Thursday, 15 June 2017

Malaria control is the best bang for your charitable bucks - really?

‘For every complex problem there is a solution that is clear, simple, and completely wrong.’  ( H L Mencken. ) Is malaria control an example?

Zambia is an ‘epidemic’ malaria zone. This means that there is very little malaria in the height of the dry season when the relevant mosquito has no stagnant water to breed in. But the annual rains in December to March turn this flat valley into a mosquito paradise, which lasts well into June and July as water collects in pools locked in by the clay soil.  As a result the risk of contracting malaria is very high. In this small settlement of 10,000 or so, we are seeing hundreds of cases daily, and the risk to foreigners working here seems to be that one in 5 or 10 will get it in any one year even though they are all aware of the need to prevent the mosquito bites, and all use nets and repellent sprays.  Mostly the illness is like an extremely severe flu if treated promptly, but a few cases ( ?5%)become severe and there is a definite mortality rate.  Seeing adults with temperatures over 40 is a bit of a shock for a GP from the UK, and personally I am taking preventative drugs!
Worldwide it is estimated that malaria kills roughly half a million people a year, mostly in Africa, and mostly children.  Because malaria is a parasite, which gets inside human cells in the blood and the liver, it seems to be able to evade the immune system.
In other areas of the world drainage of wet areas has been very effective in eradicating the mosquito, but this would be impossible here.  So malaria control here has focused on insecticidal bednets and ready access to diagnosis and treatment in order to reduce the chance of the mosquito biting an infected patient. This is available from community volunteers in the villages as well as government clinics. According to Bill Gates if we work at it we can eradicate malaria (as we have smallpox). See

But I have a sneaking suspicion that the main effect of our current efforts is to make this area i.e. the Luangwa valley inhabitable. 40 years ago there were very few people indeed living in this area, and I wonder if one reason might be that the risk of malaria was high and there was no treatment available.  Now we have both diagnosis and treatment easily available, and death rates are much lower but we have hugely increased the number of people who are living close to water which is full of anopheles mosquitoes.

So our efforts and those of the Gates foundation are no doubt at all saving huge numbers of lives in the short term. But it looks as if eradication will only happen if there is a real breakthrough in terms of vaccines, insecticides, or mass treatment.

An education solution maybe?

The problem of how to help poor African countries develop economically and help them get out of their grinding poverty - with hungry children, illiteracy, nights with no lighting, etc. confronts anyone who visits a country like Zambia. It ought to be possible to improve things, it is peaceful and not overpopulated, and it is easy to grow food and stuff like cotton to sell.  They do also have some natural resources in terms of copper and hydroelectric power.

So the standard theory is that they just need a bit of a leg up especially with improving literacy and education and malaria control, and then gradually growth and development will accelerate.

Education in particular has had huge help from Donors, and schools everywhere have signs indicating which particular charity or country has paid for their newest building. Many of the secondary pupils are sponsored by donors who pay for fees, books and even food.

But standards of education are dire. Class sizes are huge-not surprisingly,  with  the average age of the population of Zambia around 16, and an annual population growth rate of nearly 3%.  Many children miss school years intermittently due to lack of funds to buy uniforms and books. Then there are poor English language skills, lack of books, poor teacher training, and poor teacher motivation, which means that even secondary school pupils lack basic numeracy skills.  At the same time other parts of the world including India and China are leaping ahead in terms of their education especially in high tech areas. So Zambia is falling even more behind.

Is there any way of improving this situation? One possibly is to work outside the existing school system. Is one possible solution is Edulution. Using content from the US based online provider the Khan academy they employ coaches to help groups of 30 pupils in 3 hour sessions once a week throughout the year with their numeracy. Each pupil has a small tablet computer, which is linked to the coaches laptop. No internet connection is needed as the content is preloaded.  The  cost to sponsors is around $10 per month per pupil, which is much less than conventional school sponsorship. This system has recently been started in this area by the main local charity and, at my recent visit to the local school, pupils and teachers and coaches seemed happy and enthusiastic. It is early days but after my visit I am cautiously enthusiastic that this is one situation where new technology may be at least part of the answer. 

Teenage pregnancy - a problem solved?

