Tuesday, April 26, 2022

War: The inhuman cost of medical progress

 

With Ukraine certainties are few.

A family flees a village in Mykolaiv district, Ukraine, 7 April. Photo: AAP.


We cannot predict how far the mass destruction will spread, nor for how long. We cannot confidently assess the chances of a diplomatic fix or even a nuclear escalation. 

Beyond the catastrophic effects of bombs and artillery on human life, this war will have an insidious impact on millions far from the battlefields. 

The shaky public health and clinical care systems in Ukraine, a country that struggled to prosper after the collapse of the Soviet Union, are now being crippled. 

Damage to surgical supplies, electricity, clean water, food, supplementary oxygen, medications, hospital records and IT systems has been so extensive that hospitals and clinics near the front lines have been abandoned, the staff relocated. 

The stress experienced by frontline medical and nursing staff is visible. We see the scenes of heroism, as doctors and health workers continue to care for the sick and injured in those underground shelters. 

Then comes the damage less easy to see — the effect of the sanctions and embargoes imposed on Vladimir Putin's regime.

As a war waged by alternative means, there is no question that they are designed as a response offering less carnage than the West’s direct military involvement. But they carry huge implications for ordinary Russians.


Read more: 


There is also the global issue of food. Across the Middle East and parts of Asia and Africa, some 800 million people depend heavily on Russian and Ukrainian wheat.

And you can throw in the other dynamics. Inflation, an economic illness afflicting those least able to adapt, is expected to spread rapidly in the coming months. 

But there has always been that dark truth when it comes to war. Medicine benefits as a by-product of its horrors. 

The familiar example that comes to mind is the rapid developments in plastic surgery after the First World War, much of it through Dr Harold Gillies, the New Zealand-born otolaryngologist, and his revolutionary use of tubed pedicled flaps.1

A paper published in the New England Journal of Medicine at the beginning of the COVID-19 pandemic, listed just a few other examples.2

The authors (both doctors) referred to George Washington who successfully inoculated his army against smallpox. This helped to demonstrate the value and efficacy of a public health intervention which can be marked as one of medicine's greatest achievements.

There was also the US army physician Dr Walter Reed who elucidated the epidemiology of typhoid and yellow fevers during the Spanish–American War.

Then comes penicillin, another medical wonder. Alexander Fleming’s chance discovery in 1928 that the mould penicillium appeared to kill bacteria was publicised around the world at the time, but then it lingered untapped for a decade. 

It was only in 1941 when the US government responded to the imploring of Oxford researchers Howard Florey and Norman Heatley about what this drug could do, and created a system to produce and deliver it in industrial quantities.

In their paper, the authors described this as an undertaking on the scale of the Manhattan Project.

They add “By D-Day in 1944, there was abundant penicillin for wounded soldiers, and by 1945, both service members overseas and civilians at home had ready access to the drug.

“The requisite scientists, laboratories, and production facilities would never have joined together in peacetime or through private industry alone.”

Other therapies, such as chloroquine and radioisotopes, have similar histories, they say.

The sudden acceleration of medical progress through war usually benefits most those of us who only experience conflict as distant history, read about rather than suffered.

I think of how many lives penicillin has saved — it runs to millions, of course.

But ultimately your heart can’t escape what war does to the individual life. 

The following comes from Sasha, a long-serving health worker with MSF.

He's talking about the Russian attack a few weeks ago on Mariupol, the city where he was born that has been so severely battered.3


Read more from Professor Stephen Leeder: 


“In the beginning, things almost seemed more or less normal, even though we knew that nothing really was normal anymore," he wrote on the MSF's website. 

“But then the bombings started and the world we had known existed no more. 

“Our lives became weaved between the bombs and missiles falling from the sky, destroying everything. We could think of nothing else, and we could feel nothing else. 

“The days of the week stopped to have any meaning, I couldn’t tell whether it was Friday or Saturday, it was all just one long nightmare. My sister tried to keep count of the days, but for me it was all a blur.

“In the first few days, we managed to donate some of MSF’s remaining medical supplies to an emergency department in Mariupol, but [then] the electricity and phone network went down.

“How can one describe one’s home becoming a place of terror? 

“There were new cemeteries all over town, in almost all neighbourhoods. Even in the little yard of the kindergarten near my house, where children should be playing. 

“Each day is like losing your whole life.”

I am grateful to Dr Peter Arnold, OAM, for his editorial assistance and suggestions.


References: 

1.       Cal West Med 1930; 1 May.

2.       N Engl J Med 2020; 29 Apr. 

3.       MSF: Ukraine: how long will this disaster continue?; 24 March 2022

 Published in the Medical Observer 7th April 2022

Should we reopen schools or not? It’s more complicated than that

The dozens of passionate comments left on the AusDoc website as to whether schools should open shortly reveal how difficult it is to make wise decisions in an emotionally fraught setting (as when the health of our children is at stake) without a solid base of facts.   


 

It is a terribly complicated matter, unlikely to be resolved painlessly.  

