Violence in Childhood – special collection

Children experience violence in a complex range of ways. Increasingly, though, research provides evidence of effective strategies to prevent this violence. Reflecting both of these points, Psychology, Health and Medicine published a Special Issue in March 2017 – Know Violence in Childhood: A Global Learning Initiative.

Leading researchers and practitioners from diverse disciplines and countries held a series of meetings for the Know Violence in Childhood Global Learning Initiative. (The photograph above shows participants at the March 2016 gathering in London.) The Special Issue summarises important evidence reviewed through the course of the initiative, including a paper by Loraine Bacchus and Manuela Colombini – Exploring opportunities for coordinated responses to intimate partner violence and child maltreatment in low and middle income countries: a scoping review – of the Gender, Violence and Health Centre (GVHC).

Overall, the articles make a strong case for policies and investments with the potential to end violence in childhood.

Other papers by GVHC members of the Know Violence initiative include:

  • Heidi Stöckl, Bianca Dekel, Alison Gehring, Charlotte Watts and Naeemah Abrahams (submitted) Perpetrators of child homicide globally
  • Karen Devries Louise Knight, Max Petzold, Katherine R Gannett, Lauren Maxwell, Abigail Williams, Claudia Cappa, Ko Ling Chan, Claudia Garcia-Moreno, NaTasha Hollis, Howard Kress, Amber Peterman, Sophie D Walsh, Sunita Kishor, Alessandra Guedes, Sarah Bott, Betzabé Butrón, Charlotte Watts, Naeemah Abrahams (under review) Who perpetrates violence against children? A global systematic analysis of age and sex specific data
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The hobbies of 1960s male middle aged civil servants

The Whitehall study questionnaire main purpose was to measure cardiovascular and respiratory health and other associated risk factors namely smoking habits. The questionnaire was also designed to capture associated risk factors including existing medical conditions, signs of diabetes and physical activity, which initially focused on the volunteer’s commute to work and movement at work.

 

Exercise_Tables008

Table of physical activity rates in various Civil Service grades

 

From 1969 onwards, the questionnaire tried to more accurately capture the physical activity of the civil servants beyond confines of work by asking them how they would describe their walking speed and secondly whether they had any hobbies or sports. Research had begun to show that there was a correlation between lower death rates and incidence of cardiovascular disease and having a more physically demanding jobs. The answers listed for hobbies and sport were graded on the perceived level of activity e.g. swimming and other sports were high level; DIY and jobs around home moderate whilst sedentary activities like model making and music were low. From these results, investigators showed that the more physical activity meant less risk of coronary heart disease and other mortality conditions. While these results have been undoubtable useful to epidemiologists, they also provide us with a record of the social lives of London based civil servants in 1960s.

From the 9200 completed questionnaires including this question, I have surveyed 500 to create a sample list of the type of activities that Whitehall Study volunteers were undertaking.

Visualisation

Word cloud visualisation of activities most cited within sample questionnaires

 

 

[table “1” not found /]

 

 

As you can tell from the table, the number one pastime of the [male] Civil Service was gardening. According to the Office of National Statistics in a 2010 survey, gardening still rated highly as one of the main leisure activities conducted in the country, especially with those aged 45-64 (62%). This was followed by the other familiar stalwart of the UK family home, DIY. DIY and interior decorating had a relative boom after the Second World War and was popularised by TV programmes such as Barry Bucknell’s Do It Yourself.

 

The next four places go to active hobbies or sports, namely walking, swimming, golf and tennis. Racket sports and individual sports tended to rate higher than team sports such as cricket, football and rugby which is unsurprising considering the age of the participants (some volunteers noted their past activities or mentioned that they were now mostly involved with refereeing or coaching).

The next highest placed entry was motoring. Motoring activities including motorbike riding, racing and car maintenance and was far more common entry than sailing activities. Car ownership was relatively high in Whitehall Study cohort, with one study showing a figure to be 72%.

The remainder of the list shows a juggling of sedentary hobbies such as photography, model making and reading with other active hobbies such as badminton, dancing and fishing [or semi-active in this case]. Sedentary hobbies were probably more prevalent than the list suggests as some participants were likely to not think them relevant for a health survey or not wish to disclose them. What is interesting in this samples is to see some of the trends of hobbies which are now marginal or archaic. Radio making and sound recordings occurred a number of times, along with dingy sailing, and breeding show canaries. There are also occasionally very personal responses or activities listed such as one participant mentioning he wrote novels (and turned out to be a prolific author); another being the heartwarming response that he took ‘blind people on tandem bike rides’ and finally the man who decided just to put ‘sex’!

