World Pneumonia Day 2012

Today is World Pneumonia Day. While #WPD2012 should lead us to be optimistic about the capabilities we have to prevent and treat pneumonia around the world, it also provides a solemn reminder that despite being preventable and treatable, pneumonia continues to be the leading cause of death in children.

Looking back at the past year, much of my world has been shaped by thinking of respiratory health and of pneumonia, in particular. In February, I was given the wonderful opportunity to travel to Malawi to see the roll-out of the pneumococcal vaccine there and to see the myriad of ways that people are working to prevent pneumonia in their communities. I wrote about this several times, including some reflections on how the pneumococcal vaccine is being made accessible in low-income countries through an advanced market commitment, which has brought the price of the vaccine down considerably.

While there is much to celebrate since World Pneumonia Day 2011, there is still much work to be done. An effective vaccine exists for preventing pneumococcal pneumonia, but coverage needs to be expanded. In the Democratic Republic of the Congo, for example, a country ranked the third highest in the global mortality from pneumonia rankings, the PCV vaccine was introduced, yet coverage is only 9%. Effective treatments for pneumonia, including basic essential medicines such as amoxicillin and oxygen, exist and are low-cost, yet access to basic healthcare in many parts of the world remains poor. The challenges are vast and require us to think about not only pneumonia, but how to improve health systems so that not only is coverage of the pneumococcal vaccine or treatment of pneumonia expanded, but other health interventions as well. A stronger health system is more capable of preventing and responding to the health needs of the population, including the prevention and treatment of pneumonia.

This point is driven home by the Pneumonia Progress Report released today by the International Vaccine Access Center that says that:

“Nearly all pneumonia deaths occur in developing countries, and three-quarters take place in just 15 countries. The majority of pneumonia cases are preventable or treatable.”

This tells us that targeted interventions could produce big results for reducing child mortality caused by pneumonia. Doing so by strengthening health systems at the same time would undoubtedly deliver major improvements in population health and encourage the roll-out of other effective health interventions. The fact that childhood deaths caused by pneumonia are concentrated in just 15 countries tells us that the ability of the health system to cope with an all-too-common illness is weak; it’s a late indicator of a very sick health system.

As a respiratory therapist, this is an issue of great importance to me. Regrettably, many of my interactions with the pneumonia “world” have been in providing treatment to those who need it. Because of this perspective, I was delighted to read that a major initiative was launched today to ensure that amoxicillin – a first-line treatment option for childhood pneumonia, yet one that is too often unavailable – is available in the ten countries where childhood deaths from pneumonia are the highest (India (400,000 deaths), Nigeria (130,000 deaths), Democratic Republic of Congo (88,000 deaths), Pakistan (67,000 deaths), Ethiopia (41,000 deaths), Uganda (22,000), Niger (20,000), Bangladesh (19,000), Tanzania (18,000) and Kenya (18,000)). This is huge, and is certainly cause for celebration.

So, in the coming year, those of us in the fields of respiratory medicine and public health need to commit to eliminating childhood deaths from pneumonia and advocating for the scaling up of treatment and prevention of this deadly illness. We need newer, better, more innovative approaches to the delivery of basic respiratory health services in low-resource settings. Things that we take for granted, but that are all-too-frequently unavailable, like supplementary oxygen: a vital drug for treating pneumonia, but one plagued by logistical constraints making it rarely available in low-resource settings. We need to be innovators and advocators for respiratory health, and we need to take that responsibility seriously. There is much we can learn from the work that is being done between World Pneumonia Days, but there is still much work left to do.

Be sure to check out some of the many wonderful blog posts that have been posted today:

World Pneumonia Day’s Humble Beginnings – on Impatient Optimists, by Orin Levine

World Pneumonia Day: Remembering the Forgotten Killer – on the One blog

“Cyber-Doctors” Help Conquer Pneumonia in India – on Impatient Optimists, by Saul Morris

The Biggest Scandal in Global Health Today: Why are 2 Million Children Dying from Pneumonia and Diarrhea Every Year? – on Pneumo Blog, by Leith Greenslade

Watch the World Pneumonia Day video

Posted in Essential Medicines, Global Health, Pneumonia, Population Health, Respiratory Therapy | Tagged , , , , , , , , , , , | Comments Off

Eliminating the Harms of Counterfeit and Substandard Medicines in Anesthesia

Poor-quality medicines are found all over the world, and can be of poor quality for a variety of reasons: they might be made with poor-quality chemicals, they may contain toxic substances instead of the proper active ingredients, they may contain inactive or ineffective preparations, or they might be deliberately mislabeled. The World Health Organization calls them spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines.

