to provide appropriate services to Aboriginal and Torres Strait Islander peoples, and welcome them to services outside the Aboriginal and Torres Strait Islander system. The other way is by subsidising medications so that Aboriginal and Torres Strait Islander peoples can have better access to treatments.

Improving cultural sensitivity

In order to minimise non-adherence, it is imperative that the health system be more culturally sensitive towards Aboriginal and Torres Strait Islander peoples. [3] Service providers outside the Aboriginal and Torres Strait Islander health system need to be trained in the cultural values and healthcare beliefs of Aboriginal and Torres Strait Islander communities, in order to provide culturally sensitive advice and treatment. [3] Service providers should also be trained in communicating concepts to non-English speaking patients. [4] This involves the use of interpreters, which has been found to be beneficial in improving communication between Aboriginal and Torres Strait Islander peoples and health practitioners. [4] If required, these individuals can also be educated about medications through the use of pictures and anatomical models. [14] Similarly, medical practitioners should be encouraged to adhere to clinical guidelines when prescribing medications and to treat this group as they would any other group of patients. [16]

Another way of creating a culturally sensitive environment in healthcare centres is to better engage Aboriginal and Torres Strait Islander peoples in this process. [5] While interpreter services clearly fulfil this objective, [3] their role can be supplemented with other culturally sensitive practices. For example, Aboriginal and Torres Strait Islander peoples may feel more welcome if they see members of their communities in brochures. [5] It has been suggested that pharmacies displaying Aboriginal and Torres Strait Islander paintings and employing more Aboriginal and Torres Strait Islander staff will make Aboriginal and Torres Strait Islander peoples more likely to seek information and participate in screening programs. [5]

Increased engagement of Aboriginal and Torres Strait Islander peoples with health workers can be achieved by employing more Aboriginal and Torres Strait Islander Health Workers (AHWs), who have often lived in the region where they work. [17] AHWs act in a variety of capacities to better liaise with Aboriginal and Torres Strait Islander peoples in healthcare settings and facilitate a more positive experience. [5] They undertake clinical work, such as providing health checks and administering vaccinations, or conduct research and implement community development projects. [17] One study found that AHWs, together with pharmacists, have the potential to improve adherence with appropriate funding and education. [5] However more research needs to be undertaken to further evaluate the role of AHWs, specifically in reducing non-adherence.

A difficulty, however, in building culturally-sensitive practices, is that there are many Aboriginal and Torres Strait Islander cultures in Australia, not simply one unified culture. Therefore, a strategy that works for one group may not necessarily work for another. [5] Aboriginal and Torres Strait Islander peoples should therefore be involved in the formulation of policy strategies with health services to increase adherence. [3]

Subsidising medications

It is also necessary to consider the fiscal situation of individuals in Aboriginal and Torres Strait Islander communities. Aboriginal and Torres Strait Islander peoples have a lower median weekly household income than non-Aboriginal and Torres Strait Islander peoples. [1] Therefore, access to subsidised medication may be a way to improve adherence to medication. There are a number of initiatives funded by the Australian Government to try to improve adherence to medications.

As part of the Australian National Medicines Policy, a Quality of Use of Medicines (QUM) strategy was introduced in Australia in 1992. [18] This strategy included evaluating and improving Aboriginal and Torres Strait Islander health in remote areas through a number of ways, including the development of guidelines for culturally appropriate pharmaceutical services and evaluating medication use. [18] On the whole, it appears that the program achieved a number of its objectives, including improving Aboriginal and Torres Strait Islander health. [19] It was intended to complement a legislative change made around the same time to the National Health Act 1953.

This legislative change was made by the Australian Government to improve Aboriginal and Torres Strait Islander peoples’ access to the Pharmaceutical Benefits Scheme (PBS). Section 100 of the National Health Act 1953 gives the Minister for Health the power to make special arrangements for the supply of pharmaceutical benefits to people who are living in isolated areas, are receiving treatment for which pharmaceutical benefits are inadequate, or for whom pharmaceutical benefits can be more conveniently supplied. [20] If the Minister exercises this power, pharmacies can supply remote Aboriginal and Torres Strait Islander primary healthcare services with PBS-listed drugs in bulk, and Aboriginal and Torres Strait Islander patients can access prescription medication free of charge. [20]

The impact of this scheme on access to medications for Aboriginal and Torres Strait Islander peoples in remote areas has been evaluated. [21] It has been found that access to subsidised medications has significantly improved due to the S100. [21] However, it has been recommended that non-PBS medications commonly used by Aboriginal and Torres Strait Islander peoples should be included under S100, in order to further improve access. [21] In addition, there are limitations for people who live just outside the geographic boundaries and are not able to access the medications. [21] Therefore, it has been recommended that the section’s scope be broadened. [21]

More recently, the Australian Government Department of Health and Ageing began funding the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander People Program (QUMAX) in 2008. [22] The aim of this program is to improve adherence with, and access to, medication amongst non-remote Aboriginal and Torres Strait Islander populations specifically. [23] This is achieved by providing financial assistance to Aboriginal and Torres Strait Islander health services to purchase medications, as well as providing patients directly with co-payments. [23] In addition, the Closing the Gap – Copayment Measure Program was introduced in 2010 to improve access to PBS medications for all Aboriginal and Torres Strait Islander peoples who are living with a chronic disease and required treatment. [24] Eligible patients are entitled to receive a waiver on the co-payment for medications under the PBS. [24]

In 2011, the Australian Government undertook an evaluation of the QUMAX and found that there was a 14% increase in PBS utilisation by Aboriginal and Torres Strait Islander peoples, especially for anti-hypertensive, lipid-lowering and asthma medications. [23] Furthermore, there was an 18% increase in utilisation among patients who were not entitled to concessional medications. [23] Some health services combined the QUMAX initiative with Aboriginal and Torres Strait Islander health assessments and care plans, which further incentivised patients to take up subsidised medications. [23]

QUMAX has arguably shown efficacy in reducing the cost barrier to accessing and complying with medications. [23] However, it is not clear whether it has eradicated inequities in PBS expenditure between Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander populations. [23] Therefore, it should continue, taking into account the recommendations set out in the evaluation. In particular, measures to address geographical barriers by providing transport for the delivery and the collection of medications should be implemented. [23] Furthermore, the recommendation to improve cultural training amongst pharmacists should be given special attention. [23]

Conclusion

Non-adherence with medication is a significant problem. It leads to negative health outcomes for the individual, and can result in the public health system incurring high costs. Given that the rates of non-adherence and chronic disease are greater amongst the Aboriginal and Torres Strait Islander population, specific measures need to be taken in order to minimise non-adherence. Healthcare workers should be trained to be more culturally sensitive and to provide clear, unambiguous treatment advice. They should also take care when prescribing medications to provide treatments with the lowest number of tablets appropriate. Healthcare services should be made more welcoming to Aboriginal and Torres Strait Islander peoples by including Aboriginal and Torres Strait Islander artwork, employing more Aboriginal and Torres Strait Islander staff, and involving Aboriginal and Torres Strait Islander communities in the policy-making process. Policy-makers need to be aware that there are many distinct Aboriginal and Torres Strait Islander cultures, not just a single homogenous one. Finally, medications should continue to be subsidised to Aboriginal and Torres Strait Islander peoples, to ensure that those most vulnerable to chronic illness are able to access treatment.

Conflict of interest

None declared.

Correspondence

S Kumble: skum24@student.monash.edu

References

[1] Australian Bureau of Statistics. 2011 Census QuickStats [Internet]. 2011 [cited 2013 August 4]. Available from: http://www.censusdata.abs.gov.au/census_services/getproduct/census/2011/quickstat/0

[2] Healey, J, editor. The Health of Indigenous Australians. Balmain: SpinneyPress; 2010.

[3] Davidson P, Abbott P, Davison J, DiGiacomo M. Improving Medication Uptake in Aboriginal and Torres Strait Islander Peoples. Heart Lung Circ. 2010; 19(5-6):372-7.

[4] Roe Y, Zeitz C, Fredericks B. Study Protocol: establishing good relationships between patients and health care providers while providing cardiac care. Exploring how patient-clinician engagement contributes to health disparities between Indigenous and non-Indigenous Australians in South Australia. BMC Health Serv. Res. 2012; 12:397-407.

[5] Hamrosi K, Taylor S J, Aslani P. Issues with prescribed medications in Aboriginal communities: Aboriginal Health Workers’ perspectives. Rural Remote Health. 2006; 6(2):557-569.

[6] World Health Organisation. Adherence to Long-Term Therapies Evidence for Action. Switzerland: World Health Organisation; 2003.

[7] Roller, L. Medication adherence in tribal Aboriginal children in urban situations. Curr Ther. 2002; 43(11):64-5.

[8] Laba T-L, Brien J-A, Jan S. Understanding rational non-adherence to medications. A discrete choice experiment in a community sample in Australia. BMC Fam Pract. 2012; 13(61).

[9] Donato R and Segal L. Does Australia have the appropriate health reform agenda to close the gap in Indigenous health? Aust Health Rev. 2013; 37:232-238.

[10] Bailie R, Si D, Dowden M, O’Donoghue L, Connors C, Robinson G, Cunningham J, Weeramanthri T. Improving organisational systems for diabetes care in Australian Indigenous communities. BMC Health Serv. Res. 2007; 7:67-78.

[11] Altman J. The Economic and Social Context of Indigenous Health. In: Thomson  N, editor. The Health of Indigenous Australians. Perth: Oxford University Press; 2003.

[12] Lau P, Pyett P, Burchill M, Furler J, Tynan M, Kelaher M et al. Factors influencing access to Urban General Practices and Primary Health Care by Aboriginal Australians—A qualitative study. AltNat. 2012; 8(1):66-84.

[13] Cass A, Lowell A, Christie M, Snelling PL, Flack M, Marrnganyin B et al. Sharing the true stories: improving communication between Aboriginal patients and health care workers. Med J Aust 2002; 176(10):466-470.

[14] McGrath, P. The biggest worry..’: research findings on pain management for Aboriginal and Torres Strait Islander  peoples in Northern Territory, Australia. Rural Remote Health. 2006; 6(3):549-562.