The highest teenage pregnancy rate in Europe was the shameful statistic that the Blair government  decided to address. Teenagers having babies leads to all sorts of bad outcomes, high rates of prematurity and hence damaged babies requiring very expensive medical care, and also long term underemployment of the mothers, who are almost bound to remain on welfare payments and to need housing subsidies for many years. It is a medical and social disaster.  A big effort was made in schools and in the health service to provide contraception, particularly using hormone implants which work for several years (and cannot be forgotten.)

10 years later the number of teenage births has approximately halved to around 20 per 1000 girls per year. So we can clap ourselves on the back for a policy which really has achieved a worthwhile result.

But, if that is true, how can it be that very similar sharp declines  starting around 2007 have happened in other countries, such as New Zealand and the US, which did not have any major policy change in this area.  And the decline in the UK started slightly before the change in health policy. It has been suggested that it has been the rise of facebook etc. that has led to a decline in sexual activity see Telegraph article , but survey data do not support this.

It is of course impossible to look back at history and be sure of the causes of such trends. It may simply be a case of pregnancy becoming less fashionable, as also seems to be true of heavy drinking among teenagers.

In Zambia, the situation is different. The nationally the rate is about 150 i.e. over 7 times the UK figure, and about 28% of girls will become pregnant before their 19th birthday. Pregnancy rate in Zambia

Near our clinic there is a secondary school.. Parents pay fees for their children to attend, and they need uniforms and books, and they cannot work, so we are talking about the upper socioeconomic levels of rural Zambian society.  And yet there have been a lot of pregnancies recently, and as a result the school decided that all 400 or so girls should have pregnancy tests! (Medical ethics are interpreted differently here).  7 of the girls tested positive, on top of those already found to be pregnant.

Just as in the UK, this will probably put an end to any prospect of further education for these girls. The girls will be out of school for a year or so with a huge effect on their eventual attainment.  

So why the difference?  The girls can attend the local health clinic for family planning. This is done at a specific clinic on a Monday.  At the clinic the staff say that there is free access to contraception with no questions asked: But that the pupils are put off coming by ‘stigma’.  Local charities would like to go into the schools and supply/push contraception, but this is strongly opposed by traditional Zambian society, which is dominated by Christianity.

Wednesday, 7 June 2017

Commute by bike to stay healthy - the Zambian way

The British Medical Journal published the findings of a huge research project last week comparing health outcomes for people in the UK who travel to work in different ways. They found that the 2% of people who regularly commuted by bike had a 40% lower death rate, a similar reduction in cancer deaths, and less than half the risk of dying of heart disease.  Regular walking commuters also had reduced risks of dying from heart disease.

Obviously some of this difference may be because the cyclists are healthier in the first place, but the differences are huge, and very statistically significant (i.e. very very unlikely to be a chance finding). So the potential benefit to the health of the UK from a large increase in ‘active’ commuting is massive. But how can this be done.

In rural Zambia, almost all journeys to work are on foot or by bike. The mass of cycling and walking commuters on the roads in the morning and evening would gladden the heart of any public health doctor.  If only the UK population would do the same. The difference is also very obvious when one looks at the muscles on display. The glutes, the six packs and particularly the back muscles of most Zambians would be the envy of many a pilates instructor.

So how have they managed to achieve this situation? And can we copy from them?

First of all they have very little alternative! There are a few cars that operate as taxis but they are unaffordable for the majority. Secondly, they have really taken on the bicycle in the last ten to fifteen years. They can buy cheap new bikes from china for $70 or so, and recycled bikes from the US and Europe for even less. They are used as much for transporting goods (especially huge bundles of firewood) as people.  The bicycle is ideal here as the terrain is pretty flat and paths between the tiny villages on the clay earth make an excellent flat surface.  There are also few people who live more than 10 km from their work.

So many of us cannot really follow their example.

Unfortunately it seems more likely that they are beginning to follow ours!

If you do have an office job in Zambia, or work for example as a safari guide, you will be sitting down most of the time, and there are very few opportunities to take recreational exercise unless you are young and fit enough to play for one of the many football teams. So economic development seems certain to worsen the outlook here for the ‘Diseases of affluence’, and we do often see slightly overweight office workers or housewives with pot bellies and diabetes and high BP.  And the toll from these diseases in terms of Strokes and Heart failure is bad now and certain to increase.

