IHHR 2 - February 2018

Biomedicine for the 21st Century The claims made for seemingly outlandish remedies

Q&A: Daniel Shaw, GCR Making guesswork a thing of the past

Destination spotlight Small but mighty: Costa Rica as a destination for medical treatment

Issue 2 ¡ February 2018

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6-9. News

16. Stopping the stigma How employers are working together to overcome stigma and tackle mental illness in the workplace

28. Biomedicine for the 21st Century The claims made for seemingly outlandish remedies

20. Redressing the balance How much gender bias is there in healthcare?

32. Q&A: Daniel Shaw, GCR

10. Searching for a cure

Making guesswork a thing of the past

The need to move away from prescribing antibiotics for traveller’s tummy

24. ProďŹ le: Unravelling global healthcare 12. Brexit: healthcare losses and gains

Suzanne Garber dreams of a healthcare system that provides full transparency

34. Destination spotlight Small but mighty: Costa Rica as a destination for medical treatment

How will doctors and nurses leaving the UK help hospitals elsewhere in Europe?

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NEWS

What do maggots, leeches and spiders have in common?

Well, in addition to likely not being top of the majority of people’s ’most desired pets’ list, these creatures have been used in medicine since ancient times, with today’s medical researchers finding new applications for creepy crawlies. Read more in our

life-saving CPR than women. We delve headfirst into these issues. Brace yourselves!

Also in this issue, Suzanne Garber discusses her documentary GAUZE: Unravelling Global Healthcare and reveals how her own experience of becoming ill abroad led her to found a company of the same name, and Daniel Shaw outlines how GCR is striving to make the guesswork that faces patients looking for medical care a thing of the past.

There’s a few more gems in here, but I wouldn’t want to ruin the surprise! So, enjoy the second issue of IHHR2 and feel free to contact me with any ideas or if you would like to feature in a forthcoming issue – it

even though 70 per cent of employees have experienced conditions related to mental health, fewer than one in ten would confide in their employer if they were suffering from mental health problems

Editor-in-chief: Ian Cameron Editor: Lauren Haigh Sub-editors: Mandy Langfield, Stefan Mohamed, Christian Northwood, Sarah Watson Advertising sales: James Miller, Mike Forster Design: Katie Mitchell, Steve Mundey, Will McClelland Finance: Elspeth Reid, Alex Rogers, Kirstin Reid

Contact: Editorial: editorial@ihhr.global +44 (0)117 922 6600 ext. 3 Advertising: sales@ihhr.global tel: +44 (0)117 922 6600 ext. 1 Subscriptions: subscriptions@voyageur.co.uk

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would be fantastic to hear from you!

Goodbye for now and, of course, stay well!

‘Biomedicine for the 21st Century’ feature, if you dare!

We also present features on two enduringly topical issues – mental health stigma and gender bias in healthcare. Shockingly, even though 70 per cent of employees have experienced conditions related to mental health, fewer than one in ten would confide in their employer if they were suffering from mental health problems, and – unbelievably – 15 per cent feared dismissal, disciplinary action or demotion if they did so. Regarding gender bias, meanwhile, recent research found that men were more likely to receive

Lauren Haigh Editor editor@ihhr.global

Online: www.ihhr.global, @IHHRonline

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INTERNATIONAL HOSPITALS & HEALTHCARE REVIEW ISSN 2515-7981 (PRINT) ISSN 2515-799X (ONLINE) ISSUE 2

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NEWS

Breakthroughs over the rainbow Private operational investment company Rainbow Medical, which seeds and grows start-up companies developing breakthrough medical devices, has announced the results of a new study that tests the company’s device for the management of overactive bladder (OAB) complaints. Around 66 million people in the European Union and 43 million in the US suffer from OAB. OPTIMIST is a multi-center prospective study that tested BlueWind’s innovative leadless, miniature implantable Tibial Nerve Neuromodulation System. The study was conducted in four prominent clinical centers in the UK and the Netherlands and involved 36 patients with OAB who were followed for six months to evaluate the long-term performance and safety of the new device.

The results, which were published in the Neuromodulation and Urodynamics journal, showed that the device has a low-risk safety profile and may be considered an effective treatment option for OAB management.

Seventy-one per cent of the 34 patients who completed the study experienced at least a 50-per-cent reduction in OAB symptoms after six months. The study also found that the device improved all quality of life aspects of the patients,

including coping with symptoms, symptom concern, sleep disturbances and problems with social interactions.

“The results of the trial prove once again that BlueWind’s miniature implant is a breakthrough in the medical world and could lead many patients suffering from the side effects of the old technology to a different, safer and more accessible reality,” said Yossi Gross, inventor of the BlueWind technology and Founder of Rainbow Medical investment group.

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Intermountain Healthcare is collaborating with Ascension, SSM Health and Trinity Health, in consultation with the US Department of Veterans Affairs, to form a new, not-for-profit generic drug company.

The idea behind the company is to make essential generic medications more available and more affordable, bringing healthy competition to the market for generic drugs.

“Healthcare systems are in the best position to fix the problems in the generic drug market,” commented Dr Marc Harrison, President and CEO of Intermountain Healthcare. “We witness, on a daily basis, how shortages of essential generic medications or egregious cost increases for those same drugs affect our patients. We are confident we can improve the situation for our patients by bringing much needed competition to the generic drug market.”

Cardiovascular congratulations

The growing ART of reproduction in the US A new study conducted by the Georgia Institute of Technology, US and the US Centers for Disease Control and Prevention (CDC) has found that international patients are increasingly seeking in vitro fertilisation treatment in the US. The study analysed more than 1.2 million assisted reproductive technology (ART) cycles that were submitted to the National ART Surveillance System (NASS) – the federally mandated reporting system that collects ART procedure information under the Fertility Clinic Success Rate and Certification Act of 1992 – from 2006 to 2013. It found that, during this period, the number of nonUS residents receiving ART treatment in the country more than doubled, from 1.2 per cent of the total number of cases to 2.8 per cent.

