Elizabeth Blackwell Annual Public Lecture

Health in a Global World: my personal journey

Dame Parveen Kumar DBEProfessor of Medicine and Education Barts and The London School of Medicineand DentistryQueen Mary University of London

Introduction by

Professor John Iredale,Pro Vice-Chancellor for Health

Professor Rachael Gooberman-Hill, Director of the Elizabeth Blackwell Institute for Health Research

Housekeeping• Fire alarm: no test expected• Assembly point: between Wills Memorial

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upper balcony• Quiet room: room 1.5 opposite the Great

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light blue badges• Drinks Reception in Reception Room

Health in a Global World - a personal journey

Parveen J Kumar DBEProfessor of Medicine and Education

Physician and gastroenterologist

The 5th Annual Elizabeth Blackwell LectureOctober 22nd 2018

Elizabeth Blackwell

1821-1910

Bristol

Professor Ken Heaton

• Global health ....the stark facts

• Devastating effects of wars

• Women in a global context

• Climate change

• Doctors and society

Some unacceptable issues in GH

• 17 children <5 years old die every minute -70% of these are preventable

• MMR approaches 1000 per 100,000 in some LMICs

• 10 countries in Sub-Saharan Africa have <3 doctors per 100,000 population

• Government health spending in SE Asia 2.5% that in Europe

Sanitation and water ( world population)

• 1 in 5 defaecate in open

• 61% have some improved sanitation at home

• 13% live where water is collected from distant unprotected sources.

• Improved sanitation leads to less diarrhoeal disease by 32-37%

Mahatma Gandhi 1923:

‘Sanitation is more importance than independence’

Downloaded from: StudentConsult (on 25 October 2005 12:28 PM)

© 2005 Elsevier

Diarrhoea – 2.25m die yearly

Infectious diseasesMalnutrition/retarded growthPoverty and War

Save the children

SACORE

NHS Acute hospital Trust Board

Chair-Medicines Commission UK

NHS for 43yr

NICEEducational rolesU/G, Post Grad, CPD.Chaired committeesStarted MSc ingastroenterology

Global health

Research-small bowel

President

President

President

Vice -President

President

Roles that I have had the privilege to hold

Council. Trustee

Global health chapter

Teaching, examining (MBBS,MRCP, Local examinations) and lecturingSACORE, THET, Royal Society of Medicine – started Global health programme Merlin/Save the Children

RCP, RSM, BMATHET, SACOREClinical Medicine – used by most medical schools around the world ( Not USA)- Huge privilege of being invited

Teaching - Different culture, ways of teaching. Diseases -same but different in quantity ,

2016: A year of major crisis for Global Health

• Conflicts remain the biggest threat to human development– Biggest refugee crisis since WWII

• By late 2014, 60 million people forced to abandon homes

– Destruction of infrastructure

• Other challenges:– Big gaps between poor and rich , rural and urban areas

– Gender inequality persists

– Climate change and environmental degradation undermine progress achieved and poor people suffer the most

– Millions of poor people still live in poverty and hunger without access to basic services

Liberia

• Highest infant and maternal death rates

• 14 yr internal civil war

• Infra structure destroyed – roads, electricity, houses, food sources

• Killings, rape, mutilation, child soldiers –drugged, plunder

• People left devastated, demoralised,

• 40% malnutrition in children – in fertile land

• Female genital mutilation 70-85%

A fertile land ……yet malnutrition

……Local cultures, taboos

Cerebral malariaBurns ( open fires in huts)

Ante and post-natal wardHIV TB, diarrhoea, (tetanus)

Merlin run hospital in Buchanan

Empty dispensary ….but computer! Crowded wards – few facilities

• Hospital - 80+ patients (women, children, men) • 1 doctor• NO Xrays• Lab – Smear for malaria only• 3 treatments – analgesic, 1 antibiotic, anti-malariaWonderful committed medical, nursing and ancillary staff

Madam Ellen Sirleaf JohnsonPresident of Liberia

2011 Nobel Peace Prize

Leymah Gbowee of Liberia and Tawakel Karma of Yemen

Non-violent struggle for the safety of women and for women’s rights to full participation in peace-building work.

Pre-partition - Lahore India

Family history

Escaped in an army convoy

Partition

PARTITION 1947The very painful division – riots, migration, looting. Killing, bombing

Google images

Evacuated in an army convoy

The Family united in Nanking (now Nanjing), China

A lunch hosted by my parents at our home. Indian Ambassador, SirdarPannikar, is at the back (4th From left). Others are dignitaries from the UN and Government of China.