We have just finished “National Health Week” in Zambia. One of the daily messages sent out to everyone with a mobile phone last week was ‘Exercise 3-4 times a week to reduce your risk of Heart Disease and Diabetes.’  Pretty hard to understand if you are subsistence farmer! And hard to understand in a society where for most people physical exercise is work, and rest is physical rest.

So the image of happy cycle commuters is great, but we cannot learn from Zambia how to get there. They may learn from us about the dangers of a sedentary society, but it will be a hard lesson.

The positive images we can try to follow, are those of Amsterdam and Copenhagen, where bikes exceed cars for commuter journeys.  To get there we just need to invest massively in cycle infrastructure,  regulate or tax car commuting, and get employers onside in terms of secure bike parking etc.

Friday, 2 June 2017

The baffling shortage of doctors training to be GPs

After new doctors have finished their 2 year foundation programme, mainly in hospitals, they can apply for GP training which takes 3 years half of which is in relevant hospital departments, after which they are able to pick and choose where to work as a GP,  as there are a huge number of vacancies. Salaries are high and practices are begging to get new doctors to replace the many who are retiring. Earnings are as good as for NHS specialists, there is no out of hours or weekend work and there is a guaranteed job at the end of it, which there is not for other specialties. For example, there are many trained anaesthetists who cannot get jobs. And in order to qualify as a specialist, you have to do a minimum of 6-7 years training,  with a lot of on unsocial hours work.

And GPs can run their own practices, and are thus more independent of NHS managers, who blight the life of many specialists. So obviously, with more money, nice hours, a much shorter training, and the promise of being able to run their own show, young doctors are likely to prefer to train as a GP.

Except they are not!

GP training programmes are undersubscribed despite many areas resorting to golden hellos of £20,000!  And extra rounds of recruitment. And the GP registrars on training schemes are very often put off by their training and few of them opt for full time GP work at the end of their 3 year programme. So when there should be a glut of applicants for GP vacancies there is a dearth, and nowhere near enough to replace all the GP's who have had a bellyful and a good pension and are retiring.

The whole basis of the NHS is threatened by understaffed GP practices. The OECD gives the NHS a good rating overall, but bad marks for many aspects of specialist care. They say the best thing about the NHS is that patients have a ' medical home' which helps coordinate care and stops specialists advice conflicting with each other. This will be less effective with understaffed practices, nurse practitioners, temporary locum doctors and generally poor continuity of care.

So whose fault is this?, and how can it be sorted?

There are a few possibilities. Press coverage from the Daily Mail is unflattering to GP's image. The pressure of regulation from the General Medical Council and the Care Quality Commission are tiresome and a bit threatening. The 'dumping' of work by hospitals onto GP's is increasing  . The rapidly rising risk and cost of complaints and being sued is off putting. However the main issue putting young doctors off is, somewhat amazingly, the Royal College of GP's, the organisation that is supposed to be encouraging quality General Practice, and their senior members who run the GP training schemes in the various ' deaneries' around the country.

These doctors and their staff became used to having lots of good applicants over the years and failed to realise that they gradually made the training schemes worse and less attractive in many ways. They  made the training much more rigid, and stopped the practice of giving credit for relevant experience. Thus a doctor who has been training in Emergency medicine and wants to switch to GP now has to do  another spell of Emergency work. They have reduced the flexibility which used to allow trainees and trainers the chance of choosing each other. Now many areas allocate the trainees to practices by a method which seems neither fair nor transparent. They have allowed the service demands of hospitals to trump the learning needs of trainees so that they are forced to work more than their fair share of nights and weekends than specialty trainees. The training process has become an elaborate tick box exercise with some very poor quality educational sessions. As practices have got busier in recent years some are demanding more work from trainees and spending less time and effort on debriefing and educating them. And trainees are forced to sign up for college membership and have to pay over £1000 a go for an arduous exam which has a high failure rate, and which has been severely criticised for being unfair to ethnic minorities (and males!). Repeated failure is, as one would expect, catastrophic for a medical career and leaves doctors with almost no options.
In short the RCGP have blindly and bit by bit for various reasons succeeded in putting off many of  our best and brightest young doctors from the idea of General Practice. They need to stop blaming other people and sort it out.