[15] Larkin C, Murray R. Assisting Aboriginal and Torres Strait Islander  patients with medication management. Aust Prescr. 2005; 28(5):123-125.

[16] Fürthauer J, Flamm M, Sönnichsen A. Patient and physician related factors of adherence

to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study. BMC Fam Pract. 2013; 14(47).

[17] Mitchell M, Hussey L. The Aboriginal and Torres Strait Islander Health Worker. Med J Aust. 2006; 184(10):529-530.

[18] Emerson L, Bell K, Manning R. Quality Medication Use in Aboriginal Communities. Paper presented at: The 5th National Rural Health Conference; 1999 March 14-17; Adelaide, South Australia.

[19] Smith, A. Quality use of medicines – are we nearly there yet? Aust Prescr. 2012; 35:174-5.

[20] National Health Act 1953 [Cth] s 100.

[21] Kelaher M, Taylor-Thomson D, Harrison N, O’Donoghue L, Dunt D, Barnes T et al. Evaluation of PBS Medicine Supply Arrangements for Remote Area Aboriginal Health Services Under S100 of the National Health Act. Co-operative Research Centre for Aboriginal Health and Program Evaluation Unit, University of Melbourne. Melbourne; 2004. Report No.: RFT:102/0203.

[22] Couzos S, Sheedy V, Thiele DD. Improving Aboriginal and Torres Strait Islander  and Torres Strait Islander people’s access to medicines – the QUMAX program. Med J Aust. 2011; 195(2):62-63.

[23] Wallace A, Lopata T, Benton M, Keevy N, Jones L, Rees A et al. Evaluation of the Quality Use of Medicines Maximised for Aboriginal and Torres Strait Islander  and Torres Strait Islander Peoples (QUMAX) Program. Australia: Urbis; 2011.

[24] Medicare. Closing the Gap—PBS Co-payment Measure [Internet]. 2010 [updated 1 July 2010, cited 2013 August 5]. Available from: http://www.medicareaustralia.gov.au/provider/pbs/prescriber/closing-the-gap.jsp

Categories
Feature Articles Articles

The role of the food industry in tackling Australia’s obesity epidemic

Whilst a number of factors contribute to Australia’s rapidly rising obesity rates, the role of fast food companies in addressing the epidemic remains controversial. This report discusses the contribution of fast food companies to high obesity rates, explores the notion of corporate social responsibility, and discusses a range of government policies that could be implemented to limit the contribution of fast food chains in promoting obesity.

Introduction

Obesity is a major concern in Australia, with 62.8% of the adult population termed overweight (35.3%) or obese (27.5%). [1] Multiple factors contribute to these rising statistics, and whilst fast food companies undeniably contribute to obesity, defining the exact role that they play and their responsibility remains controversial. Whilst difficult to numerically define, previous studies have offered various definitions of fast food, broadly defining it as food purchased from cafeterias, restaurants and ‘big brand’ companies (such as McDonalds) that are high-calorie and low in nutritional value. [2-4] Food produced in restaurants, for example, is at least 20% higher in fat-content than the home-cooked equivalent. [5] It has now been over a decade since the infamously termed ‘McLawsuit,’ in which a group of overweight children in America filed legal action against the McDonalds corporation for their obesity-related health problems, first bringing the issue of corporate responsibility to a head. [6] Increasingly, now, trends are towards increasing regulation of the fast food industry, with recent debate over a fat tax in Australia, [7] and New South Wales enforcing nutrition labelling of fast food products. [8] The obesity epidemic continues to contribute to the morbidity and health expenditure of many developed countries, with minimal resolution on the role that fast food companies should play in tackling it.

Obesity in Australia: The contribution of fast food companies

The complex array of factors contributing to obesity makes the issue of responsibility a difficult one. [9] Australia’s obesogenic environment comprises multiple factors, such as increasingly sedentary lifestyles, poor education regarding nutrition and the accessibility of fast food. [10] In this respect, fast food companies, government and the wider community are all stakeholders with differing degrees of responsibility.

Fast food companies are considered a key stakeholder in contributing to Australia’s obesogenic environment. This is attributed to factors such as their large portion sizes, and marketing ploys that intensively promote the accessibility of unhealthy snack foods and target vulnerable groups such as low-income earners and children. [11] These factors make it difficult for consumers to make informed choices and resist unhealthy options, ultimately contributing to overeating and excess body weight. [12] Establishing a causal link between fast food companies and obesity is difficult due to the complexity of the relationship. An analysis by Chou, Rashad and Grossman (2005) indicated that a ban on fast food advertising would reduce the number of overweight children by 10% in the 3-11 year age group, and by 12% amongst 12-18 year olds, suggesting a causal component to the relationship in this vulnerable population group. [13] Accessibility of fast food outlets is also a contributing factor, with Maddock and colleagues (2004) showing that there is a significant correlation between proximity to fast food restaurants and obesity. [14] Furthermore, ever-increasing portion sizes also provide evidence for the influence of fast food companies on obesity; with Young and Nestle (2002) noting that portion sizes have paralleled the increase in average body weight. [15] Whilst some claim that fast food companies simply respond to consumer desires, and that the average consumer is well aware of the obesity epidemic, it can be argued that they are still partly responsible by providing and promoting this supply.

Corporate Social Responsibility

Corporate Social Responsibility (CSR) is a form of self-regulation that corporations integrate into their business model. [16] It involves taking responsibility for the impact of the company’s decisions on society and the environment. [17] Guler and Crowther (2010) further describe CSR as honouring the triple bottom line of people, planet and profit rather than solely focusing on profit maximisation. [18]

Proponents of CSR claim that it maximises long-term profits by encouraging firms to operate sustainably, decreasing risks despite initial costs. [19] Wood (2010) argues that ‘strategic CSR’ rewards business for CSR activities via the positive responses of consumers, employees and shareholders. [20] Ethical business policy may lead to brand differentiation and customer loyalty, increasing purchase intention and willingness to pay. Similarly, employees may be attracted and motivated by strong CSR policies, potentially increasing recruitment, work ethic and employee loyalty. Successful CSR strategies can also improve a firm’s reputation, reduce external pressure from non-government organisations (NGOs) and attract shareholders. [21] For example, Becker-Olsen et al. (2006) argues that McDonald’s funding of programs such as Maths Online, Little Athletics and its Ronald McDonald House Charities acts as subconscious advertising to improve its reputation. [21-23]

However, as well as these incentives, firms also face challenges in establishing CSR policies. Some economists claim that CSR distracts from the role of business, which is to maximise profit. [24] The financial costs of introducing CSR policies may also be barriers for firms, particularly small businesses that lack the required resources. [20] Moreover, CSR does not necessarily equate to positive consumer perceptions, as the credibility of corporations is often doubted. [21] For example, partnerships between KFC and the McGraw foundation, McDonalds and WeightWatchers, and Nestle and Jenny Craig have been criticised as marketing ploys, termed ‘weightwashing’ by the Obesity Policy Coalition. [25]

In the context of Australia’s obesity epidemic, CSR policies in the food industry may have varied impacts. Fast food companies, at a time of increasing obesity rates, may see an opportunity in utilising health policy to establish consumer goodwill and brand value, creating a profit-driven incentive to engage in obesity prevention. Self-motivation in CSR policy construction could, however, be detrimental to health prevention, with, for example, fast food companies shifting blame from ‘foods’ to ‘sedentarism’ in their marketing, rather than altering the quality of their products. [20] Additionally, as a defensive response to avoid government regulation, the food industry has created an opening for itself in a health and sports promotion role, which, whilst contributing to preventative health programs in the short-term, may in time detract from the conventional governmental role in public health, devolving government of some responsibility without effectively satisfying community needs.

Despite its challenges, the potential benefits of CSR and the rise of privatisation and globalisation make self-regulation in the food industry an important, and perhaps inevitable, approach to consider in tackling obesity. [25]

Government Regulation

In light of steadily increasing obesity rates in many Western societies, a number of governments have implemented policies to reduce the impact of fast food companies in promoting overeating. [26,27] Outlined below are four categories of legislative change and their implications.

Restricting fast food advertising

Fast food advertising can send misleading messages to consumers, particularly those less informed. [28] Ethically, from a communitarian perspective, restricting advertising may denormalise fast food by making it less ubiquitous, helping change social attitudes, which is key to combating obesity. [29] Conversely, restrictions on advertising limit choice by making consumers less aware of their options, contradicting the principle of autonomy. Whilst it could be said that advertising of healthy foods continues to provide this autonomy, critics argue that fast food is not harmful in moderation and thus consumers should be able to make an informed decision of their purchases. Similarly, in alignment with narrative ethics, individuals have different approaches to eating, which may be compromised by eliminating the information delivered by fast food advertising. [30,31] It is important to note, however, that many of these concerns assume advertising delivers accurate information, which is often not the case. Critics also claim that restricting advertising is ineffective, as there are more important factors contributing to obesity. In addition, there are concerns about how the distinction between healthy and unhealthy foods would be made and the rights of companies to market their goods. [32]

Examples of restrictions on fast food advertising include banning fast food company sponsorship of sporting events and celebrity endorsement of unhealthy foods, as well as banning advertising that targets children, a population group particularly susceptible to marketing ploys. In regards to this, banning advertising to children in prime-time hours has already been successfully achieved in a number of countries. Quebec, for example, has had a 32-year ban on fast food advertising to children, leading to an estimated US$88 million reduction in fast food expenditure. [33] Australia has been moving towards restricting fast food advertising that targets children, with the Australian Food and Grocery Council resolving to not advertise fast foods in programs where at least 35% of the audience are children. [34] However, analyses of the difficulties of self-regulation in the food industry indicate that its effectiveness depends on the rate of engagement by individual companies and is not sufficient to adequately protect consumers. [35,36]

Cost measures

A ‘fat tax’ would involve taxing foods or beverages high in fat content (other ‘unhealthy’ components such as sugar and salt could also be taxed). It aims to discourage consumers from unhealthy products and offset their health costs with the tax revenue generated. [37] Subsidies for healthy food options are considered less practical with a greater cost-burden for taxpayers. Critics argue that a ‘fat tax’ would disproportionately affect low socio-economic consumers, unless healthy alternatives are made cheaper. [38] Some argue that obese individuals are also less responsive to increased prices than consumers of average BMI, reducing the effectiveness of a tax. [39] A ‘fat tax’ could even exacerbate health problems – a tax only on saturated fat, for example, may increase salt intake, which increases cardiovascular risk. [38] Denmark was the first country to introduce a tax on fat in 2011; however, it has since resolved to repeal the legislation, claiming that it increased consumer prices, increased corporate administration costs, and damaged Danish employment prospects without changing Danish eating habits, reducing the likelihood of this approach being trialled by other countries, including Australia. [40] It should be noted, however, that country-specific differences may have contributed to its lack of success.  These include the ability of the Danish population to travel to neighbouring countries to maintain their eating habits despite the government tax, which would not be feasible in Australia. Alternatively, the government could consider combining subsidies for healthy food options with a ‘fat tax,’ as this approach would be more acceptable to the public than a tax alone, and also yield a lower cost-burden for taxpayers than subsidies alone.