The Whitehall survey questionnaires provide a partial insight into the inner world of civil servants of this period and although the main conclusions from my brief survey are hardly surprising (civil servants enjoy gardening and golf, who knew) they can sometimes delight in the details they reveal. I end with a video from 1957 showing an exhibition on doctor’s hobbies, just to show that the civil servants did not have a monopoly on male leisure activities!

Exploring public health contributions to alcohol licensing in local government: A London-based research study

Pub drinksOverview:

The London School of Hygiene & Tropical Medicine, Safe Sociable London Partnership and Southwark Public Health are conducting a research study to explore the range of influences on public health practitioners’ contributions to alcohol licensing processes in local authorities across London.  As public health has an increasing role to play in shaping local alcohol environments, we are interested in finding out more about how public health practitioners approach alcohol licensing work, to identify how to strengthen public health contributions to licensing processes.  The study is funded by the NIHR School for Public Health Research, and the study team includes researchers from London School of Hygiene & Tropical Medicine, Safe Sociable London Partnership, and Southwark Public Health.

We are already working with several local authorities, but want to include as many London local authorities as possible in the study.

We want to explore a wide range of experiences and approaches undertaken by public health practitioners in relation to alcohol licensing work, and to understand how this fits within the broader structures, relationships and context of each local authority.  We are also exploring the experiences of practitioners who have been using the Public Health Alcohol Licensing Guidance Tool developed by Safe Sociable London Partnership.  Some of you will already have spoken to Joanna Reynolds, from LSHTM, about participating in the study.

 Getting involved:

There are several stages to the study, and which involve different kinds of stakeholders, including public health practitioners, public health alcohol leads, other responsible authorities (licensing, police, trading standards etc), members of licensing committees, and other experts beyond London.

We would like to invite you to consider participating in the study in one or more of the following ways:

  • Brief online questionnaire: for public health practitioners in ALL London Local Authorities to complete. To obtain a detailed overview of licensing work.  April ’17.
  • In depth observation of public health practitioners’ alcohol licensing work: either one or two ‘situated interviews’ to understand how you approach your work, or more regular (eg weekly) sessions to observe licensing work over a period of weeks. March ’17 onwards.
  • Interviews: with public health alcohol leads, stakeholders from other responsible authorities and licensing committee members. April ’17 onwards.
  • Group discussions: with all practitioners interested in alcohol licensing, to explore how to strengthen public health contributions to alcohol licensing. May / June ’17.
  • Collection of licensing data: prospective collection of routinely collected data from public health practitioners on licence applications screened over 6 months. May ’17 onwards.

Anticipated outputs:

We aim to produce outputs from the study that will be of practical value to public health (and other) LA practitioners for their alcohol licensing work.  A first round of workshops is planned for September 2017 to discuss early findings from the study, and to engage practitioners in identifying the most useful formats and outputs to share learning.

Next steps and more information:

We will be contacting you directly to talk more about participating in the study; if you are interested and would like more information about how to get involved, please contact Joanna Reynolds: , or  Karen Lock: ;

or see the project website http://sphr.lshtm.ac.uk/public-health-alcohol-licensing-tool-evaluation/

If you would like more information on Safe Sociable London Partnership and the guidance and tool they have developed, please contact Ghazaleh Pashmi: or visit www.safesociable.com

 

SSLPSPHRatLSHTMLSHTM

18 – 24 March 2017

Peter Piot is interviewed by Times Higher Education for a feature reflecting on the higher education and research-led response to the 2014 Ebola epidemic: “I’d heard that some US universities had banned their staff from going to West Africa… I said, I’m going to do exactly the opposite…we are a school of public health, of global health…I was so pleasantly surprised by the reaction [of our staff to the call]…I was really proud.”

On World TB Day, Dave Moore provides comment to the AFP on research that shows one in five tuberculosis cases are resistant to at least one antibiotic: “Complacency about detecting multidrug resistant TB (MDR-TB) has for too long been driven by constrained resources – the notion that we can’t afford to test everybody with TB for drug resistance. In fact, the stark truth is that we can’t afford not to.” The article generates worldwide coverage, including: France24, CTV News (Canada), The Hindustan Times (India), The Malay Mail (Malaysia), Today (Nigeria) and Yahoo.