“While the number of cycles is relatively small, it is definitely growing,” said Georgia Tech’s Aaron Levine, the Associate Professor in the School of Public Policy who led the study. “Non-US residents are increasingly coming here for specialised ART treatments that may not be available in their home countries. And they’re using these techniques at greater rates than Americans.”

Patients from 147 countries were found to have received care in the US,

Bringing competition to the generic drug market

with the largest number coming from Canada, the second largest from Mexico, the third largest from the UK, and the fourth largest from Japan. Levine asserted that although the numbers are small, they are certainly not trivial, and explained that data has been limited and cross-border reproductive care hasn’t been well studied in the past.

“Our results highlight real challenges for patients to access this important medical care,” he said.

“Understanding these challenges is critical to improving access to ART today and to helping ensure patients who travel across borders to receive ART treatment receive high-quality care.”

Texas, US-based medical device company Saranas has announced that it has been named as one of the top four innovators at the recent International Conference for Innovations in Cardiovascular Systems (ICI) in Tel Aviv, Israel.

The award is one of the most significant and prestigious awards for medical intervention startups worldwide and the competition is an integral part of the conference, which attracts more than 1,800 attendees, including scientists, entrepreneurs, investors, medical device and pharmaceutical executives, and medical professionals specialising in cardiovascular interventions. “We are very pleased and humbled to be recognised by this international conference as one of the four top cardiovascular innovators,” said Saranas President and CEO Zaffer Syed. “It is further validation that our Early Bird Bleed Monitoring System can have an important impact on healthcare costs and reduce the risk of death in patients undergoing endovascular procedures. This recognition from ICI provides substantiation that our innovative technology is disruptive and important for patients.”

The Early Bird Bleed Monitoring System includes a vascular access sheath with embedded sensors that are designed to detect and monitor bleeding from a blood vessel accidentally injured during endovascular procedures. It was invented at the Texas Heart Institute. “Our Early Bird system is designed to protect and, in some cases, save the lives of patients undergoing an endovascular procedure by letting doctors detect the onset of bleeding early and take appropriate steps to address the bleed and allow the procedure to continue,” commented Saranas CMO Dr Philippe Genereux.

NEWS

Developing health provisions outside of the US CoinMD, Inc., a private membership network designed to make healthcare more affordable, has expanded the services available on its network to include healthcare providers outside of the

US. With the US domestic cost of healthcare at an all-time high, the company is targeting medical tourism.

Company CEO Thomas McMurrain said that domestic healthcare costs will continue to rise at a steady rate for the foreseeable future, and that this will create a healthcare crisis that excludes the majority of Americans from being able to afford life-saving treatment.

In the CoinMD second whitepaper, entitled How the Network Benefits Consumers and Health Providers, the company’s leadership describes exactly why the platform benefits medical tourists.

This is primarily by allowing patients to bring their own medical data with them, giving low-cost foreign healthcare professionals access to medical records they would otherwise be unable to use

when delivering care.

“Different doctors reach conflicting conclusions from lab tests, or order duplicate tests,” said McMurrain. “Different doctors give contradictory clinical advice. Unknown to one another, they prescribe drugs that create adverse reactions. By giving patients their own medical data, we can finally empower people to make the best choices concerning their medical needs.”

The belief is that current legislation fails to describe a framework through which blockchain technology could reach its full potential as a secure, private transaction tool for medical procedures and treatments. However, nations that have developed medical tourism industries offer fewer obstacles to the implementation of innovative healthcare record technology.

help Children’s continue to transform paediatric healthcare by leading in providing innovative, quality care. The partnership will help us deliver on our commitment to improve the life of every child

by providing our staff with the clinical support tools and training that can drive a consistent patient experience, improve workflow throughout our network and help improve patient outcomes.”

Driving innovation Health technology company Royal Philips and Children’s Hospital and Medical Center of Omaha have announced a 10-year strategic partnership that will help drive innovation in paediatric care.

The partnership will seek to identify opportunities to help enhance the quality and cost effectiveness of patient services – for example, exploring connected solutions in diagnostic imaging, patient monitoring, respiratory solutions and clinical informatics.

Children’s Hospital and Medical Center will aim to standardise care across departments using Philips’ technologies, with a view to enhancing patient and employee experience across the organisation. The collaboration will work to develop a technology plan intended to provide business stability and predictability.

“As the only full-service paediatric specialty healthcare centre in Nebraska, we know that families from across the region are putting their trust in us,” said Dr Richard G Azizkhan, President and CEO of Children’s Hospital and Medical Center. “Partnering with Philips will

Cannabis-friendly travel options Cannabis-friendly travel company CANRVE provides safe travel options for registered medical marijuana patients in the US and beyond.

Recent changes in legality in the US and Canada have created a gap in the marketplace for those who rely on medical marijuana, and others who use cannabis recreationally. Although the use of cannabis has been partially legalised, it’s not allowed in public spaces, and most traditional hotels enforce a zero-tolerance policy.

CANVRE offers private home rentals,

a dispensary and marijuana medical doctor location guide, local lifestyle activities, events and private cannabis chef services. “We are passionate about the rights of the travelling cannabis community, as well as scientific developments in the medical marijuana sector, and are donating two per cent of sales proceeds to cannabis research,” said CEO and founder Orbin Johnson.

The company is currently in negotiations with selected hotels ready to welcome cannabis users.

It offers listings in the nine US states that have legalised medical and recreational use, as well as Canada, and plans to launch options in Jamaica soon.

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NEWS Expanding clinical care The University of Kentucky (UK) Markey Cancer Center in the US has unveiled a new inpatient floor on the 11th floor of the Albert B Chandler Hospital Pavilion A. The floor has a unit in each tower, with Tower 100 housing the James and Gay Hardymon Patient Care Unit, a 31-bed unit for medical and surgical oncology patients, while Tower 200 houses the Darley Blood and Marrow Transplantation Unit, a 32-bed unit for bone marrow transplant and blood cancer patients. Between these two units, eight new cancer inpatient beds have been added.