Nutrition labelling

Nutrition labelling aims to ensure consumers understand the nutritious value of foods. In Australia, all food labels must abide by the national Food Standards Code. [41] Options to simplify food labelling include traffic light food labelling, which codes foods red, yellow or green based on their fat, sugar and salt content. [42] Another option is health warnings on unhealthy foods to deter consumption. [43] Australia-wide, a new star rating system for packaged foods has been developed by a working group which included industry and public health experts; as of June 2013, this has been approved by state and federal governments. [44] The scale will rate foods from half-star to five stars based on nutritional value, despite concerns raised by the Australian Food and Grocery Council over the cost to manufacturers and how nutritional value would be determined. Sacks et al. (2009) argues, however, that there is insufficient evidence to suggest that food labelling would reduce obesity. [45] Critics also argue that more restrictive practices, such as health warnings, are excessive and impractical considering the ubiquity of high fat foods. [46]

Limit physical accessibility of fast food

Easy accessibility of unhealthy foods makes them difficult to resist. Making fast food less accessible again denormalises it, helping change social attitudes. This is supported by studies showing that obesity rates are higher in areas with an increased number of fast food outlets. [14] Zoning laws have been suggested as a policy tool to limit the accessibility of fast food, with findings suggesting success in reducing alcohol-related problems. [47] Other approaches to restrict access include removing fast food from high accessibility shelves in supermarkets, banning fast food vending machines and banning fast food from school canteens. Victoria, for example, has imposed strict canteen rules restricting the sale of fast food to twice a term. [48] However, critics argue that restricting the accessibility of fast food may undermine consumer autonomy and choice, impinge on the legal rights of companies to market their goods, and could also be a precedent for government intervention in other areas. [49]

Conclusion

Whilst it is difficult to define the extent of the role that fast food companies play, there is no doubt that they significantly contribute to Australia’s obesity epidemic through their large portion sizes, low quality food, extensive fast food advertising and high accessibility. Ultimately, combating obesity will require a multi-faceted approach that denormalises unhealthy foods – a process that requires both consumers and government to take a role in regulating the quality, marketing practices and accessibility of unhealthy products produced by the food industry.

Conflict of interest

None declared.

Correspondence

S Bobba: samantha.bobba@gmail.com

References

References

[1] Australian Bureau of Statistics. Overweight and Obesity [Internet]. Canberra: ABS; 2012. [Cited 2013 Apr 11]. Available from:http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/33C64022ABB5ECD5CA257B8200179437?opendocument

[2] Driskell, J, Meckna, B, Scales, N. Differences exist in the eating habits of university men and women at fast-food restaurants. Nutri Res. 2006; 26(10):524-530.

[3] Pereira, M, Karashov, A, Ebbeling, C, Van Horn, L, Slattery, M, Jacobs, D, Ludwig, D. Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005; 365(9453):36-42.

[4] Duffy, B, Smith, K, Terhanian, G, Bremer, J. Comparing data from online and face-to-face surveys. Int J Market Res. 2005; 47(6):615-639.

[5] Seiders, K, Petty, RD. Obesity and the role of food marketing: a policy analysis of issues and remedies. JSTOR. 2004; 23(2):153-169.

[6] Mello, MM, Rimm, ER, Studdert, DM. The McLawsuit: The fast-food industry and legal accountability for obesity. Health Aff. 2003; 22(6):207-216.

[7] Lewis, S. Federal government backed study into fat tax on fast foods. News.com [Internet]. May 20 2013. [Cited 2013 Apr 15]; Available from: http://www.news.com.au/lifestyle/food/federal-government-backed-study-into-fat-tax-on-fast-foods/story-fneuz8wn-1226646283704

[8] Thompson, J. Forcing fast food chains to join the fight against obesity. ABC News [Internet]. November 8 2010. [Cited 20/4/2013]; Available from: http://www.abc.net.au/news/2010-11-08/forcing-fast-food-chains-to-join-the-fight-against/2328572

[9] Frewer, LJ, Risvik, E, Schifferstein, H. Food, people and society: A European perspective of consumers’ food choices. Heidelberg: Springer; 2001.

[10] Germov, J, Williams, L. A Sociology of food & nutrition: The social appetite. Melbourne: Oxford University Press; 2004.

[11] Bronwell, KD. Fast food and obesity in children.  Paediatrics 2004; 113(1):132.

[12] Young, LR, Nestle, M. Portion sizes and obesity: Responses of fast-food companies. .J Public Health Policy. 2007; 28(2):238-248.

[13] National Bureau of Economic Research. Fast-food restaurant advertising and its influence on childhood obesity. Cambridge: NBER, 2005. [Cited 2013 Apr 55/4/2013]. Available from: http://www.nber.org/papers/w11879

[14] Maddock, J. The relationship between obesity and the prevalence of fast food restaurants: state-level analysis. Am J Health Promot. 2004; 19(2):137-143.

[15] Young, LR, Nestle, M. The contribution of expanding portion sizes to the US obesity epidemic. Am J Public Health. 2002; 92(2):246-249.

[16] McBarnet, DJ, Voiculescu, A, Campbell, T. The new corporate accountability: corporate social responsibility and the law. Cambridge: Cambridge University Press; 2007.

[17] Maloni, MJ, Brown, ME. Corporate social responsibility in the supply chain: An application in the food industry. J Bus Ethics. 2007; 68(1):35-52.

[18] Guler, A, Crowther, D. A handbook of corporate governance and social responsibility. Fanham: Gower; 2010.

[19] Porter, ME, Kramer, MR. Strategy and society: the link between competitive advantage and corporate social responsibility. Harv Bus Rev. 2006; 84(12):78-92.

[20] Wood, DJ. Measuring corporate social performance: A review. Int J Manag Rev. 2010; 12(1):50-84.

[21] Becker-Olsen, KL, Cudmore, AB, Hill, RP. The impact of perceived corporate social responsibility on consumer behaviour. J Bus Research. 2006; 59(1):46-63.

[22] McDonalds. McDonalds Corporation: Worldwide social corporate responsibility. 2009. [Cited 2013 Apr 16]. Available from: http://www.aboutmcdonalds.com/etc/medialib/csr/docs.Par.32488.File.dat/mcd063_2010%20PDFreport_v9.pdf

[23] Royle, T. Realism or idealism? Corporate social responsibility and the employee stakeholder in the global fast-food industry. Business Ethics: A European Review. 2005; 14(1):42-55.

[24] Peattie, K. Corporate social responsibility and the food industry. AIFST. 2006; 20(2):46-48.

[25] Martin, J. Rich pickings, fat or thin. Sydney Morning Herald [Internet]. 2010. [Cited 2013 Apr 27]; Available from: http://www.smh.com.au/lifestyle/wellbeing/rich-pickings-fat-or-thin-20110115-19rvj.html

[26] Mitchell, C, Cowburn, G, Foster, C. Assessing the options for local government to use legal approaches to combat obesity in the UK: Putting theory into practice. Obes Rev. 2011; 12(8):660-667.

[27] Diller, PA, Graff, S. Regulating food retail for obesity prevention: How far can cities go? J Law, Med Ethics. 2011; 39(1):89-93.

[28] Carter, OB, Patterson, LJ, Donovan, RJ, Ewing, MT, Roberts, CM. Children’s understanding of the selling versus persuasive intent of junk food advertising: Implications for regulation. Soc Sci Med. 2011; 72(6):962-968.

[29] Veerman, JL, Van Beeck, EF, Barendregt, JJ, MacKenbach, JP. By how much would limiting TV food advertising reduce childhood obesity. Eur J Public Health. 2009; 19(4):365-369.

[30] Caraher, M, Landon, J, Dalmeny, K. Television advertising and children: lessons from policy development. Public Health Nutr. 2006; 9(5):596-605.

[31] McNeill, P, Torda, A, Little, JM, Hewson, L. Ethics Wheel. Sydney: University of New South Wales; 2004.

[32] Henderson, J, Coveney, J, Ward, P, & Taylor, A. Governing childhood obesity: Framing regulation of fast food advertising in the Australian print media. Soc Sci Med. 2009 69(9): 1402-1208.

[33] Dhar, T, & Baylis, K. Fast-food consumption and the ban on advertising targeting children: the Quebec experience. J Marketing Research. 2011 48(5).

[34] Collier, K. Crackdown on junk food advertising during shows children watch. Sydney Mornng Herald [online newspaper]. November 02 2012. [Cited 2013 Apr 20]; Available from: http://www.news.com.au/lifestyle/parenting/crackdown-on-junk-food-advertising-during-shows-children-watch/story-fnet08ui-1226508730232

[35] Sharma, L, Teret, S, Brownell, K. The Food Industry and Self-Regulation: Standards to promote success and to avoid public health failures. Am J Pub Health. 2010; 100(2):240-246.

[36] King, L, Hebden, L, Grunseit, A, Kelly, B, Chapman, K, Venugopal, K. Industry self regulation of television food advertising: responsible or responsive? Int J Ped Obes. 2011; 6(2):390-398.