Children, parents, teachers, and workplaces will all be affected one way or another. What might be workable in one locality may not work in another – making a ‘one-size-fits-all’ solution an awkward fit.   

We know that COVID-19 thrives in areas of low-socioeconomic privilege, and we should attend especially to the needs of schools in poorer areas when considering closing them.   

The Australian Bureau of Statistics compared the distribution of deaths reported as due to COVID-19 up to the end of July 2021 in five equal groups, or quintiles, of the population according to socio-economic status. 

It found 155 deaths occurred among men in the least privileged quintile – compared with 43 among the most privileged. And 156 deaths occurred among least privileged women – compared with 40 among the most privileged.1  


So, I wonder if it might be possible to have different policies with regard to school opening for different localities depending on socioeconomic status?   

But hang on, let’s suppose we did make school closure or opening a local decision, what would follow?   

The decisions, if taken locally, would be fearsomely difficult to administer because of their sheer variety. They may overload the bureaucratic system and we have quite enough confusion as it is.  

The US has been criticised for taking this local approach with the choice to open left to 14,000 or so school districts.  

This had “splintered the conversation about school closures into thousands of noisy arguments”, according to The Economist in its 15 January edition.2  

If we closed schools in line with the death statistics just quoted, then those schools in poorer suburbs would be shut while those in the more affluent suburbs would be open.   


Read more: 


These latter schools may bear the hallmarks of privilege in other ways too including better building stock, less crowding, more health-literate parents, high rates of vaccination and with easy access to healthcare.   

In the poorer areas, if schools remained shut, who would look after the children and enable home learning? Probably parents or other carers who may really need to work to maintain the family income.   

The educational and social development impacts of school closures on the children would be greatest in the areas least able to compensate. Damned if you do and damned if you don’t.  

An international declaration advocating an approach to COVID-19 that favours herd immunity in concert with protection to the most vulnerable and signed in October 2020 by 916,000 epidemiologists and infectious disease specialists, has strong words about lockdowns.3   

“Keeping students out of school is a grave injustice,” the Great Barrington Declaration says.  


That was before Omicron. 

I’m afraid you run into some hard and uncomfortable truths here relating to health and social inequality.  

The significance of inequalities – which we always knew were reflected in health and disease differences – is revealed starkly in the death data related to COVID-19 just quoted. The well-known association of poverty with illness has been amplified greatly.   

It’s as though the virus has stimulated a ‘PCR’ or ‘polymerase chain reaction’ on a substrate of social gradients in health and disease. 

For the moment though – tough as it may seem to say it – we may be left to ‘muddle through’ with regard to school openings.   

If schools do open, so should the windows. If open spaces, indoor and outdoor, are available, use them.   

If the kids can tolerate masks, then they should be encouraged to wear them (I have a profoundly intellectually impaired grandson and he will never wear one).  

Highly effective masks for teachers and administrative staff should be readily available.   

If vaccines are available, let’s jab.   

COVID-19 is not over, and we should be prepared for more mutations and more anguish.   

In the process of that preparation, let’s refresh our thinking about the principles of good health promotion as the basis for effective prevention. 


In 1974, Marc Lalonde, the then Canadian Minister of National Health and Welfare, commissioned a report called A New Perspective on the Health of Canadians.4   It received international acclaim. It aimed to answer Lalonde’s question about why, with all the money Canadians spent on health, things weren’t better.  

At the time a vast amount of that money went into the hospital system, but as the report went on to show, many of the health problems Canadians experienced where potentially preventable if action was taken on the determinants of health way beyond medical care and hospitals.   

It offered the Health Field Concept as a basis. Take for example road deaths: lifestyle, environment and healthcare organisations contribute to traffic deaths in the proportions of something like 75%, 20% and 5% respectively, the report said. Yet this is not how Canadians (and us) had been splitting the money. 

If we adopt this approach to COVID-19, we will not only ensure that our hospitals can cope, but do more about the impact of poor lifestyle and environment on seriously affected communities.  

Schools in less privileged areas are more likely to be of poorer construction. Ventilation may be inadequate.

The prevalence of Omicron may be higher in the community and vaccination rates in the community lower.  

The communities have less reserve to cope with home schooling – think home computers and quiet spaces for students. These are all things that we can do something about! 


We need short-term solutions such as these to the vexed question of school opening, allowing space for different opinions because we don’t have the data to be definitive.  But it is surely better to do something beneficial than nothing. 

COVID-19 has torn into the most vulnerable of our communities in a shocking manner.  

We need to think beyond the current pandemic to the widening gap in health between the haves and have-nots in our society. 

It would be sad if we do not, as Australians, take this opportunity to consider what kind of humane society we want for our future in which we can all flourish – and invest accordingly. 


References: 

1.       The Australian Bureau of Statistics, COVID-19 Mortality, COVID-19 deaths that occurred by 31 July 2021

2.       The Economist, 15 January 2022 

3.       The Great Barrington Declaration, October 2020 

4.       A New Perspective on the Health of Canadians, 1974


Published in the Medical Observer, 19 January 2022