“For more than 30 years, Markey has been providing exceptional cancer care to the citizens of Kentucky, and our patient volume has increased dramatically in the past several years,” said Dr Mark Evers, Director of the UK Markey Cancer Center. “This is the first time we’ve been able to expand clinical care into new space. We are thrilled

to open up this state-of-the-art facility for our inpatients, which has been specifically designed to

Building a world-class medical information company Provider of personalised, clinically actionable medical informatics and telemedicine Aeon Global Health has announced the appointment of Dr Armando Moncada to the position of CMO of its Anatomic Pathology business line.

Dr Moncada has expertise in the fields of gynaecologic, breast, and head and neck pathology and cytopathology, as well as in molecular pathology and oropharyngeal and cervical cancer genomics. He has been working in pathology for 20 years and has served as CMO of PCG Molecular for the past decade.

“It is with great pleasure that we welcome Dr Moncada to our leadership team,” said Sonny Roshan, Chairman and CEO of Aeon Global Health. “He has built an impressive reputation for his work in actionable molecular and genetic information related to an individual’s risk for developing cancer. We are confident that this will serve Aeon well as we continue to build a worldclass medical information company.”

Accelerating clinical research Tartu University Hospital, an eHealth pioneer and the only university hospital in Estonia, has joined the network of hospitals on Clinerion’s PRS platform, which accelerates clinical research by improving the efficiency and effectiveness of trial recruitment.

The hospital is the pioneer of eHealth in Estonia, with 80 per cent of its medical data communication being digital. It currently runs 30-40 trials each year, and by joining the PRS platform, the hospital’s clinical trials facilities will be exposed to a wide range of global clinical trials run by Clinerion’s clients, international pharmaceutical companies and contract research organisations.

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“Co-operation with Clinerion will make our immense trial capabilities and expertise more visible and accessible internationally. It will certainly bring Tartu more trials at the cutting edge of medical innovation,” said Margus Ulst, CMO of Tartu University Hospital. “With our partnership, we also hope to improve our data quality and harmonise our coding practices to international standards.”

cater to the needs of our patients and staff alike.”

The new floor was designed with functionality in mind, as well as to facilitate a multidisciplinary approach to care.

Markey’s nursing staff gave input on the layout of the floor, based on their personal experiences and feedback from patients. “Our nurses are with these patients 24 hours a day, so they truly are the backbone of inpatient care,” said Colleen Swartz, Chief Nurse Executive and Chief Administrative Officer of UK HealthCare, which represents the hospitals and clinics of the University of Kentucky. “Their recommendations for the creation of this floor were invaluable and have allowed us to make Markey’s already stellar quality of care even more patient- and family-centred.”

NEWS

Wellness directory

Treating infections without antibiotics

Payment platform for travel organisers WeTravel has launched a free, public directory of thousands of wellness centres worldwide called RetreatCenterDirectory.com. Each listing has a detailed description, photos and contact information.

The directory was launched in response to the increasing popularity of, and demand for, wellness tourism. Indeed, the Global Wellness Institute estimates that wellness tourism is expected to grow annually by 7.5 per cent, compared to the 3.4-per-cent annual growth rate of conventional tourism. WeTravel compiled data on thousands of retreat centres worldwide and has made this information accessible all in one place, in the form of a searchable directory.

“A lot of people within the wellness community want to organise retreats for their clients and they turn to WeTravel to handle payments. However, one major part of planning a retreat is finding the right location. This public directory will make finding the perfect location quicker and easier,” said Johannes Koeppel, CEO and Co-Founder of WeTravel.

R&D entity Global Health Solutions, LLC, which focuses on novel, best in class products for infection control, skin, and wound care, is working towards developing a non-antibiotic solution for superficial skin infection.

Hexagen Wound Dressing, the company’s lead advanced wound care product, is a topical formula that is used nationwide to assist with healing in acute and chronic wounds. However, this product doesn’t address the needs of patients with infected wounds. To do so, the company is expanding its drug development programme to include a superficial infection treatment candidate that is based on the same technology that underlies Hexagen Wound Dressing.

“Standard of care, [and] topical treatments for skin-based infection have seen little to no innovation in the past half-century. Yet, over this same period of time, we have seen a dramatic rise in the number of antimicrobial resistant organisms and resulting disease states,” said Global Health Solutions founder and CEO Bradley Burnam.

“Our non-antibiotic new drug candidate is gentle, powerful, and has shown no signs of resistance among even the most virulent pathogens. We look forward to working closely with the FDA to bring

New partnership facilitates clinical trials

In partnership with Provisio Inc, which was founded to address the continuing problem of finding qualified patients and investigators for clinical trials, Clinerion, which enables early patient access to innovative treatments, has expanded the coverage of its services in the Americas, adding 60 million patients in North America.

Over the past year, Clinerion’s coverage has expanded across Europe, Asia and South America, and with Provisio’s 60 million patients in the US, the new partnership extends Clinerion’s coverage in the Americas.

The partnership expects to enable hospitals, hospital clusters and trial sites in the US to gain exposure to the international clinical trials that are run by Clinerion’s clients. “Provisio is pleased to gain access to Clinerion’s broad data footprint outside the US,” said Mike Hassell, CEO of Provisio.

Ulf Claesson, CEO of Clinerion, said that the company is thrilled to have Provisio as its partner in the US: “Not only do they provide us with the means to expand our service offering to the important US market, but they will become a key local resource in the US for Clinerion. This is the next step for Clinerion in the Americas.”

this important product to fruition.”

CMO Dr Neil Ghodadra said that the growing number of antibiotic resistant organisms is alarming and presents daunting clinical implications: “Doctors need viable, alternative treatment options for acute and chronic superficial infections, especially those colonised by drug resistant microbes. This is an important product not just for physicians, but for patients who may become victims of pathogens for which we lack sufficient tools to address.”