[37] Mytton, O, Gray, A, Rayner, M, Rutter, H. Could targeted food taxes improve health? J Epidemiol Community Health. 2007; 61(1):689-694

[38] Clark, JS, Dittrich, OL. Alternative fat taxes to control obesity. Int Adv Econ Res. 2007; 16(4):388-394.

[39] Tiffin, R, Arnoult, M. The public health impacts of a fat tax. Eur J Clin Nutr. 2011; 65(1):427-433.

[40] Denmark to scrap world’s first fat tax. ABC News [online newspaper]. November 11 2012. [Cited 2013 Apr 16]; Available from: http://www.abc.net.au/news/2012-11-11/denmark-to-scrap-world27s-first-fat-tax/4365176

[41] Martin, T, Dean, E, Hardy, B, Johnson, T, Jolly, F, Matthews, F, et al. A new era for food safety regulation in Australia. Food Control. 2003; 14(6):429-438.

[42] Magnusson, R. Obesity prevention and personal responsibility: the case of front-of-pack labelling in Australia. National Institute of Health; 2010. [Cited 2013 Apr 24]; Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091573/

[43] Cinar, AB, Murtomaa, H. A holistic food labelling strategy for preventing obesity and dental cavities. Obes Rev. 2009; 10(3):357-361.

[44] Winter, C. Government touts star rating system for food to fight obesity epidemic, ABC News [online newspaper]. June 27 2013. [Cited 2013 Apr 21]; Available from: http://www.abc.net.au/news/2013-06-13/food-labelling-system-to-encourage-healthy-eating-options/4752032

[45] Sacks, G, Rayner, M, Swinburn, B. Impact of front-of-pack ‘traffic-light’ nutrition labelling on consumer food purchases in the UK.Health Promot Int. 2009; 24(4):344-352.

[46] Dunbar, G. Task-based nutrition labelling. Appetite. 2010 55(3): 431-435.

[47] Mair, JS, Pierce, MW, Teret SP. The use of zoning to restrict fast food outlets: a potential strategy to combat obesity.  2005. [Cited 2013 Apr 22]; Available from: http://www.publichealthlaw.net/Zoning%20Fast%20Food%20Outlets.pdf

[48] Rout, M. Junk food bans at schools. Herald Sun [online newspaper]. October 16 2006. [Cited 2013 Apr 21]; Available from: http://www.heraldsun.com.au/news/victoria/junk-food-bans-at-schools/story-e6frf7kx-1111112365970

[49] Reynolds, C. Public health law and regulation. Annandale: Federation Press; 2004.

 

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Patient Specific Total Knee Arthroplasties: A technological solution to the ageing population

Australia is faced with an ageing population and is bracing for the significant health challenges of this changing demographic. Individuals born during the post-war population boom of the late 1940s are now progressing into the over 65 age bracket, which has led to the emergence of a number of unique health and economic challenges. While the majority of older adult Australians continue to live at home, caring for the ageing population will inevitably require additional healthcare resources.

Of today’s older Australians, nearly half of the individuals aged 65-75 will have five or more long term physical health conditions. [1] By 2050, it is expected that the number of individuals aged 65-84 will have doubled, and the number of people aged over 85 quadrupled. [2]

The full challenge of the ageing population will be faced by today’s generation of medical students. The future health system will not simply need to deliver more of the same services, but do so in a more efficient manner, making use of the most advanced technologies in a cost and time-efficient manner. The system will need to adapt to the complex needs of the elderly patient, optimising coordinated care between primary and tertiary health care facilities.

Currently, within the population of Australia some 15% (3.1 million) are affected by arthritis, with osteoarthritis being the leading cause. [1] Being a degenerative condition, the incidence of osteoarthritis increases with age, and accounts for the primary cause of approximately 97% of total knee arthroplasties (TKAs) performed in Australia. [3] The dramatic increase in the population aged over 65 represents an immense increase in the numbers of individuals at risk of osteoarthritic knee changes. Given the inevitable wave in those requiring joint arthroplasty, are we fully prepared for this expected number?

In 2011, a total of 40,470 TKAs were performed in Australia. [3] This represents an increase of 5.7% on the previous year and a further increase of 83.7% since 2003. [3] There is also a growing trend of patients requiring TKAs at an earlier age, further adding to the workload of surgeons and hospitals. [3] Given the growing demand and expected increase in the patient population, there is a clear impetus to evaluate novel surgical approaches used in total knee arthroplasties.

Patient specific total knee arthroplasties (PSTKA) are one possible solution to this growing demand. They provide an anatomically individualised approach to surgery based on pre-operative computer tomography (CT) or magnetic resonance imaging (MRI). Following imaging, a patient specific cutting block is manufactured from a digital 3D reconstruction of the patient’s joint. The cutting blocks are then used to guide intra-operative bone resection, followed by installation of a pre-sized prosthesis. [4]

After initial assessment, the surgeon will decide upon the use of CT or MRI, based on personal preference. The scans are sent electronically to a manufacturing company of choice, where they are converted into a digital 3D reconstruction of the patient’s anatomy using computer-aided design. At this stage, the surgeon will review the digital reconstruction and finalise coronal and rotational alignment parameters. The review process allows the surgeon to make changes prior to manufacture, specific to the patient’s functional requirements. Following this process, the custom designed disposable cutting blocks are then authorised for fabrication. Intra-operatively, the cutting blocks are attached to the distal femur and proximal tibia to accurately guide bone resection prior to the insertion of a customised prosthesis. [4] The primary advantage of the fabricated cutting blocks is their ability to accurately guide the quantity of bone resection, maintaining the desired coronal and rotational alignment for optimal prosthesis placement. [4]

Companies such as Medacta in Sydney, NSW, currently offer this service. From the time of the initial scans, the patient specific cutting blocks can be reviewed, and manufactured ready for use in as little as three weeks. Review prior to manufacture is a fully online process, allowing the surgeon to log in via any computer and make the necessary changes before authorising the cutting blocks for production. The time taken by the surgeon to review the specifications can range from 5-15 minutes, depending on the complexity of patient anatomy and individual skills. [5]

By finalising operative procedures prior to surgery, there is less demand for intra-operative decision making by the surgeon, further streamlining the process. [6] The individualised planning allows finalisation of prosthesis size, position and alignment prior to the first incision being made. [4] While this process may require additional out-of-operating commitments by the surgeon, overall it may lead to a reduction in the total theatre time per patient.

 

 

 

 

 

 

 

 

 

Manufacturers of this technology propose a number of positive outcomes. Advantages include reduced operative time when compared to conventional techniques, [4] pre-operative sizing of prosthesis, reduced bone resection [6] and optimal alignment of the tibia and femur post-surgery. [7-9] This method also does not require violation of the intramedullary canal as used in some conventional TKA methods. [4] Additional costing benefits may also be found in a reduction in the number of instrument trays required for surgery, leading to reduced setup time and sterilisation cost. Conventional methods require an average of 7.3 intra-operative instrument trays, compared to 2.5 used in PSTKA (p <0.001). [14]

A sensitive indicator of the success of TKA is prosthesis survival, measured in years post surgery. This idea is supported in research by Berend et al. (2004), who demonstrated that a tibial varus deformity greater than three degrees was associated with implant failure at rates 17 times greater than seen in patients with tibial deviation of less than three degrees post surgery. [10] In the literature, alignment of the tibia on the femur within three degrees in the coronal plane remains a consistent indicator of surgical outcome. [10-12]

A study conducted by Ng et al. (2012) examined the post-operative alignment outcome in 569 PSTKA, compared to 155 TKAs performed using intra- and extra-medullar alignment techniques. Of the patients undergoing PSTKA, only 9% had alignment outside of three degrees post-operatively, when compared to 22% using conventional methods (p=0.02). [11] While there is evidence in the literature that alignment outcome in PSTKA are comparable to those achieved with computer assisted surgery (CAS), utilisation of CAS in America remains low due to the cost of the technology, with only 3% percent of TKA being performed using CAS alignment systems. [12]

Of particular interest to both surgeons and hospitals is the proposed reduction in surgical time offered by PSTKA. Research conducted by Hamilton et al. (2013) compared intra-operative time of 52 patients undergoing PSTKA, and those undergoing conventional methods. [14] That study demonstrated no reduction in surgical time offered by those receiving PSTKA. Of interest, the study noted the fact that the surgeon who performed all 52 of the cases had vast experience using conventional methods prior to the study. This included performing over 1,500 conventional TKAs compared to 20 PSKTA. [14] With this significant limitation in mind, there is clear impetus for further evaluation into the possible time efficacy of PSTKA when performed by surgeons equally skilled in both techniques.

In further research assessing the time efficacy of PSTKA, Nunley et al. (2012) reported a positive trend in reducing tourniquet time from 61.0 ± 15.0 minutes in the conventional group, compared to 56.2 ± 15.1 minutes in the PSTKA group (p=0.09).  Alternately, another recent study demonstrated a significant reduction in total operating theatre time from 137.2 ± 33.6 in the conventional group, compared to 125.1± 22.7 in the PSTKA group (p=0.028). [6] While some of these results are not statistically significant, they highlight the need for continued evaluation of PSTKA compared to alternative methods of TKA. Evaluation of the current research reveals an optimistic view of PSTKA in its ability to reduce intra-operative time. [15] With any new approach to surgery, practice is needed to hone the skills essential for efficiency.