In cases of deliberate counterfeiting, the products are intended to look like genuine medicines, leaving healthcare workers uncertain as to which drugs are real (and could therefore help) and which drugs are counterfeit (and could cause harm).

In anesthesia, the stakes are high: many of the drugs that are used are given by injection, either into the veins or into the spine. When the drugs that are injected are compromised or contaminated, this could mean that bacteria or toxic substances are being injected directly into the body, causing immediate and severe harm. Anecdotally, we have heard stories of harm being caused in this way, such as pregnant women in Rwanda who received injections of contaminated spinal anesthetics for a caesarean section and became paralyzed. Several other similar stories have emerged as we have begun to talk about these issues.

Regrettably, however, there have been no major studies of anesthetic drugs in low- and middle-income countries that might help us to identify the sources of these problems. Our colleagues are thus left to hope for the best, knowing that the drugs they are using might be of poor quality and, as a result, might cause harm when they administer them.

We want to fix this. Counterfeit medicines are a huge problem around the world that we don’t know enough about, and worse – don’t yet know how to fix. We want to work with our colleagues in Zambia to try and tackle this problem and improve safe surgery and anesthesia. So, we have applied for funding from Grand Challenges Canada to do exactly this. But, we need help to vote for our project and make sure that we get the funding to support our work against counterfeit anesthetics. We need you to register and vote for our project on the Grand Challenges Canada website.

Our proposal is straightforward: We want to figure out the cause of poor-quality anesthetics in public hospitals and see if we can use existing technologies at the point-of-care to identify medicines that are likely to cause harm.

How will we do this?

We want to use an existing device called the TruScan to test medicines in public hospitals in Zambia for their authenticity. The TruScan is a handheld Raman spectrometer (for the science fans, here’s the Wikipedia page) that allows the user to essentially point-and-shoot at a drug, through the packaging, to determine its authenticity as compared to the device’s database. Basically, a front-line health worker can hold a vial up to the device and have it tell them if it is authentic, or not.

Because we don’t know much about why injectable anesthetic drugs are of poor-quality, we need to validate the use of this device in the field before we can say that this is an effective way of preventing harmful drugs from reaching patients. There are a range of other problems that we hope to be able to detect and eliminate – bacterial or fungal contamination, for example – that might not be responsive to this approach. That’s why every drug that we test at the point of care will also be tested in a lab in Canada, to make sure we haven’t missed anything. Once we know and understand the issues, we can figure out how to go about solving them.

What do we hope will come from this project?

We hope that we will be able to show that handheld devices like the TruScan can be used by front-line health workers to identify poor-quality medicines before they are delivered to patients. If our project is a success and we have a high rate of detection, we think that this could save lives and provide us with enough evidence to support integrating this kind of device into other health facilities where we know poor quality medicines are a problem. By empowering local health workers, particularly anesthesiologists, we hope to be able to show that better control of the drug supply chain can be attained by local staff.

If our project is a success, then this gives us solid evidence to support scaling up this kind of intervention. Furthermore, it also will provide us with valuable information on the drug supply in anesthesia: something that we know relatively little about in low- and middle-income countries. Of course, preventing counterfeiting at the source is always preferable, and there are a number of initiatives doing just that, which compliment the work that we are undertaking (like mPedigree or Sproxil.

How can you help?

First, watch our Grand Challenges Canada video, register, and VOTE for us.

Second, share our video with your friends and colleagues and encourage them to do the same.

Surgical care is an integral component of a strong, functioning health system. Regrettably, millions of people are denied access to safe surgical care around the world. There is a growing momentum to strengthen the quality of surgical care available, and ensuring access to safe and effective anesthetics is a critical component of these initiatives. But, we need to know more about what the problems in the anesthetic supply chain are and how to fix them. This project is an important part of this work and we hope that you will support us.

Posted in Anaesthesia, Essential Medicines, Global Health, Humanitarian, International Development, Population Health, Surgery | Tagged , , , , , , , , , , , , , , , , , , , | Comments Off

Health Systems in Humanitarian Emergencies – Monday October 22 at the Canadian Conference on Global Health

My colleagues from the Canadian Red Cross and the Pan-American Health Organization and I will be presenting a workshop today at 13:30 at the Canadian Conference on Global Health in Ottawa. The title of our workshop is Health Systems in Humanitarian Crises: Transitioning from Emergency Response to Health Systems Strengthening, and we’re going to be discussing several important aspects of the evolution of the humanitarian response to major emergencies.