New clinical care guidelines for mitochondrial disease management New clinical care guidelines have been issued for patients with mitochondrial disease. They are expected to help manage and care for these patients.

The disease is caused by defects in genes that affect the function of mitochondria, and can affect nearly every organ in the body. However, as Dr Amy Goldstein, clinical director of the Mitochondrial Medicine Frontier Program at Children’s Hospital of Philadelphia (CHOP) and president of the Mitochondrial Medicine Society (MMS), highlights, standards of care are not uniform across centres or clinicians: “To take just one example, clinicians need to know how often to order laboratory tests to monitor the health of patients with mitochondrial disease.

Our guidelines reflect expert consensus based on our current knowledge of mitochondrial medicine.”

In creating the guidelines, MMS appointed an international panel of 35 mitochondrial medicine specialists to review current knowledge and develop recommendations.

These recommendations address a range of medical

specialities, including cardiology, neurology, critical care medicine, nephrology, endocrinology, audiology and ophthalmology. The guidelines also address special issues encountered by patients during pregnancy and high-altitude travel and compile a list of medications, such as statins and acetaminophen, that must be used with caution or avoided in patients with mitochondrial disease.

The guidelines are the first set of published recommendations for patient management and clinical care decisions and the authors recognise that the guidelines will need to be updated in line with the evolution of mitochondrial medicine.

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FEATURE

Looking into the issue of traveller’s tummy, Anthony Harrington highlights the need to move away from the knee-jerk prescription of antibiotics So-called ‘traveller’s tummy’, or galloping diarrhoea, afflicts as many as half of those who travel to foreign parts. While this statistic is worrisome enough, it masks an even deeper issue, which is that doctors, in developing countries particularly, are very prone to reaching for antibiotics as their first port of call to treat any foreigner who turns up in their surgery with traveller’s tummy.

The problem with this is that the world is finding that antibiotics have been prescribed so freely to both humans and livestock, for a whole range of conditions, that we are in danger of finding ourselves with none, or very few, effective antibiotics in the very near future.

A world without antibiotics would also be a world where no one would dare to do bowel surgery, and transplants of all kinds would be impossible.

There is also the not-altogether irrelevant fact that

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antibiotics are not particularly useful if the cause of the diarrhoea is viral or fungal, rather than down to bacteria. Antibiotics have no efficacy in the case of viral infections, unless the virus has weakened the individual’s resistance to the point where a bacterial infection has also developed.

So, as Professor Colin Garner, Chief Executive of the charity Antibiotic Research UK notes, the fact that antibiotics are routinely prescribed for cases of traveller’s tummy in China, for example, is seriously

An age-old problem The project, which Dr Brown is in the process of seeking to put through a pilot human trial in China, involves an innovative cure based on three cheap and easy-to-obtain ingredients. These three ingredients, says Dr Brown, work together to boost the human immune system in a way that none of the three can singularly achieve. The result, he hopes, will be a very fast acting cure for traveller’s tummy that does not rely on antibiotics.

What is common to all forms of severe diarrhoea … is the speed with which sufferers can become dehydrated, which poses its own dangers worrying. Antibiotic Research UK recently teamed up with Dr David Brown, the Co- Inventor of Viagra and a prolific and enthusiastic seeker of new drugs and non-microbial cures, in order to support his latest project, which aims to provide a nonantibiotic cure for traveller’s tummy.

But first, it is worth considering the scale of the challenge that diarrhoea poses to the medical profession. As Professor Garner notes, and as we have already highlighted, diarrhoea is multifactorial as far as its causes are concerned. It can be caused by bacteria, by a reaction to unfamiliar

FEATURE spices and foods, or the cause can be viral or even fungal. What is common to all forms of severe diarrhoea, however, is the speed with which sufferers can become dehydrated, which poses its own dangers.

“This is an age-old problem and a lot of work has been done on it over the years, but it still causes illness, and in extreme cases, death,” said Professor Garner. “The treatment for diarrhoea in children is pretty well known, and consists of fluids and salt.

That tends to be a very effective treatment and is usually administered intravenously.”

However, Professor Garner pointed out that diarrhoea continues to cause an unacceptably large number of deaths in children in developing countries. According to the World Health Organization (WHO), in 2015 nearly nine million children under the age of five died in developing countries, with diarrhoea being second only to pneumonia as the major cause of these deaths.

Tackling the underlying infection Today, perhaps the most frequently used nonantibiotic drug used to combat diarrhoea is Imodium, which has Loperamide as its active ingredient. It should be stressed that Loperamide does not cure diarrhoea, so much as alleviate the symptoms. What happens with diarrhoea, when the small and/or large intestine becomes irritated by whatever agent caused the diarrhoea, is that its squeezing action, which moves faecal matter and liquid through the gut, speeds up. This leaves little time for fluids and electrolytes to be absorbed by the small and large intestine, leading to runny stools and fluid and salt loss, as well as heightening the potential for abdominal cramps. Loperamide calms the gut and slows down digestion, reducing its activity and giving more time for fluids to be

wrong, and some microorganisms can pull a jujitsu stunt on it and turn its strengths against it,” said Brown. This is what happens in part in diarrhoea. In a normal immune response, the system triggers an inflammatory reaction which acts as a call to battle for the killer cells produced by the immune system, and they clean out the troublesome bacteria.

However, with severe diarrhoea, the inflammation of the small and large intestines goes beyond what is required to trigger a reaction from the killer cells and becomes a major problem in its own right.

The system keeps using more and more of the body’s fluids to try to flush out the problem and the intestines become over-active. The real danger then is that lesions develop somewhere in the gut or colon and bacteria enter the bloodstream, causing septic shock, with potentially fatal consequences.

Dr Brown’s idea is to find relatively benign ways of boosting the immune system so that it can do its job. What he wants to do, he points out, has a parallel with the latest treatments for cancer.