Mishal Khan is quoted by CNN on the challenges faced by Cambodia to deal with TB. The country has one of the highest rates of infection in the world: “Cambodia has a high rate (of infection) due to under diagnosis. People can remain undiagnosed for prolonged periods of time. So bringing it down is going to be a challenge as there are people that can spread it.” Mishal also takes part in a live Financial Times Facebook Q&A discussing how we can end the TB epidemic.

Kaye Wellings provides comment to Bloomberg on new statistics showing teenage pregnancies in the UK are at their lowest recorded rate. Speaking on the US family planning debate, Kaye says: “Education didn’t stop anyone getting pregnant. It provides the motivation not to get pregnant. Contraception provides the means by which you can avoid pregnancy. You need both.”

A USA Today article on items ‘dirtier than your toilet’ mentions Val Curtis’ 2011 study which found faecal matter is on one in every six smartphones. The article generates coverage in over 150 regional US outlets including MSN, Florida Today and Detroit Free Press.

Forbes reference School clinical trials being carried out in Uzbekistan which are testing drugs to tackle drug-resistant TB.

An article in The Observer references School research in Nicaragua which aims to reveal the cause of chronic kidney disease that is sweeping through the country’s male population.

Emilie Karafillakis is interviewed by ARTE’s Vox Pop (France) on the issue of vaccine confidence in Europe.

Jo Lines is quoted by The Science Times on the susceptibility to malaria faced by Venezuelan’s miners: “There are a large number of miners drilling holes in search of minerals. These holes with stagnant water are breeding grounds for mosquitoes.”

Hanna Tuomisto speaks to Impact Lab on the potential environmental benefits of lab-grown meats: “Producing beef in vitro could reduce greenhouse gas emissions from cattle by over 90%, and land use by 99%, but only if the vats were fed with pond scum called cyanobacteria.”

Recap: 2017 ICEH Alumni Workshop & 2015/16 Graduation Ceremony, 7-10 March, 2017

Alumni Workshop 2017 2

The 2017 ICEH Alumni Workshop was held 7-10 March, 2017 and it was a great success. I wish I could thank each one of you in person for the success of the workshop, but until that time comes please enjoy the photo gallery of the week’s celebration (link below).

Just like last year the alumni and current MSc Public Health for Eye Care students have expressed how valuable the alumni workshop is for them and this is accredited to the support and enthusiasm of everyone involved in attendance and those from afar throughout their entire MSc experience. As this is the only workshop of its kind at LSHTM we are happy to hear this.

There has been a large interest in the alumni presentations. Below is a summary of the presentations of the alumni who were in attendance at the workshop for your viewing.

On behalf of the Disability and Eye Health Group, thank you to everyone who contributing to a successful workshop and we look forward to celebrating our new alumni next year and the years to come.

Photos: Click here to view photos on Flikr

ICEH Alumni Presentation Summaries: Alumni Workshop 2017 – Presentation Summary

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TB superbugs need special attention – why do we continue to turn a blind eye?

David_MooreBy David Moore, Professor of Infectious Diseases and Tropical Medicine at the London School of Hygiene & Tropical Medicine

“It is quite possible that we will see a drug-resistant tuberculosis epidemic of unprecedented global scale.” The view of Dr David W Dowdy from Johns Hopkins Bloomberg School of Public Health in a Lancet Respiratory Medicine comment piece this week. Alarming words, and we need to listen.

Continue reading

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Converting shipping containers into clinics in Haiti and Namibia

Diploma in Health Planning, Policy and Finance (HPPF) alumna (1995) Elizabeth Sheehan founded Care 2 Communities (C2C) in 2008. At the time, having worked as a physician’s assistant in the developing world for more than 10 years, she saw women and children dying, and families falling apart, simply because they had no access to care. Elizabeth consulted with health and development experts to explore innovative solutions, and came up with a concept: convert the surplus of used shipping containers around the world into clinics. C2C ensures these clinics provide comprehensive primary care and education closer to where women and children live. The clinics offer quality pharmaceuticals and a lab where patients can get accurate results and diagnoses on-site. C2C hires talented local clinicians who are a part of the communities in which they work. C2C builds a strong supply chain and efficient operations so the clinics are open to serve families every day. Elizabeth refused to accept the status quo and instead combined quality services and innovative design. Since she founded the organization, C2C has opened three clinics – two in Haiti and one in Namibia, which have served more than 15,000 women and their families. Learn more about the work of C2C in this alumni report written by Elizabeth Sheehan.