This is a critical challenge for the humanitarian community: knowing when the emergency ends and reconstruction begins. However, health systems strengthening in emergencies is about more than shifting perspectives; as we saw during the Haiti earthquake, many international actors actually further weakened Haiti’s already fragile health system by displacing health workers and taking over clinics – issues that Merlin addresses in a report titled Is Haiti’s Health System Any Better?

So what can be done? How can interventions directed to the emergency response phase of major disasters also contribute to the long-term sustainability and strengthening of health systems? This is what we intend to discuss today. Follow the conference using the #CCGH2012 or #CSIH tags, and by following the conference’s host – the Canadian Society for International Health@globalsante.

Here’s the abstract from our presentation:

This symposium is designed for researchers, NGOs, policy makers, and donors who are involved in emergency humanitarian assistance, post-conflict health systems strengthening, and health services delivery in fragile states. The symposium will present collected evidence and stimulate discussion highlighting current challenges in health systems strengthening in humanitarian emergencies, of relevance to a broad audience – from field-level staff to senior decision-makers.

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Some Thoughts on Using Randomized Controlled Trials in International Development

I recently came across a post on the Council for Foreign Relations’ Development Channel that asked: Are Randomized Controlled Trials a Good Way to Evaluate Development Projects?

This is an incredibly important question because, as the authors note, “International donors have spent well over $2 trillion in development assistance over the past five decades, but there remains significant uncertainty about what works and doesn’t work to reduce poverty and grow economies.” Aid accountability has become an increasingly salient prerogative of many donors, yet showing that aid gets where it is supposed to and achieves desired goals continues to be a challenge because we often propose complex interventions whose outcomes may not be linear (for instance, providing school books or desks should not be equated with learning, but it is much more easily quantifiable) and may be longer-term rather than short-term outcomes.

The randomized controlled trial is a mainstay of biomedical research because it allows us to compare the effects of an intervention – a drug, a therapy, a process of care – in one group (the intervention group) and compare it with the results of another population who receives either nothing (often in the form of a placebo), or receives the usual treatment, which we assume to be inferior to the new intervention. By controlling for a number of variables, we try our best to make sure that the two populations are comparable (equally matched numbers of men and women, in the same age range, with similar burdens of disease, etc.) and that they are representative of the population in which we would like to use this tested intervention in, assuming the results show promise.

Issues of methodological and interventional complexity aside, it’s important that we consider the social contract between researchers and research subjects that allows us to conduct this research in order to advance biomedical science. While the underlying principle of the RCT is to advance medical science, we can’t do so without respect for our patients and our research subjects. That is, we can’t perform experiments on people without respecting their basic human rights, including things like their right to autonomy and their right to not participate in research if they don’t want to.

Taking it one step further, we compare our new interventions against the gold standard in order to show an improvement. If no treatment exists, then providing a placebo may be considered acceptable as a control arm; however, when an effective treatment exists, denying patients that treatment in order to provide a placebo to compare your intervention against, would not. For example, if you want to demonstrate a new formulation of insulin is effective, you would have to compare your new intervention against existing types of insulin. You couldn’t deny patients something that they need or that we know is good for them just to show that your new formulation or treatment protocol works better than nothing.

The reason behind experimentation and the use of randomized controlled trials is that we are answering a question about the intervention, and we are unsure whether the intervention is better than existing treatments, or doing nothing. In short, there is a general uncertainty as to whether a treatment will be beneficial. This is known as clinical equipoise in research ethics.

In international development, we are often uncertain of the models for appropriately scaling up development initiatives, but it would be unfair to say that we are uncertain of the many of the interventions. For instance, we know that funding education or immunizations are important and successful interventions for children or that ensuring access to clean drinking water reduces water-borne illnesses. These are not questions of science, they are questions of political will that allow the absence of these interventions to persist.

What is often unclear is not whether interventions, per se, are effective in a global context, but rather what models best allow them to be scaled up and run sustainably. Testing models of implementation in a randomized controlled trial is notably different from testing the effectiveness of the intervention, itself. So, when we know that the intervention is effective, can we justifiably randomize a population to a model that would result in it being unlikely that they would receive it? I don’t believe that we could.