Possible drawbacks highlighted in current literature include the additional workload of pre-operative imaging. Specifically, the cost of pre-operative CT or MRI remains a consideration. While the scans do not require interpretation by a radiologist, saving both time and money, the cost of a MRI ranges from A$500 to A$1000 depending on the institution. Additionally, in the use of CT imaging there is dosing of ionizing radiation, which must be considered. [4]

In addition to patient outcomes, the cost involved in adopting a new approach to surgery must always be considered. Currently, PSTKA is not cost-effective on a case-by-case basis, when compared to conventional TKA. PSKTA is, however, more cost effective when compared to computer-assisted TKA surgery. [13]  Interestingly, the authors noted a reduction of 28 minutes per case of operating room time in PSTKAs, and this was not factored into the costing analysis. At an institutional level, perhaps an increased case turnover in the operating room will prove cost effective when compared to alternative techniques. [13]

At this point in time, further research needs to be conducted into the durability and longevity of PSTKA. While this requires extended follow-up and evaluation of records, survival rates of implants may become particularly important in light of the growing trend toward a younger patient population. [3] Currently, TKAs are being performed at an earlier age due to increasing levels of obesity, active lifestyles and increasing life expectancy. [3] With this younger population group comes the need to provide patients with prostheses that will last, reducing the need for subsequent revision. Importantly, with aseptic loosening of prosthesis being shown as the most common cause of premature failure, perhaps a customised approach to initial surgery may demonstrate improved longevity at follow-up. [9]

As in any new area of research, there is a particular need for larger trials with extended follow-up. The purpose of this article is not to condone the widespread use of PSTKA, but rather to illustrate the importance of technology and the continued search for improvement. As doctors, it is essential to always question current methods of practice and seek to refine technique, finding improvements where possible. PSTKA makes use of some of the most advanced imaging and engineering techniques currently available, and provides an innovative approach to knee surgery. There is no doubt PSTKA offers an exciting alternative to conventional surgical methods, meshing surgical expertise with advanced engineering technologies. In the future, could the 3D printing of patient specific prostheses take this technology to the next level?

Acknowledgements

Associate Professor Nigel Hope (MBBS, PhD, FRACS, FAOrthA) for continued encouragement and sparking an interest in Orthopaedic research.

Medacta for providing images.

Conflict of interest

None declared.

Correspondence

D Kerr: davidkerr56@gmail.com

References

[1] Australian Institute of Health and Welfare 2010. Australia’s health 2010. Australia’s health series no. 12. P1-523. Canberra: AIHW.

[2] Australian Government. Australia to 2050: future challenges. Canberra: 2010 Feb p1-22.

[3] Ryan P, Miller S, Cashman K, Lui YL, Tyman S. Hip and Knee Arthroplasty Annual Report. Australian Orthopaedic Association Joint replacement registry 2012, p120-124.

[4] Nam D, Mc Arthur BA, Cross MB Mayman DJ, Haas SB. Patient-specific instrumentation in total knee arthroplasty: a review. J Knee Surg. 2012 Jul;25(3):213-9.

[5] Spencer BA, Mont MA, McGrath MS, Boyd B, Mitrick MF. Initial experience with custom-fit total knee replacement: intra-operative events and long-leg coronal alignment. Int Orthop. 2009 Dec;33(6):1571-5.

[6] Nunley RM, Ellison BS, Ruh EL, Williams BM, Foreman K, Ford AD, Barrack RL. Are patient-specific cutting blocks cost-effective for total knee arthroplasty? Clin Orthop Relat Res. 2012 Mar;470(3):889-94.

[7] D. White K. L. Chelule B. B. Seedhom .Accuracy of MRI vs CT imaging with particular reference to patient specific templates for total knee replacement surgery. Int J Med Robotics Comput Assist Surg 2008; 4: 224–231.

[8] Harrysson OL, Hosni YA, Nayfeh JF. Custom-designed orthopedic implants evaluated using finite element analysis of patient-specific computed tomography data: femoral-component case study. BMC Musculoskelet Disord. 2007 Sep 13;8:91.

[9] Boonen B, Schotanus MG, Kort NP. Preliminary experience with the patient-specific templating total knee arthroplasty. Acta Orthop. 2012 Aug;83(4):387-93.

[10] Berend ME, Ritter MA, Meding JB,Faris PM, Keating EM, Redelman R, Faris GW, Davis KE. Tibial component failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 2004;428(428):26-34.

[11] Ng VY, DeClaire JH, Berend KR, Gulick BC, Lombardi AV Jr. Improved accuracy of alignment with patient-specific positioning guides compared with manual instrumentation in TKA. Clin Orthop Relat Res. 2012 Jan;470(1):99-107.

[12] Canale ST, Beaty JH. Campbell’s operative orthopaedics. Vol One. Elventh ed. Philadelphia, PA: Elsevier Inc; 2008.

]13] Watters TS, Mather RC III, Browne JA, Berend KR, Lombardi AV Jr, Bolognesi MP. Analysis of procedure related cost and proposed benefits of using patient –specific approach in total knee arthroplasty. J Surg Orthop Adv 2011;20(2).

[14] Hamilton WG, Parks NL, Saxena A. Patient-Specific Instrumentation Does Not Shorten Surgical Time: A Prospective, Randomized Trial. J Arthroplasty. 2013 Aug;(13)00480-4.

[15] Mont MA, McElroy MJ, Johnson AJ, Pivec R; Single-Use Multicenter Trial Group Writing Group. Single-use instruments, cutting blocks, and trials increase efficiency in the operating room during total knee arthroplasty: a prospective comparison of navigated and non-navigated cases.J Arthroplasty. 2013 Aug;28(7):1135-40.

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Chocolate, Cheese and Dr Chan: Interning at the World Health Organization Headquarters, Geneva

Introduction

In early 2013, Ban Ki-Moon, Margaret Chan and Kofi Annan had something in common: they may be completely unaware of it, but I saw them speaking in Geneva, and not merely because I lurked around Palais de Nations. Rather, wielding my very own blue United Nations (UN) ID card as an intern at the World Health Organization headquarters (WHO), I became a de facto insider to events on the international stage.

Between January and March, I undertook an 11 week internship with the WHO Emergency and Essential Surgical Care (EESC) Program in the Clinical Procedures Unit, Department Health Systems Policies and Workforce. The WHO is the directing and coordinating authority for health within the UN. It is responsible for providing leadership on global health issues, setting the research agenda, setting and articulating norms, standards and evidence-based policy options, providing technical support to countries, and monitoring and assessing health trends. [1] At some point during your studies, you will encounter material developed and disseminated by the WHO. You may have cited WHO policies in your assignments, looked up country statistics from the Global Health Observatory before your elective, or at least seen the ubiquitous Five Moments for Hand Hygiene posters, which emerged from WHO guidelines. [2] In other words, if you haven’t heard of the WHO or don’t recognize the logo, then I suggest taking a break from textbooks and click around the many fascinating corners of their website. Perhaps watch Contagion for a highly stylized (but filmed partially on location) view of an aspect of their work. [3]

The WHO and Surgery

The WHO established the EESC Program in 2005, in response to growing recognition of the unaddressed burden of mortality and morbidity caused by treatable surgical conditions. [4] This reflects the lack of prioritization of surgical care systems in national health plans and the ongoing public health misconception that surgical care is not cost-effective and impacts only upon a minority of the population. [5] These misconceptions apply as much to those in the field of public health, as well as to surgeons on the ground and in the literature, let alone those at other agencies. This was reflected by the question I all too commonly faced when explaining my internship: “The WHO is involved in surgery?”

In reality, surgical conditions contribute to an estimated 11% of the global burden of disease. It is a field that cuts across a number of public health priorities. [6] For example, progress on many of the Millennium Development Goals demands the prioritization of surgical care systems, most obviously in connection with maternal and newborn care. [7] Timely access to surgical interventions, including resuscitation, pain management and caesarean section, are vital to reducing maternal mortality. [8] Even in its most basic forms, surgical procedures can play a role in both preventative and curative therapies, from male circumcision in relation to HIV control to the aseptic suturing of wounds. However, surgery also has a very real impact on poverty by addressing the underlying causes of disability which often contribute to unemployment and debt.  These include the management of congenital and injury incurred disabilities and preventable blindness. [9] Surgery can be a complex intervention because it relies upon numerous elements of the health system to be functioning completely. There is little point in having access to basic infrastructural amenities like electricity, running water and oxygen, when at the moment of an emergency it is unavailable. Similarly, having equipment and supplies alone are insufficient when there is a shortage of a skilled workforce to wield them.

The WHO EESC is dedicated to supporting life-saving surgical care systems in the areas of greatest need, through collaborations between the WHO, Ministries of Health and other agencies. The WHO Global Initiative for Emergency and Essential Surgical Care (GIEESC) is an online network linking academics, policy makers, health care providers and advocates across 100 countries. Together, they developed the WHO Integrated Management for Emergency and Essential Surgical Care (IMEESC) toolkit to equip health and government workforces with WHO recommendations, skills and resources, focusing on emergency, trauma, obstetrics and anaesthesia, in order to improve the quality of, and access to, surgical services. [4]

In terms of my role, let me begin with the caveat that, as an intern, one can be called upon to conduct a wide variety of tasks within the huge scope of the WHO. My experiences differed greatly from those of colleagues and are not necessarily reflective of what one may encounter in other departments, or even in the same program at different times of year. I applied through the online internship application, but amongst my colleagues, this was in fact a rarity. [10] By far the majority of interns had applied directly or through their university to the specific areas of the WHO that aligned with their interests.

I undertook both administrative and research tasks, working very closely with my supervisor, Dr. Meena Cherian. There is a paucity of evidence capturing the surgical capacity, including infrastructure, equipment, health workforce and surgical procedures provided, across facilities in low- and middle-income countries. Through the GIEESC network, the WHO Situation Analysis Tool captures the capacity of first-referral health facilities to provide emergency and essential surgical care. [4] One of my key roles was in data collation and analysis. In terms of tangible outcomes, in the span of my internship I was able to contribute to two research papers for submission. In terms of my education, however, it was the administrative roles that demonstrated many of the key lessons about working in international organizations, and for which I am most grateful. Although menial tasks like photocopying and editing PowerPoint presentations can seem futile, carrying those documents into meetings allows one to witness the behind-the-scenes exchanges that drive many international organizations. This deepened my understanding of the WHO’s functions, strengths and limitations. In my experience, exacerbated by funding limitations and the rise of game-changing new players from the non-government sector, such as the Bill and Melinda Gates Foundation, attracting and justifying resource allocation to marginalized areas like surgery becomes a full-time job in itself. Opportunities for collaboration with such NGOs can result in successful innovation and programming, as with the polio eradication campaign. However, although inter-sector and inter-department collaboration is seemingly an obvious win-win, the undercurrents of turf wars and politicization of health issues can make such collaborations seem like a delicate diplomatic performance. Effective WHO engagement with external stakeholders cannot come at the cost of its intergovernmental nature or independence from those with vested interests. [1] Such are the limitations imposed on international organizations by the international community and the complex relationships between member states.