In poor countries like Haiti, the major causes of death and disability are treatable, preventable illnesses. The need for accessible, affordable primary care is urgent. According to a study from the World Bank, interventions at the primary care level are able to address 90% of community health care demands (Doherty & Govender, 2004). In fact, a health system based on strong primary care delivers better health outcomes at lower cost (Starfield et al., 2005). Primary care affords greater accessibility to the community, especially the poor.

 

Figure 1

Figure 1

 

In 2013, Care 2 Communities launched a social enterprise model for primary health care delivery to low-income communities in northern Haiti: one of the most challenging global markets for healthcare operations. The need for high-quality, community-based care is urgent: government facilities are under-resourced and care standards are low, operations costs are high, and market forces are distorted by an influx of subsidized, intermittent operators that do not meaningfully or reliably reach those in need.

Using the social enterprise model (Figure 1), Care 2 Communities seeks to deliver high-quality health services to poor and low-income families in Haiti. C2C is a fundamentally “mission-driven” organization which has borrowed elements of a private-sector operating model.  This is because we believe that Haitian families need and deserve a reliable, long-term solution to their health challenges — a solution that cannot be achieved through donor funding alone.

Poor families are made more vulnerable by inconsistent or unreliable health service providers. We intend to change that. By running clinics as social enterprises, C2C offers something unique and important to our patients: a guarantee that low-cost, high-quality services will keep the community healthy. C2C offers quality services at the lowest possible cost, and uses these affordable patient fees to support clinics consistently. Focusing on primary care “brings the greatest benefits to the health of families and communities”. Mothers are able to care for their children, children can stay in school, and the entire community will benefit from a  healthy workforce.

 

Maylennie’s Story

Maylennie’s story highlights the impact C2C clinics have on the communities in which they serve:

Maylennie is just over two years old. Her mother was 22 years old when she was pregnant with Maylennie and her twin, who did not survive past four months. As Maylennie’s father lives in the bordering Dominican Republic and can rarely afford to send money home to his family, her mother struggles with caring for her four children on her own. Since birth, Maylennie has experienced numerous health issues. She was hospitalized at two months of age for weight loss and skin infections, but her health never really improved.

Image 2Last August, Maylennie was the first child to join C2C’s malnutrition program. On her first day, she weighed 6.8kg (14.9 lbs) and had an arm circumference of 11 cm and edema on her feet, both clear indicators of Severe Acute Malnutrition (SAM). After 12 weeks in the program, Maylennie reached a target weight of 8.6 kg (19 lbs) and her health has significantly improved, with her playful personality showing.

With the personalized nutrition education Maylennie’s mother received, along with continued support from community health workers and C2C medical staff, we know that Maylennie now has a fighting chance for a healthy future. In a landscape of under-resourced, low-quality clinics, C2C sets itself apart with a commitment to the highest standard of care, from nutrition support for little ones like Maylennie to using a social business model to ensure that care can continue to be accessible for poor families that need it most.

For more information on Care 2 Communities, please visit their website at care2communities.org.

References:

Doherty J, Govender R. Washington: World Bank, World Health Organisation, Fogarty International Centre of the U.S. National Institutes of Health; 2004. The cost-effectiveness of primary care services in developing countries: a review of the international literature. Working Paper No. 37. Disease Control Priorities Project.

Contribution of primary care to health systems and health. Starfield B, Shi L, Macinko J. Milbank Q. 2005; 83(3):457-502.

Images courtesy of Elizabeth Sheehan

Special collection for World TB Day 2017: Insights from recent health policy and systems research

By Mishal Khan (London School of Hygiene & Tropical Medicine)

Background

Tuberculosis (TB) is now the leading cause of death from an infectious disease, and in addition to its impact in terms of mortality, TB has considerable social and economic consequences for individuals. Furthermore, the long (6 to 8 month) duration of treatment, and critical need to ensure adherence to treatment in order to avoid generation of drug resistance, places a substantial burden on already overstretched health systems in low- and middle-income countries. TB is not a new disease, however, and was declared a ‘global emergency’ by the World Health Organisation (WHO) in 1993.