“In cancer treatments, there is a transformation happening today. The focus is on using drugs that boost the immune system, as opposed to the traditional approach where drugs were used that killed everything, but hopefully killed the cancer cells first, since cancer cells are the most active and the fastest growing, hence react quicker to the poison.”

An innovative idea Dr Brown originally specialised in the cardiovascular field and in drug development.

Three of his drug inventions are on the market today. He switched into the bacterial field about a decade ago when doing work with the Gates Foundation. “The Foundation funded a study that

In 2015, nearly nine million children under the age of five die annually in developing countries, with diarrhoea being second only to pneumonia as the major cause of these deaths absorbed, resulting in firmer stools.

This can bring rapid relief to an upset stomach, but it may not cure the underlying infection and if the immune system cannot deal with the underlying infection, the condition can worsen to the point where Loperamide fails to be effective.

Dr Brown has a different approach. “The first thing to be said is that diarrhoea works on the immune system. We have two immune systems, the innate and the adaptive,” he said.

The innate immune system is the body’s first line of defence. It covers all the surface areas, including internal surface areas, which means the skin, the nose, eyes, lungs and intestines – wherever the body first comes into contact with micro-organisms. “The innate immune system is very powerful, but occasionally it goes

aimed to reduce baby and child deaths, and that made me aware of the high infant mortality figures from diarrhoea in developing countries. That inspired me to work in this field and traveller’s tummy is such a perennial and persistent problem for everyone who either has to go, or chooses to go, to foreign parts, that it was clearly the area to focus on,” he said.

The problem became a personal one for him when he started making annual trips to Tibet. “My wife and I travelled there in 2005 and we visited an orphanage there and fell in love with it. We now go there every year for two or three weeks at a time, to provide medical services to the orphanage and to the local community. The challenge, however, is that the orphanage is situated on a mountainside at 10,000 feet above sea level. It

is bitterly cold for 19 hours a day and you catch infections there very easily, usually lung infections or diarrhoea, so the routine response is to prescribe antibiotics,” he recalled.

Already in South India and Tibet, the overprescription of antibiotics has led to a very high degree of resistance to most antibiotics. “So many of our antibiotics there have a very poor chance of working, and this also held true for the antibiotics I was taking with me on the trip. I was writing up my thinking on antibiotics at the time and the problem was really scary,” he said. “WHO had produced its report on antibiotic resistance in so many microorganisms and it was clear that over prescription was a real problem.”

Dr Brown was doing his evening meditation when suddenly the idea of combining three common ingredients as a cure for diarrhoea came to him. “The idea came fully formed and from my scientific knowledge and knowledge of the immune system, I was convinced it could work,” he said.

In the time old tradition of medicine, Dr Brown’s first human subject was himself. “On my next trip to Tibet, a month later, I again had diarrhoea and painful stomach cramps. I had brought the mixture with me and within twenty minutes of my taking it, I felt fine. The stomach cramps had gone and that was the end of the diarrhoea too.”

Promoting understanding Dr Brown was Chair of Antibiotic Research UK’s Science Committee and a trustee when he explained his diarrhoea idea to the charity and Professor Garner as CEO. The two then had a meeting in March 2017 organised by the charity with the UK Chief Medical Officer, Dame Sally Davies, who is well known for her work aimed at preventing the indiscriminate use of antibiotics around the world. Dame Sally Davies put them in touch with Professor Paul Little of Southampton University, who has contacts in Hong Kong who specialise in arranging human clinical trials.

“We are now in the process of setting up a pilot human trial. I cannot release any information about the ingredients and their combination, since one of the criteria for a blind trial is that neither the prescribing physician nor the patient knows what is being administered,” Brown explained.

“This is essential since if the cure was widely covered in the press, the placebo group being used for comparative purposes could go and buy the ingredients themselves and dose themselves, rendering the study invalid.”

Dr Brown is also about to launch a website on sepsis to try to promote understanding of the fact that bacterial infections of all sorts are best treated in a more holistic way. “We need to address both the bacteria and the individual immune system, to help antibiotics be more effective in saving lives, just as we now do in cancer therapy. We are still in the Dark Ages as far as our understanding of septic shock is concerned and it can be a real killer with diarrhoea as well. So it is very much a continuation of my interest in finding a cure for traveller’s tummy,” he concluded. l

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FEATURE

Tens of thousands of doctors and nurses working in the UK are likely to leave the country as a result of the UK’s decision to part way with the EU, crippling the NHS. Robin Gauldie reports, exploring how this could help hospitals elsewhere in the Europe More than any other slogan, the ‘Vote Leave’ campaign’s promise of £350 million per week of extra funding for the UK’s cash-starved National Health Service (NHS) helped persuade Britons to vote for Brexit. With little more than a year to go before Britain finally quits the European Union (EU), there is no indication that promise will be kept.

Instead, UK chancellor Philip Hammond’s November budget pledged, not £350 million per week, but £350 million for the whole of winter 2017-18 – part of a £2.8-billion increase for the NHS to be spread over the next three years.

Critics say that is not enough. Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the UK healthcare system, says the provision ‘falls well short of what is needed to relieve the massive pressures facing the NHS’. “Over the years the NHS has required increases of around four per cent above inflation to deal with demand and maintain services. What the government is promising for next year represents around 1.4 per cent, plus whatever is allocated to cover the lift in the pay cap.”

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The NHS, which is already short of staff after a decade of cuts and ‘austerity measures’, could lose more than 40,000 nurses and other medical staff as a result of the UK’s departure from the EU, according to a document leaked from the UK’s Department of Health. Around 12,000 doctors and 20,000 nurses and midwives working for the NHS come from EU countries, and a question mark hangs over their continued right to live and work in the UK after Brexit. Many intend to leave Britain, or have already left. According to official figures, around 10,000 EU workers left the

(RCN), which represents nurses in the UK, said the government has offered ‘no security or reassurance’ that EU staffers working in the NHS will be able to keep their jobs. “Few are able to live with such uncertainty,” said Janet Davies, chief executive and general secretary of the RCN. The UK’s impending separation from the EU makes the recruitment problem worse, according to Frances O’Grady, general secretary of the British Trades Union Congress (TUC), and it is uncertainty over their future in Britain, not just low pay, that is discouraging EU medical staff from

Germany needs about 100,000 additional nurses in the next few years, but English-speaking nurses still face obstacles to working in Germany, because of the language requirements.