Ultimately, learning to collaborate with colleagues across cultural, economic, resource and contextual barriers under the tutelage of my supervisor has implications for any future endeavor in our increasingly globalized workplaces.  Learning to navigate such competing social and political interests is as applicable to clinical practice as it is to public health. Furthermore, the Experts for Interns program initiated by the WHO Intern Board provides bi-weekly lunchtime seminars specifically designed to broaden the scope of the intern experience by facilitating discussion with experts in various fields. [11] These were particularly valuable as an opportunity to ask direct questions, challenge preconceived notions and reexamine the historical development of public health, global health and the role and scope of the WHO.

Personal Highlights and Challenges

Geneva is an international city, home not only to WHO HQ and the United Nations in Europe, but also to a number of other UN Agencies and international non-governmental organisations, including Médecins Sans Frontières and the International Committee of the Red Cross. This means that, at any given time, there are a huge number of international and cultural events occurring. During my stay alone, there was the WHO Executive Board Meeting, the Geneva Human Rights Film Festival, a number of conferences, the UN Human Rights Council and some truly high profile speakers. Hans Rosling, the rock star of epidemiology and a founder of GapMinder, has put together a great TED Talk, but seeing him speak in person was one of my most lively, educative and stimulating experiences. [12,13] It is a memory I will treasure and return to for motivation, particularly when rote learning another fact for an  exam seems impossible. For many of us who aspire towards a career in global health, seeing these famous faces and learning firsthand about their work and career pathways is more than just inspiring, it can become a raison d’être.

From a slightly more cavalier perspective, Switzerland is centrally located in Europe, and Geneva as an international city is a great base from which to travel. It is easy to find sale flights to major European destinations, and the train to Paris takes only three hours. As an unpaid intern, your weekends are your own and most supervisors are generous about allowing travel grace. The opportunity to explore a new city every weekend is alluring, and with options like the demi-tariff, the half-priced fares on Swiss trains, it’s certainly a possibility. The Geneva and Lac Leman region features charming villages and cities with the sort of breathtaking mountain views that makes everything look like a postcard, not least if it’s covered in a blanket of pristine white snow. This is the other key attraction of Geneva in winter: if you’re into snow sports, you will be based within an easy day trip to some of the best pistes in the world. Indeed, the Swiss penchant for such trips seems to be why Sundays find Geneva a ghost town of sorts. Aside from the odd museum, absolutely nothing is open on Sundays, to the point where if you make my mistake of arriving on Sunday, it may be difficult to even find food.

Even if you can find food on a Sunday, affording it and anything else in Geneva is not easy. The cost of living is high, and, despite the high turnover of ex-pat staff, finding a place to stay is extremely difficult. As Australians we have it luckier than most, by being able to make use of OS-HELP loans while studying overseas. There is an ongoing discussion about paid internships within the UN, and there are varying practices amongst agencies. Some, notably the International Labor Organization, pay interns, while the WHO and others do not. This has become an advocacy issue amongst interns, as it severely limits access to the educative and career-oriented experiences internships provide for those from middle- and low-income nations. However, it seems unlikely that this will change in the near future. Nonetheless, with careful saving, planning and some basic austerity measures, finances should not deter you from this experience.

Another potential challenge is that Geneva is in francophone Switzerland; it is geographically surrounded on most sides by France. Many WHO staff and interns live, or at least shop, across the French border, where I discovered amazing supermarkets with entire aisles devoted to Swiss and French cheeses and chocolate. As a hopeless Francophile, this was a delicious highlight. I took classes and developed my French while safely working in a predominantly anglophone environment. If you have never studied French, then learning basics pre-arrival would be recommended, though it is possible to get around Geneva without, as the locals are very generous in this regard. However, there were often times when my linguistic limitations perpetuated anglophone dominance, forcing colleagues to transition into my language of choice. Such language barriers can also contribute to cultural misunderstandings.  For example, early on I committed the fauxpas of being too casual in the more hierarchical workplace, where professional titles were used even in personal conversations. Coming from the more egalitarian Australian context, this can come as something of a culture shock, though it varies considerably between different offices and departments.

As a result of my experiences, I am now both more cynical and more hopeful about the future of global health. The bureaucratic limitations of the WHO are also where its authority lies. Sifting through convoluted Executive Board meetings, it is easy to become skeptical about the relevance of this 65-year old organization. However, this belies the power of health mandates supported by member state consensus, whether in regards to the Tobacco Free Initiative or the Millennium Development Goals. Such change and reform, though slow, is broad reaching and invigorating.

Finally, the most significant and meaningful experiences I shared during my internship were not with the famous faces of global health, but with my peers. Across the various organizations based in Geneva, there are a huge number of interns from all over the world. Making connections with these kindred spirits, who shared my interests and a similar desire for an international career, was such a privilege. Even when our areas of interest did not intersect, it was amazing to learn from the expertise of fellow interns and students. For example, a fascinating experience was encountering a student at CERN (Conseil Européen pour la Recherche Nucléaire, better known to us non-physicists as the home of the Large Hadron Collider) with whom I was able to have a sticky beak at the labs and lifestyles of modern physics’ greatest thinkers. Just as he is progressing towards becoming a don of theoretical physics, at some point in the next few decades many of the friends I’ve made through this internship are going to become the next generation of global health leaders. More importantly, creating such networks across continents and across specializations has been instrumental in shaping my sense of self and perspective, and has left an indelible mark in the form of new education, career and lifestyle aspirations.

Where to from here for you

There is an online intern application through the WHO website. Although I completed this as my elective term, I also encountered a number of students from Australia for whom this was a summer opportunity to experience the organization, or as part of their research. I would strongly urge any student with interests in public health, global health, policy or research to consider applying for this opportunity, and to do so by contacting the departments of your interests directly.

In terms of surgery and global health, please visit the EESC program website at www.who.int/surgery for further information, and to become a GIEESC member.

Acknowledgements

The author wishes to acknowledge the generosity of the WHO Clinical Procedures Unit, particularly Dr. Meena Cherian of the WHO Emergency and Essential Surgical Care Program, who hosted her internship, and the financial support of the Australian government OS-HELP loan program.

Conflict of interest

None declared.

Correspondence

L Hashimoto-Govindasamy: laksmisg@gmail.com

References

[1] World Health Organization. About the WHO. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/about/en/

[2] World Health Organization. Clean care is safer care: five moments in hand hygiene. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/gpsc/tools/Five_moments/en/

[3] International Movie Database. Contagion. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.imdb.com/title/tt1598778/

[4] World Health Organization. Emergency and essential surgical care. [Internet]. 2013 [cited 2013 March 26]/ Available from: http://www.who.int/surgery/en/

[5] Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372:139–44.

[6] Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: Jamison D, editor. Disease Control Priorities in Developing Countries. 2nd ed. New York. Oxford University Press; 2006.

[7] United Nations. Millennium Development Goals. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.un.org/millenniumgoals/

[8] Kushner A, Cherian M, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg. 2010;145(2):154-160.

[9] PLOS Medicine Editors. A crucial role for surgery in reaching the UN Millennium Development Goals. PLOS Med. 2008;5(8):e182.doi:10.1371/journal.pmed.0050182

[10] World Health Organization. WHO employment: WHO internships. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.who.int/employment/internship/interns/en/index1.html

[11] WHO Interns. Experts for interns (E-4-I). [Internet]. 2013 [cited 2013 March 26]. Available from: http://whointerns.weebly.com/experts-for-interns.html

[12] TED: Ideas worth spreading. Hans Rosling: Stats that reshape your worldview. [Internet]. 2006 [cited 2013 March 26]. Available from: http://www.ted.com/talks/hans_rosling_shows_the_best_stats_you_ve_ever_seen.html

[13] Gapminder. Gapminder: for a fact-based worldview. [Internet]. 2013 [cited 2013 March 26]. Available from: http://www.gapminder.org/

Categories
Feature Articles Articles

Emergency medicine in Australian medical student education

“The best way to predict the future is to invent it.” Alan Kay

Introduction

As the coalface of Australian healthcare, Emergency Medicine (EM) faces the growing healthcare challenges of the wider community. Today, these challenges form a unique ‘triple whammy’ – overseeing the implementation of the National Emergency Access Target (NEAT) or “4-hr rule”, in an effort to manage access block and emergency department overcrowding as a result of the increased care needs of an ageing population, whilst at the same time with limited resources attempting to maintain the quality of education and training of a burgeoning junior medical workforce. [1,2]

Amidst this conundrum, medical student EM education may sometimes be left in the shadows. [3,4] The unique arena of the emergency department with its volume, breadth and variety of undifferentiated patient cases not only provides countless learning opportunities for medical students but also allows them to contribute to healthcare teams in practical and meaningful ways. This ranges from assisting in initial assessments, to performing indicated procedures, to formulating discharges, and even research involvement. [5,6] All of which are useful and valuable skills favoured upon in a junior medical doctor and reduces the workload of the supervising team. [7-9] While some may argue that the general wards offer similar opportunities, the increasing attempts in improving efficiency and subspecialising medicine have led to the bulk of diagnostic and therapeutic interventions to be conducted in the emergency departments prior to acceptance by inpatient units. [4]

Students themselves find EM rotations extremely valuable, with many practical benefits for their future medical careers. [10] However, the already hectic and stressful EM work environment, coupled with enhanced time pressures from NEAT, increasing numbers of interns needing to complete an ED term, and the significant teaching and supervision requirements within EM departments may prove to be hurdles that limit the chances for medical students’ education. [11]

Thus, it may be prudent to re-examine this issue of our workforce challenges and to re-assess  medical student education.