While there have been many successes in TB control in recent decades, particularly around standardisation of case management and recording in public health facilities, progress towards disease reduction is far below what is needed and what is planned. If we keep going as we are – with global incidence declining just over one percent per annum – it will take more than 150 years to meet the 2035 End TB targets of reducing deaths by 95% and incidence by 90%. This signals, I believe, a need for critical reflection on the design and implementation of health systems and policies to control TB, and investigations on how to improve our approach to TB control. Here, more health policy and systems research is critical, and has to some extent failed to receive the attention it deserves. For example, the Global Plan to Stop TB 2011–2015 set a target US$10 billion for Research and Development (R&D) across five key areas – drugs, basic science, vaccines, diagnostics and operational research – with health policy and systems research notably lacking.

HPP’s special collection to mark the day

To mark WorlMishal 3d TB Day, Health Policy and Planning has made some key recent papers freely available in a special collection. It is hoped that these will generate debate and spur future studies to inform policy and public health practitioners and researchers.

The global strategy to control TB, which was originally known as DOTS and has now evolved to become the Global Plan to Stop TB, can have a huge influence on national TB control programmes. The first paper in the collection, by Quissel and Walt (2016), examines how a ‘global network’ for TB control formed, how it shaped policy, and factors influencing its effectiveness over time.  While having a standardised ‘global’ strategy for TB control – or any disease for that matter – has some advantages, appropriateness for different contexts is a major challenge. This is illustrated by an important study by Birch et al (2016), which raises questions about the requirement for daily observation of treatment, and how best to consider patients’ needs during the lengthy course of treatment. The study, which is available as part of the special collection, found that a requirement to visit a clinic daily to access treatment in South Africa may result patients being more likely to miss treatment.

Of course critiquing existing strategies may well be easier than designing better ones, and a recent systematic analysis (2015) of the emerging TB control strategy in Myanmar highlighted critical gaps in evidence to inform policy and resource allocation. In this setting and many others, policy and public health practitioners are therefore making decisions on how to allocate large sums on donor funding without an evidence base to guide them.

Finally, taking a step back to examine the global TB control strategy and what may have shaped it, a policy analysis by Shearer et al (2016) highlights the important role of changes in institutions and ideas to drive policymaking, but proposes that change in policy networks is a necessary intermediate step. Indeed, although the current approach is to have separate (vertical) disease control programs for TB, HIV, malaria and other diseases, a concern with this is that wider health system issues that are not disease specific get neglected. An example of a wider health system issue that impacts on TB control – engaging with for-profit private healthcare providers dominating health service provision in many low- and middle-income countries – is addressed in the final paper in the collection.


Check out our special online collection out together by Dr Khan to mark #WorldTBDay here: https://academic.oup.com/heapol/pages/world_tb_day_2017.

Also listen to our podcast with Dr Mishal Khan explaining the importance of the day along with how we can keep up the momentum and discussion: http://bit.ly/2ocHiFP.

Link to the live webcast of the World TB Day event hosted by LSHTM and UCL: http://www.ucl.ac.uk/live/world-tb-day.

Mishal was also on facebook.com/financialtimes for an interview with them.

Pedometer challenge meets male middle aged civil servants from 1970s

 

The belief that ’10,000’ steps is good for you is relatively ingrained fitness lore worldwide. The belief has spread through high profile global step fitness challenges and the prevalence of relatively cheap, accurate digital step counters. However, before we all became fixated with collecting our own personal health stats and viewing everything as units of ‘steps’, there was a time when such a practice was peculiar: namely the 1970s* [* or, any other time but for narrative purposes let’s say the 1970s].

 

Pedometer from the 1970s

Back then, pedometers were hardly known and were mainly used as a medical instrument. It was for this purpose they were used by groups of randomly chosen male middle-aged civil servants measure rates of exercise in 1970, as part of Whitehall Study.  The study aim was to measure exercise in a typical week that would account for walking at work and during leisure time. The potential effect of the level of physical exertion and rates of coronary heart disease [CHD] had then only recently been indicated, with the MRC trial of anticoagulant therapy on myocardial infarction (1969) noticing that rates of CHD were more frequent and fatal within inactive workers.

 

The follow-up study involved randomly selected Whitehall Study volunteers receiving an invitation from Dr Geoffrey Rose, the study’s lead investigator, whether they would be willing to participate in the study. Volunteers who agreed to participate in the study would then receive a mileage record sheet, pedometer and a pedometer instruction sheet.