NHS between the Brexit referendum and mid2017. Those who might have replaced them are increasingly reluctant to move to Britain.

A climate of uncertainty In March 2017, British newspaper The Guardian reported that the number of EU nurses registering to work in England had dropped by 92 per cent since the Brexit vote. At the same time, the number leaving the NHS had risen by 68 per cent, the newspaper said, citing information compiled from NHS sources. The Royal College of Nursing

seeking employment in the NHS. “We’ve already seen nursing applications from EU nationals fall off a cliff,” said O’Grady, writing in The Guardian.

The British Government is under increasing pressure, both from within the UK and from EU Brexit negotiators, to guarantee that EU nationals who already live and work in Britain will be able to continue doing so. Prime minister Theresa May and her foreign secretary, Boris Johnson, have both made reassuring noises, but there are fears that such promises will be meaningless if Britain leaves the EU without an agreement on trade and other issues

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– the so called ‘hard Brexit’, which to many seems increasingly likely. But even if an agreement is reached that embodies such guarantees, Britain has become a less attractive place for medical staff to live and work, and the staffing drain will continue.

Limits on pay increases since 2010 mean NHS nurses earn £2,000 a year less, in real terms, than before the recession, making it difficult for hospitals to retain staff or recruit replacements. In October, Philip Hammond lifted the longstanding one-per-cent cap on pay increases. Whether that will translate into real rises that make up for eight years of stagnation is uncertain.

There is also plenty of credible, anecdotal evidence that EU nationals working in the UK no longer feel welcome in Britain and fear being treated as second class citizens. Not only EU workers are affected. The mood of xenophobia whipped up by less scrupulous elements of the ‘Leave’ campaign and media has resulted in an upsurge of ‘hate crimes’ against non-white Britons and immigrants from Asia and Africa. That mood may also make it harder for British hospitals to attract staff from Commonwealth countries – traditionally a major recruiting ground – to replace departing EU employees. Nursing staff from poorer Commonwealth nations will likely still be attracted to the UK by the prospect of relatively high wages. In the UK, a nurse earns on average £23,519 (€26,632). In Germany, the average annual pay is around €27,500; in Sweden,

around SEK348,000 (€35,000); and in the Netherlands €30,000.

Staff shortages For EU workers who repatriate part of their earnings from their jobs in Britain, the decline of sterling since the Brexit vote also means the money they send home is worth substantially less, with £1 worth €1.13 in December 2017, compared with a high of €1.44 in mid-2015, a year before the referendum. Meanwhile, as the UK’s economy

Could an exodus of thousands of doctors, nurses and other medical staff from Britain help the rest of the EU to solve its staffing problems? falters, EU economies are strengthening. Some central and eastern European countries have improved pay and conditions in recent years to increase retention of nurses and other health workers, according to the Health at a Glance 2017 report released in November by the Organisation for Economic Co-operation and Development (OECD). Hungary phased in a 20-per-cent pay rise for nurses and doctors between 2012 and 2015. The Czech Republic also increased hospital workers’ pay, while the Netherlands has

seen a steady growth in remuneration for nurses, according to the OECD. In 2014, a European Commission report (Mapping and Analysing Bottleneck, Vacancies in EU Labour Markets) cited the drift of healthcare workers to the UK as a major cause of staff shortages in the healthcare sectors of ‘new’ EU countries.

Meanwhile, a shortfall in the number of people training to become health workers affected most of the ‘EU15’ countries, including Britain. Across the EU, 21 countries reported shortages in their healthcare workforce, the report said.

Other sources indicate that the Netherlands alone will face a 45,000-person shortfall in healthcare sector workers by 2025, while Germany must expect a shortfall of more than 200,000 by 2030.

By 2020, the EU overall may have one million fewer healthcare professionals than it needs to serve an ageing population. Experts like Paul De Raeve, Secretary General of the European Federation of Nurses Associations, which represents nurses in 27 European countries, warn that low pay and tough working conditions are causing nurses to leave their profession. Could an exodus of thousands of doctors, nurses and other medical staff from Britain help the rest of the EU to solve its staffing problems?

A survey by the British Medical Association (BMA) has found that almost half of all EU doctors working in the UK are considering leaving.

Nearly one-fifth have made firm plans to >>

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relocate elsewhere. Another 29 per cent said they were ‘unsure’ whether they would stay in Britain.

“The top three reasons cited for considering leaving were the UK’s decision to leave the EU, a current negative attitude toward EU workers in the UK and continuing uncertainty over future immigration rules,” the BMA stated. The survey pinpoints Germany, Spain and Australia as the three countries doctors would most like to move to. “If you want to take a look into the future of the German labour market, look at the hospitals and retirement homes. There are endless jobs for certified nurses,” said Chris Pyak, managing director of Immigrant Spirit, a Dusseldorf-based recruitment agency for medical and other professionals. “When I was working in German hospitals in the 1990s, there were 200 applicants for every job. Nowadays, there are only three applicants for every 10 jobs,” he stated, citing figures from the Arbeitagentur, Germany’s government-run job-seekers’ agency.

“We have seen a substantial increase in applications from the UK. These are usually professionals with special skills, such as intensive care nurses.

If they own a degree from an EU university, their

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education is legally of equal value to a German medical education,” he said. “But there is one challenge: to work in the medical field you need to speak German at B2 level and you need to pass a German medical terms exam. These are legal requirements. So, we face an absurd situation: Germany needs about 100,000 additional nurses in the next few years, but English-speaking nurses still face obstacles to working in Germany, because of the language requirements.” The issue is not unique to the UK, Pyak said. “We also see an increase in enquiries from the US, since many international professionals don’t feel secure there anymore.”