  1. Could added investment in extension and evaluation of EM to medical students pique their interest in a future EM career?
  2. Would an increased focus on EM teaching better equip and innovate Australia’s future healthcare workforce?

Why is EM important in medical student education?

As a population-based specialty, EM education offers medical students a glimpse into the domain of public health. Patients present with illnesses and injuries that have high population prevalence, and presentations vary even across times of the day. Students are therefore exposed to a dynamic socioeconomic, cultural and demographic case mix. This serves to broaden not only the variety in conditions that students would see within an EM rotation, but also widens their perspectives on pertinent issues affecting different age groups in the Australian healthcare setting.

EM also provides an opportunity to learn about pre-hospital care, including co-ordinating ambulance and paramedic transfer services, retrieval, wilderness and disaster medicine.  Students encounter clinical scenarios they would not otherwise see such as occupational and environmental health, toxicology and trauma, and are also exposed to accident and injury surveillance, treatment and prevention.

EM has unique content areas that form the foundation of medical student training. In fact, EM exposure is seen as a form of clinical training assurance and a measured criterion for both students and junior doctors to be work-ready, and is considered essential and highly valuable as a core intern term in all states around Australia. [7]

With each undifferentiated presentation, students are encouraged to complete a focused history and examination, consider emergency interventions and prioritise differential diagnoses, rather than needing to pinpoint a correct diagnosis in a second. They then formulate streamlined investigation and management plans, and have opportunities to perform basic procedures which form part of the initial evaluation of many patients. Students can also receive positive feedback and critique from clinicians on their performance, and even observe and learn from their more senior colleagues in managing acutely ill patients. [4]

There are other unique benefits of students training in the ED environment. With the rollout of NEAT, clinicians may be increasingly pressured to make time-critical evaluations and decisions. Students would therefore not only be able to observe time and cost effective patient assessment strategies but also hone problem solving and task prioritisation skills. [12] The acute management of common ED presentations would be better appreciated as fewer patients stay in the ED for hours or days and are transferred to the wards within four hours. Furthermore, a minimum of 40% and up to 73.3% of patients within the ED are available for directed-learning purposed interaction with student doctors – a significantly higher percentage than inpatient wards. [4,13]

Many EDs now also contain short stay units (SSU) where patients requiring short admissions or periods of observation are managed. A multidisciplinary healthcare team is often involved in the care of these patients, and students are able to work with the team and are involved in allied health discussions and discharge planning meetings.

How can students learn more?

Access

Medical students are usually not rostered on overnight shifts due to a lack of senior medical staff and thus inadequate supervision. A 24-hour rostering of students may be one way to combat the need for more placement opportunities, provided it does not overload junior medical staff. Elective night shits have already been occurring though there is no current data evaluating medical students’ learning during those specific shifts. Nonetheless, there would be benefit in providing observational exposure to a different case-mix of patients, especially in resuscitation situations, where students can play a more hands-on role during night shifts.

E-learning

Simulation skills laboratories have been a proven tool in improving theoretical knowledge and procedural skills for medical students, especially in deteriorating patient or acute resuscitation scenarios. [14] These courses, along with other electronic resources can also be utilised for on or off-site learning. More traditional trauma training courses and more novel methods such as cadaver based simulation course for advanced emergency procedures have also proved useful in equipping medical students with basic and advanced procedural skills. [15]

Decision supports

Competency-based training including the use of logbooks and clinical pathways has been shown to improve quality of care in some areas of medicine. [16-18] Logbooks are currently used at various specialty training colleges including ACEM, and adoption for EM education can assist students to measure their abilities against a minimum standard. Medical diagnosis or treatment protocols or checklists can also guide students in developing a systematic approach to evaluating and treating various conditions.

How can students contribute more?

Previous research has shown the potential benefit that engaging medical students as paid assistants of the healthcare team can have on performance efficacy and workflow. Pilot projects have been tested in Germany and the USA. [8,9]

If introduced, a similar system within the EM departments where medical students assist in triaging patients, undertake basic procedures and complete preliminary paperwork alongside a nurse or rapid assessment clinician may expedite care and reduce waiting times for patients.  They could also aid in collating relevant medical information from GPs, specialists, residential care facilities and families. This would ease the paperwork burden for clinicians, improve efficacy of clinician-patient contact time and at the same time provide learning opportunities for students whilst collecting and synthesising information.

Medical students can also play an important role in academic aspects of EM. It is sometimes difficult for clinicians to allocate specific time for research whilst balancing patient care; thus students can assist in identification and recruitment of subjects, drafting of protocols and briefing of staff members on ongoing projects.

Where to from here?

The immediate challenges EM departments face should not deter EM clinicians’ involvement in training medical students for the future. [11] Rather, a collaborative effort with students to enhance EM learning will give future doctors a skillset applicable in any emergency scenario, regardless of specialty area.

As such, students’ feedback on EM rotations and learning techniques should be considered when planning EM curricula. Allocation of dedicated teaching time and educators along with adequate funding for implementation of various initiatives such as e-learning and simulation courses should also be made available for use.

Further research evaluating the current state of EM medical student education nationwide is crucial to identify key areas for improvement. Pilot projects testing novel ways such as those listed above to allow students to contribute to EM departments will also be beneficial to further evaluate innovative learning techniques.

Despite the added cost and effort required, EM training has proven invaluable for medical students and remains an essential part of their training. It is therefore highly recommended that EM continues to maintain a strong presence in medical students’ curriculum. [5]

Conflict of interest

None declared.

Acknowledgments

The authors would like to thank Dr Tony Kambourakis and Dr Simon Craig for their valuable assistance in guiding the development of this manuscript.

Correspondence

C Liew: cwlie2@student.monash.edu

References

[1] Braitberg G. Emergency department overcrowding: The solution to any problem is a matter of relativity. MJA. 2012;196(2):88-9.

[2] Chong A, Weiland TJ, Mackinlay C, Jelinek GA. The capacity of Australian ED to absorb the projected increase in intern numbers. Emerg Med Australas. 2010;22(2):100-7.

[3] Dowton SB, Stokes M, Rawstron EJ, Pogson PR, Brown MA. Postgraduate medical education: Rethinking and integrating a complex landscape.MJA. 2005;182(4);177-180.

[4] Celenza A. Evolution of emergency medicine teaching for medical students,Emerg Med Australas . 2006;18(3):219-220.

[5] Celenza A, Jelinek GA, Jacobs IG, Murray L, Graydon R, Kruk C. Implementation and evaluation of an undergraduate emergency medicine curriculum.  Emerg Med Australas. 2001;13:98–103.

[6] Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department.Acad Emerg Med. 2006;13(8):860-6.

[7] (AMA). AMA. AMA Positional statement: Core terms in internship. 2007 [29 Feb 2012]; Available from: http://ama.com.au/node/2712.

[8] Schuld J, Justinger C, Kollmar O, Schilling MK, Richter S. Contribution of final-year medical students to operation room performance—economical and educational implications. Langenbeck Arch Surg. 2011;396(8):1239-44.

[9] Davis DJ, Moon M, Kennedy S, DelBasso S, Forman HP, Bokhari SA. Introducing medical students to radiology as paid emergency department triage assistants.JACR. 2011;8:710-5.

[10] Avegno JL, Murphy-Lavoie H, Lofaso D, Moreno-Walton L. Medical students’ perceptions of an emergency medicine clerkship: An analysis of self assessment surveys.IJEM. 2012;5(1):25. Epub [Epub ahead of print]

[11] Indraratna PL, Lucewicz A. Impact of the 4-hour emergency department target on medical student education.Emerg Med Australasia. 2011;23(6):784.

[12] Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum.Acad Emerg Med. 2010;17:S26-S30.

[13] Celenza A, Li J, Teng J. Medical student/student doctor access to patients in an emergency department.Emerg Med Australas. 2011;23(3):364-71.

[14] Langhan TS. Simulation training for emergency medicine residents: Time to move forward.CJEM. 2008;10:467-9.

[15] Tabas JA, Rosenson J, Price DD, Rohde D, Baird CH, Dhillon N. A comprehensive unembalmed cadaver based course in advanced emergency procedures for medical students.Acad Emerg Med. 2005;12:782-5.

[16] Taylor MD, Harrison G. Procedural skills quality assurance among Australasian College for Emergency Medicine fellows and trainees.Emerg Med Australas. 2006;18(3):268–275

[17] Nagler J, Harper MB, Bachur RG. An automated electronic case log: Using electronic information systems to assess training in emergency medicine.Acad Emerg Med . 2006;13:733-739.

[18] Chu T, Chang S, Hsieh B. The learning of 7th year medical students at internal medical – evaluation by logbooks. Ann Acad Med Singap. 2008;37:1002-7.

 

 

Categories
Feature Articles Articles

Fiction and psychiatry: The tale of a forgotten teacher

“Wherever the art of medicine is loved, there is also a love of humanity.” -Hippocrates

Reading this declaration today, conjures an unsettling, or almost unpleasant feeling that this once foundational concept may today be lost in time.  A ‘love for humanity’, whilst still lingering in the minds of some clinicians has been largely side-lined by science, research, evidence based practice,  being mindful of patient’s rights, family criticisms and practicing medicine with caution against being sued or criticised ourselves. We may benefit to keep in mind the words of American, philosopher Will Durant, “Every science begins as philosophy and ends as art.”

Ironically, it seems that science may provide answers to the apparent diminution of humanity in medicine. A recent editorial advocated that empathy in medicine may have a neurobiological basis and therefore can be up-regulated through specific neurobiological correlated education methods, in order to enhance professionalism and compassion.[1,2] Suggestions such as these reflect society’s growing dependence, or perhaps near enslavement to science which may soon become a surrogate for what were once regarded as inextricable, innate, features of our humanity – empathy and wisdom.