 

Whitehall_Followup002

Instructions for using a pedometer

The alien nature of the pedometer was encapsulated by Dr Rose’s description of a pedometer as a little instrument looking like a pocket watch, which clips onto your trousers, or goes in a pocket, and the dial records the distance that the wearer walks. The instructions sheet sent to those volunteers emphasized the care needed to prevent false readings through any other transport other than by foot, as it was reliable to record mileage by bus, train, car or bicycle.

 

Whitehall_Followup007

Extract from a letter from a volunteer expressing his difficulty in performing test due to unusual work circumstances and a German exchange student.

 

The correspondence within the archives leave a record of the difficulty associated in getting volunteers to ‘volunteer’, with several letters back to Geoffrey Rose explaining their difficulties in participating. Letters received back were often apologetic citing holidays, overseas placements or change in work environment. Others raised the difficulty of finding a typical working week to undergo the test, as the letter expresses below (though doesn’t fully make clear how hosting a German exchange student was going to effect the test).

 

The researchers also had to factor in the unreliability of the post office in delivering the pedometers and the failure of the instrument itself. Mr Broadbent noted that ‘this pedometer over-registered mileage by about 50%. Suspecting this, I timed myself over a 40-minute walk in Seaford. I walked fairly briskly and covered probably about 2 miles. The pedometer showed 3 miles”. Dr Rose wrote back a very candid response noting first that pedometer performance had never been satisfactory, and that the over-representation was possibly down to the average stride with some individuals having a much larger stride than the average.

 

Whitehall_Followup005Whitehall_Followup004

 

 

 

 

 

 

 

 

 

It does not seem that the results of the pedometer trial were the basis of any major changes within the direction of the Whitehall Study but displayed how the study had expanded from its original remit on surveying cardiorespiratory risk to include physical exercise and social factors. The longitudinal data from the study confirmed that high physical exercise rates gave protection from a range of mortality outcomes and not just CHD [G. David Batty et al. 2010].

Whitehall_Followup001

Table showing some of the results from pedometer trial group. Average miles walked for the group was 1.89 miles or 3992 steps if you prefer

 

References:

Forget walking 10,000 steps a day – I have another solution, Stuart Heritage, The Guardian, Tuesday 21 February 2017

Physical Activity and Coronary Heart Disease, Geoffrey Rose, Proceedings of the Royal Society of Medicine, Volume 62, November 1969, pp 1183-1188

Walking Pace, Leisure Time Physical Activity, and Resting Heart Rate in Relation to Disease-Specific Mortality in London: 40 Years Follow-Up of the Original Whitehall Study. An Update of Our Work with Professor Jerry N. Morris (1910–2009), G. David Batty, Martin J Shipley, Mika Kivimaki, Michael Marmot & George Davey Smith, Annals of Epidemiology, 2010

 

World Tuberculosis Day – Unite to End TB in Papua New Guinea

By Jeremy Hill (London School of Hygiene & Tropical Medicine)

World tuberculosis (TB) day is a valuable opportunity to focus on the global epidemic of tuberculosis. In London, I’ll be attending a symposium hosted by LSHTM and UCL  where the program includes the breadth of topics: from the natural history of TB, through to strategies for its elimination. While I’m there I will also be thinking of TB Day last year, which I spent in a very different setting; Daru, the capital of Papua New Guinea’s Western Province and my home for most of 2015 and 2016. My role there was as a doctor at Daru General Hospital; primarily, I was looking after patients affected by a severe epidemic of tuberculosis. Aside from the large number of people affected, the epidemic in Daru is made all the more challenging by high rates of drug resistant TB, including the most difficult to treat infectious strains,  multi-drug resistant and extensively-drug resistant TB (MDR- and XDR-TB). Being a small town of 16,500 people in a remote and under-served part of the world, this slow-burn humanitarian crisis is not very well known, especially in comparison to the much larger scale of the epidemic in more populous parts of the world. However the intensity of the problem, the devastating impact on people and their communities, and the committed response of program leaders and their teams on the ground are all good reasons for members of the health policy community to pay attention.

Context

DOTSY - TB day PNGLet’s start with some context. Daru is an island, 5km across, located just off the southern coast of Western Province. To the south, across the narrow Torres Strait, is the Australian state of Queensland, to the east is the mouth of the Fly River (Papua New Guinea’s longest), and to the West is the protected coastline and the border with Indonesia’s West Papua. The mainland to the north is a remote, sparsely populated region of swamps, forest and waterways – people coming from villages in the South and Middle Fly Districts often travel for days by foot, vehicle and canoe to access essential services in Daru. Responding to droughts, resource limitation affecting regional services, and degradation of the Fly River by the Ok Tedi mine in its headwaters, many displaced people have stayed in Daru to form overcrowded waterfront settlements. This combination of displaced and transitory populations, resource limitation, food insecurity and health seeking across international borders sets the scene for amplified TB transmission and for big challenges to the continuity of TB care.