If we do determine that randomized controlled trials are the way that we should proceed in international development, then I argue that the same safeguards need to be in place for conducting these trials with new medical innovations: they need to be approved by a competent research ethics board, there needs to be an oversight committee capable of determining throughout the study whether the intervention or the control is disproportionately placing participants at risk (and if it is, they need to have the authority to stop the trial/study/intervention), and there needs to be an ethical obligation to publish negative findings. If we are going to apply rigorous scientific methods to international development, we need to apply all of these methods and not only the ones that suit us and our information needs best.

And of course, it’s worth noting that not everything that we know about effective interventions has been proved through a randomized controlled trial. I suspect that the authors of this cheeky paper in the British Medical Journal are still waiting for participants for their randomized controlled trial on parachute use to prevent death and major trauma related to gravitational challenge

References
Gordon C S Smith, & Jill P Pell (2003). Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials BMJ, 327 DOI: 10.1136/bmj.327.7429.1459

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Broadening Our Knowledge of Respiratory Therapy and Respiratory Care

While most of my life is currently spent working in global health and population health, I originally trained as a respiratory therapist and have continued to maintain a clinical practice throughout my graduate school years. I have worked in adult critical care, anesthesia, emergency medicine – the list goes on. Recently, I was appointed as the new Editor-in-Chief of the Canadian Journal of Respiratory Therapy (CJRT), a small Canadian journal focusing on the practice and the science of respiratory therapy.

As the Editor, my goal is to transform the journal into an increasingly useful and widely-disseminated journal that focuses on the implementation of best practices for respiratory therapy and respiratory care in Canada and around the world. This means that we want to be publishing high-quality research that tells us how effective interventions can be implemented in major Canadian academic health centres, as well as in village health clinics in places like Malawi. We are equally as interested in publishing reports that investigate community-based treatment of pneumonia in Lusaka as we are in reviews of packages of services to reduce ventilator-associated pneumonia in Toronto. We are working to ensure that the journal maintains a strong online presence and to solidify its status as an open-access journal, so that the results of valuable research continues to reach those who can benefit from it most.

To that end, we are actively seeking submissions for upcoming issues of the journal, so I thought I would post some of the topics we are interested in on here. This is by no means an exhaustive list, but rather just a few thoughts on areas that we are interested in developing:

  • Community-based respiratory therapy/respiratory care for common respiratory illnesses (in adults and children)
  • Respiratory Therapist (RT)-led  clinics for asthma, COPD, or other chronic diseases
  • Models of care for community-based respiratory therapy: home care, chronic disease management, etc.
  • RTs working in community-based interprofessional care teams
  • Respiratory Therapists working with hard-to-reach populations
  • The role of respiratory therapists in urban health centres, including homeless, refugee, and immigrant populations (among others)
  • Considerations for respiratory therapists working with immigrant and refugee populations in Canada
  • I am particularly interested in a respiratory therapy-focused review of the Canadian Guidelines for Immigrant Health and this would be a very good subject for a review for a first-time author with an interest and expertise in the field
  • Organization and delivery of respiratory therapy in rural or remote communities in Canada, including RTs involved in telehealth, medevac, or critical care outreach services, as well as rural respiratory therapy, in general
  • New clinical leadership roles for RTs in acute care settings
  • Evaluations of new RT-led care pathways (ventilator weaning, trach management, acute asthma exacerbations, non-invasive ventilation, etc.)
  • Evaluations of the role of RTs in interprofessional care teams
  • Role of RTs and Anesthesia Assistants in peri-operative care and patient management
  • RTs as cardiac arrest team leaders
  • Evaluations of new devices, modes of ventilation, or adjuncts to respiratory therapy
  • Case studies of unique or challenging patients encountered in your practice

We are interested in structured evaluations, as well as interesting commentaries or reviews of the above topics and more. Writing and publishing a review of an interesting or controversial clinical treatment or role is a great introduction to research and publication, and we are happy to support first-time authors. Back issues of the CJRT are currently being re-developed and will be posted in a more friendly manner shortly. Our instructions to authors have recently been updated and are available online here: http://www.csrt.com/en/publications/authors_instructions.asp

Posted in Global Health, Medical Publishing, Pneumonia, Population Health, Respiratory Therapy, Surgery | Tagged , , , , , , , , , , | Comments Off