Beveridge reminds us that, “Doctors need a deeper understanding of their patients that takes account of emotional and existential aspects.”[3] Literature offers us a multitude of human experiences that may serve to deepen our appreciation of the breadth of human consciousness. As T.S. Eliot stated, “We read many books, because we cannot know enough people.”[3]

Psychiatry is one field of medicine which demands a strong level of empathy and a sophisticated level of interpersonal communication. Psychiatry studies the human mind with its complexities of emotions, behaviours, motives, experiences and reactions. Crawford describes the existence of a ‘synergism’ between literature and psychiatry as they both focus on the human mind from two separate paradigms: first, a scientific, biomedical framework of medicine; second, an artistic, creative medium of fiction. He questions, despite this congruence, why does literature still ‘remain the poor relation of the medical textbook?’[4] The concept of two paradigms, or a dualisms of brain and mind is explored further by Australian philosopher David Chalmers who describes how these two entities are different and how understanding each one requires a unique method.[5]

It is at this junction, between clinical psychiatry and fictional literature that our journey begins. This essay will explore some of the reasons for why we, as students and health professionals should and should not engage in fictional reading. We will then delve into some literary examples that provide insight into mental illness.

Benefits of fiction

Reading fiction may allow us to better connect with individuals such as our patients emotionally by first connecting with fictional characters. Evans proposes that when we read for enjoyment, “Our defences are down – and we hide nothing from the great characters of fiction.”[6] He contrasts this to a doctor-patient interaction where doctors, “do [their] best to hide everything beneath the white coat, or the avuncular bedside manner.” Over many years, all that is left is a professional, clinical interaction at the cost of a personal connection with the patient. He reminds us that, “It is at this point where art and medicine collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients.”[6]

Psychiatry tends to place a greater emphasis on thought form when making diagnoses, whilst the patients are more concerned with thought content, even though a doctor may at times miss the subtleties in form too. Literature can make us more aware of the importance of the content to the individual and connect more closely with the patient’s experience. Sims illustrates this:

“The patient is only concerned with the content, ‘that I am pursued by ten thousand hockey sticks.’ The doctor is concerned with both form and content, […] in this case a false belief of being pursued. As far as the form is concerned the hockey sticks are irrelevant. The patient finds the doctor’s interest in form unintelligible and a distraction from what he regards as important. […] The nature of the content is irrelevant to the diagnosis.”[7]

The analysis of thought form leads us to a clinical diagnosis which justifies clinical interest in form over content; thought process over a patient’s narrative. Crawford hypothesises that with the increasing biomedical dominance in psychiatry, there is bound to be further marginalisation of content. He argues that in fiction, the content, which encompasses all human experiences, emotional responses and behaviours, is more valuable and effective in conveying an understanding about the narrative than the form.[4]

Shortcomings of fiction

Not everyone values literature in the context of medical progress – Wassersug proclaimed that, “Real medical progress has not been made by humanitarians but by doctors equipped with microscopes, scalpels, dyes [and] catheters, […] similarly psychiatry should be seen as a branch of the natural sciences.”[3] He argues that literature has nothing to offer to psychiatry, a field which should be led by advances in neurosciences, not narrative.

Reading has been described as a ‘selfish’ activity that can expand individual intellect but cannot instil a spirit of altruism or increased sensitivity towards others.[3] The physician Raymond Tallis illustrates how reading may in fact make us less empathetic; he quotes Tolstoy’s tale of an aristocratic woman weeping over a theatrical tragedy, while outside a real tragedy eventuates as her faithful coachman freezes to death. This anecdote highlights the ability of the arts to delude the woman, to believe herself to be sensitive, when in fact she is actually being inconsiderate.[3]  Some arguments against reading fiction may be valid. However, they are not sufficient to completely discredit the opportunity fiction provides us to expand our sense of enlightenment, self-development and inspiration in a way that a factual textbook simply cannot.

Fiction and mental illness

Literature is an instrument to present facets of mental illness that may not be captured through textbooks, lectures or case presentations. Oyebode suggests that fictional narrative achieves its aims by magnifying or exaggerating specific aspects of characters such as their mannerisms, behaviour or speech to make them stand out to the reader. Oyebode analyses Patrick McGrath’s Asylum to illustrate how delusional jealousy may be the result of multiple trivial everyday occurrences:

“Driven by the morbid processes to suppose that his wife was betraying him with another man, he had reasoned first, that they must have ways of signalling their arrangements, and second, that their activities must leave traces. He had then manufactured evidence of such signals and traces from incidents as banal as her opening a window as a motorbike was going past in the street below, and from phenomena as insignificant as a crease in a pillow or a stain on a skirt.”[8]

Oyebode presents a detailed, focussed magnification on the protagonist’s paranoid, obsessive thoughts about everyday occurrences. This allows the reader unrestricted access into the thoughts that occupy a person’s mind suffering with delusional jealousy.

Oyebode provides a glimpse into nihilistic thoughts through McGrath’s Spider:

“I was contaminated by it, it shrivelled me, it killed something inside me, made me a ghost, a dead thing, in short it turned me bad […] I wonder…what they will find when they cut me open (if I’m not dead)? An anatomical monstrosity surely.”[8]

The emotive and dark imagery in this writing serves to illuminate the depth of nihilism; the torment the protagonist faces at the mercy of his own mind. Once again, the account provides important insight into a paradigm of thought that may otherwise be foreign to an external observer.

Jenny Diski describes the experience of depression beautifully in Nothing Natural:

“Here it was again. Unmistakeably it. […] A physical pain in her diaphragm, a weight as if she had been filled with lead, the absurd difficulty of doing anything – automatic actions having to be thought out to be achieved: how do you get across the room, make the legs move, keep breathing, think carefully about it all. […] The unreasonable difficulty of everything made more unreasonable, more difficult knowing that nothing physical was wrong. […] Depression was an excess of reality: intolerable and unliveable.”[4]

This detailed deconstruction of depression exposes the destructive power of depression to render a person physically powerless whilst they are mentally completely aware of what is happening to them. Literature forms a bridge between the internal world of our patients and our global comprehension of their condition. This bridge elevates us from helpless bystanders to active and effective treating practitioners.

Sometimes the words of fictional characters may attack the reader directly, encouraging the reader to engage in self-reflection. The protagonist, from Kristin Duisberg’s The Good Patient, expresses that mental health practitioners:

“have chosen their profession to deny a terrifying truth other doctors accept – there are ills for which there is no cure.”[4]

At first glance this idea seems completely bizarre, as no psychiatrist believes they can cure all psychiatric conditions. However, it is hard to completely dismiss it without the thought lingering on in our subconscious. This attack stimulates some introspection to determine whether there may be any truth behind it at all. The words of this fictional character have the power to leap off the pages, and into our subconscious to question our role and limitations when treating patients with mental illness.

Literature tries to ‘de-pathologise’ mental illness as evidenced by Sally Vickers in The Other Side of You:

“We are most of us badly cracked and afraid that if we do not guard them with our lives the cracks will show, and will show us up, which is why we are all more or less in a state of vigilance against one another.”

By addressing this ‘cracked’ nature inherent in all of us, the author indirectly places all of us on a spectrum of mental illness. She implies, the only difference between mentally healthy and ill is where we stand on this spectrum. Concepts such as this break down the differences between ‘normal’ and ‘mentally ill’ and help liberate us from our own inbuilt stigmas against mental illness.

An extensive list of texts and their relation to mental illness can be found at www.madnessandliterature.org

Commentary

Literature, good TV and theatre for that matter, may not completely depict psychiatric psychosis or other psychiatric conditions in their entirety and complexity. They do however give us a glimpse into the differences between internalising (major depression, generalised anxiety and panic disorders, phobias) and externalising (alcohol and drug dependence, antisocial personality and conduct disorders) disorders.

We find ourselves in an age where the growth of information, triumphs of science and expansion of technology appears to be propelling us into a biomedical dominated practice of medicine. The question that we must ask ourselves is whether this scientific dominance is encroaching on our capacity for empathy, understanding and appreciation? Fictional literature may provide us with an opportunity to re-connect to our humanity in a way that no other medium can. Literature may not make us better diagnosticians, or change the value system of our profession, but it will make us question ourselves, our thoughts, and our perception of others. This new level of reflection and understanding can result in a more wholesome interaction with patients which will strengthen the therapeutic alliance between patient and doctor.

The study of humanities should not take priority over crucial clinical elements, but it can be used as an adjunct to clinical education. There is evidence to suggest benefit of reading already, and a number of medical schools have implemented medical humanity subjects and faculties because of their appreciation of its inherent value.[9-11] However, reading is something that is not restricted to the classroom; it cannot be tamed by our teachers and it has a timeless ability to touch us if we let it. Alexandra Trenfor writes, “The best teachers are those who show you where to look but don’t tell you what to see,” and fiction is like this teacher – it provides us with a narrative, but leaves its meaning and essence for us to discover ourselves.

Conflict of interest

None declared.

Correspondence

K Makhija: karan.makhija88@gmail.com

Reference

[1] Kaptein AA. et al., ‘Why, why did you have me treated?’: The psychotic experience in a literary narrative. Med Humanit. 2012; 37: 123-26.

[2] Riess H. Empathy in medicine-a neurobiological perspective. JAMA. 2010;304: 1604-5.

[3] Beveridge A. Should psychiatrists read fiction? Bri Jour of Psychiatry. 2003; 182: 385-87.

[4] Crawford P,Baker C, Literature and madness: fiction for students and professionals. J Med Humanit. 2009; 30: 237-51.

[5] Chalmers DJ. The puzzle of conscious experience. Scientific American. 1995;volume?: 62-68.

[6] Evans M, Greaves D, Exploring the medical humanities. BMJ. 1999: 319: 1216.

[7] Sims A. Symptoms in the Mind. 2003; Philadelphia: Saunders/Elsevier Science Ltd.

[8] Oyebode F. Fictional narrative and psychiatry. Advances in Psychiatric Treatment. 2004;10: 140-45.

[9] Shafer A, Borkovi T,  Barr J. Literature and medical interventions: An experiential course for undergraduates. Fam Med. 2005; 37(7): 469-71.

[10] State of the Field Committee, Arts in healthcare. Washington DC: Society for the Arts in Healthcare, 2009.

[11] Bonebakker V. Literature & medicine: Humanities at the heart of health care: A hospital-based reading and discussion program developed by the Maine Humanities Council. Academic Medicine. 2003; 78(10): 963-67.