Papua New Guinea is included on on all three high-burden lists published by the WHO (overall burden, and separate lists for DR-TB and TB/HIV coinfection), with an overall case notification rate in 2015 of 368 per 100,000. However, the TB epidemic in Daru is much more intense: in 2015 we diagnosed 120 people with DR-TB, yielding a local case notification rate of more than 700 per 100,000 for DR-TB alone. For all forms of TB, the notification rate was around 3000 – compare this to the rate of 6 per 100,000 just a few kilometres south in Australia. The burden of disease in Daru is extraordinary, and the impact on the community was profound. Remembering that DR-TB treatment involves at least 20 months of daily observed medicines, with 8 months of daily injections, imagine the prominent place that DR-TB treatment of 120 new patients each year would have in a small town. Imagine schoolchildren excusing themselves from class once a day, or adults managing this around work, or the hundreds of people contributing to the implementation of this sort of treatment program. Imagine a similar program of IV chemotherapy if it were a large cluster of cancer cases in a similar low resource setting. I’m still blown away by the resilience and ingenuity of staff and patients in Daru – and with this in mind I will highlight a few personal observations.

  1. Patients are almost always resilient and committed to their treatment, even those TB clinicwho are missing it

While working as a doctor in Daru, I encountered the convenient attitude of blaming drug-resistance on patients
who don’t take their treatment. I encountered this amongst, patients, leaders, nurses, doctors and myself. In contrast with this perception, patients who missed treatment usually had genuine, understandable reasons for doing so – sometimes a consequence of the treatment regimen itself. Reviewing our program data for weekly treatment adherence conclusively put this to rest: adherence to treatment remained higher than 90% regardless of the resources or staff available. Further, we could pick out the groups of patients who were vulnerable to missed treatment. Families dependent on subsistence fishing or farming, for example, would occasionally miss treatment to obtain food. This emphasised to me the common sense approach of improving adherence by identifying and helping patients deal with the day to day difficulties that TB treatment causes.

  1. Innovations and policy changes at a global level can directly and immediately affect programmatic management

Although Daru is remote and inaccessible, the peer reviewed findings, recommendations, guidelines agreed and published by multilateral organisations or journals such as Health Policy and Planning are not. In addition to this, the TB epidemic in Daru is exceptional – TB is the leading cause of death in Papua New Guinea, and with transmission of DS-, MDR- and XDR-TB occurring in the community, new tools and innovations can and should be rapidly implemented with commensurate monitoring and support. Health policy actors should orient their work to make it accessible to decision makers in high-burden settings; efforts to do so are welcome and already having an effect.

  1. Multiple partner organisations collaborated to deliver a high-quality DR-TB treatment program despite limited resources

By collaborating, working towards shared goals, and adapting where necessary, Daru General Hospital and the Western Province Health Office worked with partners World Vision, the Burnet Institute and HHISP to rapidly improve the DR-TB program in short order. By drawing on the expertise of multiple different partners to deliver basic outcomes, the program built trust with the Daru community, National TB Program, funders from the Australian Department of Foreign Affairs and Trade and multilateral organisations. Starting with infection control and triage at the hospital, and ending with community based treatment and implementation of new TB drugs, leaders at these organisations demonstrated that many aspects of programmatic management of DR-TB are low-tech but administratively complex, and can be done well with limited resources.

Conclusion

Despite the improvement in the curative program, the epidemic is undiminished – of course, treating patients as they arrive at the hospital will not put a dent in that. In response, program leaders are planning a systematic screening initiative, a dramatic intervention that will require support at all levels, including multilateral TB policies and peer-reviewed publications. So, wherever you are on the 24th, remember that our discussions, publications, tweets and actions in this field should be oriented towards the patients and communities affected by TB. Know that patients are committed, know that people want treatment, and remember that policies to support scale up of case finding, diagnosis, treatment and prevention should respond to that – this is true of the largest scale epidemics, the smaller but focused burden in Daru, and everything in between.

Look out for our #WorldTBDay special online collection and further blogs and podcast on Friday 24th March!