An uncertain future “The number of EU doctors looking to return to their home country would seem to be significant,” said Paul Brooks, who launched his international recruitment agency EU Health Staff in 2004 to bring medical staff from the ‘new’ EU countries such as Romania, Bulgaria, Hungary and Poland to the UK and other wealthier EU states. He expanded his services to recruit EU hospital doctors for organisations in Germany, Sweden, the UK and Ireland and GPs for practices in Australia,

New Zealand and Canada. “I think that a lot of EU doctors working in the UK have retained contacts with their home country and original hospital, and so haven’t needed an agency to help them get a job back home,” he said. “Some of these countries now pay their doctors much better, so they may be willing to return. Others, such as Bulgaria, still give their doctors very low salaries, so I think they’ll stay in the UK. Germany is looking for doctors and I think quite a few German doctors have returned there. Some of the other Eastern European nationalities will have gone there as well.

According to Brooks, the system of recruiting doctors from overseas to the UK has got jammed up by a combination of Brexit, which has reduced the value of the pound versus European currencies and increased the perception of a bias against EU migrants; more complex registration requirements at the General Medical Council and NHS England; and stultifying NHS bureaucracy surrounding international recruitment. As with all other issues surrounding Brexit, the future remains uncertain. But it seems likely that short-staffed hospitals in other EU countries may benefit from Britain’s losses. l

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FEATURE mental health, fewer than one in 10 would confide in their employer if they were suffering from mental health problems, and 15 per cent feared dismissal, disciplinary action or demotion if they did so.

Mental health policies are becoming more prevalent in British workplaces, but only 20 per cent of those surveyed said their employer regularly engaged with them on mental health and one in 10 said their company’s policy was not enforced. Increased workload, financial worries and workplace bullying were cited as the top three causes of mental health issues, with stress emerging as the most commonly reported condition.

The problem is not unique to the UK. According to the 2017 EU Compass for Action on Mental Health and Well-being report Mental Health in the Workplace in Europe, figures suggest almost 40 per cent of the population suffers from a mental health disorder each year. Anxiety and depression were identified as the most common and disabling conditions. The report notes that ‘no substantial country variations have been identified in the prevalence of mental disorders’. “A growing incidence of work-related mental diseases has been observed, as well as increased absence from work and early retirement due to mental illness in most European countries,” says the report. “Promoting mental health at work has become a vital response

lose €270 billion due to absenteeism and presenteeism, the EU Compass report estimates. It is unsurprising, then, that it concludes that mental health now represents a priority in the EU. In 2016 the EU introduced the Joint Action on Mental Health and Well-being, aimed at helping individual organisations to develop infrastructures to support mental health diagnosis and treatment, and the European Framework for Action on Mental Health and Wellbeing, intended to bring together key stakeholder networks across the EU. Identifying solutions The report also identifies examples of good practice at national level, such as Finland’s Wellbeing Guild of Entrepeneurs, a project which supports mental health in small and mediumsized enterprises; Germany’s PsyGA (Psychische Gesundheit in der Arbeitswelt), which targets human resources managers, company medical officers and work council managers; the Dutch SP@W (Stress Prevention at Work) programme, aimed at providing a roadmap to help companies identify and deal with workplace stress; and the UK’s Individual Placement and Support Programme, aimed at getting people with mental health problems into work through partnership between clinical teams and employment specialists. In Sweden, new provisions within the Swedish Work

In the US, depression in the workplace costs employers about $210 billion each year … and results in 120,000 deaths to these challenges since the workplace is both a major factor in the development of mental and physical health problems but also a platform for the introduction and development of appropriate preventive measures.”

However, the increase in reported mental illness in the workplace may in fact be an indication of more positive attitudes to the problem. The report cites EU-wide statistics from Eurobarometer, which show that in 2010, European citizens felt more negatively about the issue than they did in 2005/06. But, it says: “The increase is thought to be due to reduced social stigma and discrimination against people with mental illness, leading to greater recognition of previously hidden problems, rather than a true increase in prevalence.”

Employers and other stakeholders are increasingly working together to overcome stigma and tackle mental illness in the workplace. Robin Gauldie reports A new mental health report produced by Benenden, a British non-profit group of healthcare organisations, reports that while 70 per cent employees had experienced conditions related to

Counting the cost Mental illness is also costly for employers, health insurers and private and public sector health care providers. In the US, depression in the workplace costs employers about $210 billion each year in direct healthcare costs, lost productivity, absenteeism, suboptimal performance and high rates of disability, according to the American Psychiatric Association, and results in 120,000 deaths and nearly $190 billion in healthcare costs.

On the other side of the Atlantic, treating workrelated depression costs the healthcare systems of EU nations €60 billion a year, and employers

Environment Act came into effect in March 2016.

In the US, the American Psychiatric Association’s Center for Workplace Mental Health has collaborated with a group of employers, business groups on health and other stakeholders to develop a Working Well Toolkit of practical advice for employers on how to lead a mentally healthy workplace. The Center’s website also has turnkey programmes for employers to start the conversation about mental health in the workplace, notes Darcy Gruttadaro, Director of the centre.

Going postal Even seemingly low-stress jobs can be taxing, and bullying and loss of esteem have been identified as major causes of workplace mental health issues.

‘Going postal’ has been common slang for cracking up, with violent results, since the 1990s. It was coined, supposedly, after a series of workplace shootings by employees of the US Postal Service, driven over the edge by the everyday pressure of work.

Around eight million Americans live with posttraumatic stress disorder (PTSD), according to the American Psychiatric Association. However, while employers can take steps to support employees with PTSD, there are limits to what they can do. US employers may not legally ask applicants whether they have PTSD or any other medical condition, notes the APA’s Centre for >>

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FEATURE Workplace Mental Health: “Workplace settings are not treatment settings, and organisations should not try to replicate the role of a mental health service provider.”