Stimulation - achieving a balance

There is a lot of evidence that the epidemic of Attention Deficit Hyperactivity Disorder in the developed world is an increasing problem, and that it may be caused by overstimulation of children, especially by exposure to ‘rapidly paced television programmes’.  These children become impulsive, do poorly at school, and are later on they are far more likely to have car crashes, get divorced, and go to prison.

And all of us in the developed world are now bombarded with input from TV, emails, texts, and social media. We have to tune out deliberately in order to get on with anything!

This seems to be one problem that we do not have in rural Zambia.  Most children here have no TV, no computers, no toys, no bikes, no mobile phones, no books, and no electricity for reading even if they had something to read. They lack even simple footballs – so they have to make them out of bits of plastic and tape and plastic bags. So going for a walk or bike ride through a rural village means dealing with a crowd of kids all keen to hold your hand and walk along with you as you are probably the most novel and interesting event of their day.

So we need more footballs in Zambia, and less TV in the UK. But how?

Thursday, 18 May 2017

Peak 'Stuff'

Peak stuff  

Ikea has warned that in Europe we tend no longer to want to have more possessions, preferring to spend any spare cash on services and experiences. Services tend to be labour intensive and expensive in Europe, and with the oncoming demographic change in our society, this is likely to get worse.

We haven’t quite got to the same situation in Zambia. Here, ‘Stuff’ is highly prized and endlessly repaired, and imported goods that would be cheap by almost any standard are replaced by hand made craft produce that require many hours of patient labour. The population is growing and there are lots of young fit people who have no regular work.

Floor Mats are made from palm leaves that are divided into strips. Some of them are died black and then they are very skillfully folded into neat patterns. It takes a skilled man a day to make a mat, which he sells for about $2 US.  So his monthly income is $60 US! Bricks are made by finding the right sort of clay which is locally abundant, and pouring it into a mould and then firing the result in a brick oven using charcoal as a fuel.. Market gardeners cycle into market in the morning with huge home made baskets of vegetables on the back of the bike. There is lots of football played in the afternoons as it begins to cool down but the kid’s balls are home made from all sorts of stuff held together with sticky tape.

There are of course a few things that cannot easily be made by craftsmen. Shoes are important status symbols: none for the poor, flipflops for most, and the top layer of society ie teachers, nurses, safari guides etc have proper shoes, which are always smart.  Bicycles are used to transport goods and people. Commonly one sees huge bundles of firewood or a whole family on one bike. Dad rides with one child on the cross bar and wife and baby on the luggage carrier (yes South Luangwa is very flat!). Every 2 km or so along the roads is a cycle repair workshop, and they are always busy fixing the very cheap bikes ($70 US) that are imported from China. Mobile phones are an essential tool. They are all ‘pay as you go’  with vouchers costing as little as 10 cents. They do of course break regularly, and there is another whole industry with little booths selling airtime and spare parts and lots of young guys fixing them with primitive tools such as screwdrivers made from bicycle spokes. Plastic bowls for washing up and washing clothes, and metal saucepans for cooking are other essential imports.

The zietgiest that says that people’s time is cheap and that stuff is valuable has some unfortunate effects in the local health clinic, which has a tiny budget of $80 a month to spend on buying tools and equipment. This means that relatively well paid nurses (and volunteer doctors) spend time wandering around from room to room trying to locate rare items like a pair of scissors, or a weighing scales, or a thermometer, or a BP machine.

So we have something in abundance that they value and lack i.e. stuff, and they have something in abundance that we value and lack ie human labour. This is of course a classic economic example where trade could be of huge benefit to both parties. And to some extent this is what the hugely labour intensive safari holiday industry does, exchanging this labour for hard cash which Zambians use to buy more Stuff that they do really really need.  

The classic  trade would of course be agricultural produce from Africa to supply overcrowded Europe, but it is hampered by the tradition of small scale farming, ignorance, long supply lines, and tariffs and other restrictions.

We need some way of using African labour to meet our needs, and pay for it so that they can meet theirs.  Ideas are welcome!