Chinese civil war 1927-37

1946-50Sino- Japanese war in between

Fled back to new INDIA- Lived in tents

Boarding school

The Lawrence School SanawarSimla Hills

School moto : Never give in

Travels of the family – Left India for the UK by boat (Batory)

Training doctors for the world

3 weeks on a ship

By air on a clipper

evacuated in an army convoy

New Young Doctors at Bart’s Hospital 1967

Women– in a global context

• Most important - for family survival

• If mother dies - child is unlikely to survive

• Educate women

• Raise their status in communities

• Simple healthcare/nutrition/cleanliness

.........however

Elizabeth Blackwell

“A blank wall of social and professional antagonism faces the woman physician that forms a situation of singular and painful loneliness, leaving her without support or professional counsel”

Every Minute...

Maternal Death Watch

• 380 women become pregnant

• 190 women face unplanned or unwanted pregnancy

• 40 women have an unsafe abortion

• 1 woman dies from a pregnancy-related complication

Courtesy of Prof LRegan

Levels of Maternal Mortality

Courtesy of Prof L.Regan

‘Women are not dying of diseases we cannot treat.

They are dying because societies have yet to decide that their lives are worth saving.’

Professor Mahmoud Fatallah

Elizabeth Blackwell

‘If society will not admit of woman's free

Development, then society must be remodeled’

Ethiopia

• 12 new medical schools with European curriculum

• Taught about modern medicine but ....no modern equipment/therapies

• Young leading with little experience of medicine

Ethiopia

Impossible decisionsNo imagingShot by husband …multiple fractures. Very poor prognosis.

Husband goes free.

Student ward roundAfrica ..but Western medical textbooks

From www.gajit.com

Global warming

64

36

20

80

Percentage change in yields to 2050

-50 -20 0 +20 +50 +100

UN Development Programme, 2009

Plus climate-related:• Flood/storm/fire damage• Droughts – range, severity• Pests (climate-sensitive)• Infectious diseases (ditto)

CLIMATE CHANGEPoor Countries Projected to Fare Worst

MODELLED CHANGES IN CEREAL GRAIN YIELDS TO 2050

The “Cuban paradox”The power of public health

How can a country in economic crisis for 20 years

• achieve first world health statistics?

• send >30,000 trained health professionals to poorer countries?

At 1959 revolution:• IMR 65/1000 live births, life expectancy 58 years• 50% of the 6,000 Cuban doctors fled the country

B. Sethia

Health inequalities stem from social inequalities

Where people are born, grow, live, work and age

• The poor tend to be unhealthy

• Significant social gradient in health

- the lower the persons social position

the worse his or her health

Best health + life expectancy in university educated

Michael Marmot

UK Marmot Review - Fair Society : Healthy Lives 2010

Lives on the Line

The Jugaard principle- frugal innovation

6 principles:

• Seek opportunity in adversity – use problems to create innovation

• Do more with less – be frugal

• Think and act flexibly- improvise, adapt

• Keep it simple- simple to make, use, repair

• Include the margin – use marginalised market

• Follow your heart- solve a problem

Learning from LMICs

Improving health and well-being at lower cost

• Technology

• Innovation

• THINKING DIFFERENTLY

– Task shifting

Google picture

MEDICINEAND THE

MEDICAL PROFESSION TODAY

A ‘changing’ profession

The doctor and his patientCompassion, empathy, altruism

Advanced technology +

Patient involvement

Pool of Bethesda Barts Great Hall William Hogarth 1697-1764

Lancet 1999

‘Medicine used to be simple, ineffective and relatively safe. It is now complex, effective and potentially dangerous’

Doctors have a greater capacity to do good

but .....their capacity to do harm is greater than ever

Sir Cyril Chandler - Editorial

Number of Doctors, Nurses and Midwives per 10 million population (WHO data)

Crisp N, Chen L NEJM 2014; 370: 950-7

Summary

• Human rights for all

• The devastation of wars and conflict

• Educate women – best for survival of the family

• Innovate. Think of simple ways of doing things –Jugaard

• Medicine is getting complicated but a lot can be done in low income countries with collaborationbetween countries

Books for backgroundGlobal Health: bringing new thinking

to the NHS

2007 2010 Lord Nigel Crisp

Written by 127 medicalstudents from

all around the word.

Proceeds to Global health Student projects

Never give up!

• ‘Courage is going from failure to failure without losing enthusiasm ‘

Winston Churchill

Final remarks by

Professor Rachael Gooberman-Hill, Director of the Elizabeth Blackwell Institute for Health Research

Thank you for attending

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