It seems possible that increased acceptance of PTSD as a genuine form of mental illness has been led by its recognition, especially in the US, as a common problem among military veterans, police officers and other professionals who are exposed to overwhelming levels of stress – for example, in combat situations – but who, until relatively recently, were expected simply to cope.

“The prevalence of PTSD in the US military and veteran population has significantly raised the visibility of the condition,” said Darcy Gruttadaro.

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“The alarmingly high rates of suicide in the military and veteran population has also raised the visibility of PTSD as public officials and national leaders search for effective approaches to early identification, early intervention and linking individuals with mental health care.”

Mental health remains taboo The Benenden Mental Health Report found that only eight per cent of British employees would confide in their employer about mental health issues. In the US, the figure is higher, but stigma continues to be a barrier to employees seeking mental health care, according to Gruttadaro.

“Research shows that one in five employees

experiences a mental health condition, yet about 70 per cent conceal their mental health condition from their employers. Engagement is essential

Let’s de-stigmatise mental illness as we did with cancer and many employers in the US are looking at innovative approaches to improving engagement.”

However, as in the UK, many employees experiencing mental health conditions are not coming forward to seek treatment, Gruttadaro said,

FEATURE The more we talk about mental health – in the workplace, in community settings, with family and friends – the more we normalise and open the topic

for fear that coming forward may result in losing their jobs, damage relationships with co- workers and put their future employment at risk.

“Employers will likely continue to focus on effective engagement to encourage employees to seek mental health care when needed because mental health conditions, like depression, are costly.”

Over-work was the biggest cause of mental healthrelated illnesses, according to the Benenden survey, and healthcare workers find it no easier to open up to line managers and colleagues than do employees in other sectors.

Hospitals are, of course, themselves high-pressure working environments, and doctors, surgeons and other medical staff are not immune to stress, depression and trauma. In 2013, following a survey that showed that many doctors in Australia were ‘burnt out, subject to psychological stress and suicidal thoughts, and drinking too much alcohol’, Dr Steve Hambleton, then President of the Australian Medical Association, said the medical profession needed to do more to provide supportive workplaces for doctors and medical students. He said awareness of doctors’ mental and other health issues was increasing, with changing attitudes among younger doctors and a greater focus among

medical practitioners on their own health and the health of their colleagues in hospitals and in private practice.

Improvements across the profession Five years on from Dr Hambleton’s intervention, the AMA is spearheading a drive to help doctors recognise and respond to mental illness in themselves and their colleagues. Doctors’ Health Services, formed by the AMA in 2015 to establish Australia’s first national health programme for doctors, is working to increase efforts to support colleagues with mental health issues and those exposed to ‘critical and distressing incidents’.

AMA Vice-President Dr Tony Bartone said not enough doctors engage in preventive healthcare such as healthy lifestyle, proper work-life balance, and regular check-ups. “These simple, yet vital, actions can keep stress and depression at bay,” said Dr Bartone. “The stress can build up over time and, in worst-case scenarios, can lead to self-harm and suicide.”

“Across the profession, we have to get better at seeing the signs when matters like ageing, burnout, compassion fatigue, traumatic events, bullying, and harassment are eating away at our colleagues

and ourselves,” said Professor Simon Willcock, Clinical Director of Primary Care at the Macquarie University Health Sciences Centre and facilitator of the AMA forum. “These things affect our health and wellbeing and our effectiveness as doctors, and ultimately can affect the quality of care we are providing our patients.”

Ending stigma, increasing recognition of mental health conditions as real illnesses, enabling people with mental illnesses to approach their employers, and above all educating stakeholders to recognise the very real costs of mental illness to business, are the keys to addressing an issue that affects businesses and workers worldwide.

“The more we talk about mental health – in the workplace, in community settings, with family and friends – the more we normalise and open the topic,” said Darcy Gruttarado. “Mental health remains a taboo topic for many. We can change that by proactively starting conversations about mental health in the workforce and beyond.

Remember when cancer was the ‘C’ word? That’s no longer true, so let’s make that same change with mental health.”

And if the healthcare sector cannot itself lead the way on this issue, who can? l

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FEATURE Following research that found that men were more likely to receive life-saving CPR than women, Tatum Anderson delves deeper, asking how much gender bias there is in healthcare Cardiopulmonary resuscitation (CPR) saves lives and tens of millions of people have been trained to perform it. But a recent piece of research found that men were more likely to receive life-saving CPR than women. And, scarily, were more likely to survive.

Researchers looked at who aids people having a heart attack or stroke in public settings. They found that while 45 per cent of men received assistance, only 39 per cent of women did. And, as a result, men had a 23-per-cent increased chance of survival compared to women.

Many different hypotheses have been suggested to account for the difference in who is given CPR – perhaps some people are reluctant to perform CPR on women for fear of touching breasts, for example. But Audrey Blewer, Assistant Director for Educational Programmes at the Center for Resuscitation Science, University of Pennsylvania, US, who carried out the research, said the reasons are still unclear. “It’s an interesting finding and it probably opens off a lot of questions and areas for enquiry going forward,” she said. “We haven’t really done too much of in terms of research in the resuscitation community.”

In fact, says Blewer, her decision to look at CPR is based on growing information on how women are treated in the rest of the healthcare system. “I think that there is a lot of precedent and current publications looking at gender bias in terms of clinicians, prescriptions and various types of medication or even procedures in the cardiovascular field,” she said. “We are also seeing differences in emergency response. A lot of that motivated our thinking about whether there may be differences in terms of gender bias in individuals doing CPR in a cardiac arrest victim.”

There have long been shocking employment and pay disparities between male and female doctors and nurses. But the research highlights an increased interest in understanding how a woman and a man may be treated differently at a hospital, in an emergency room or any part of the healthcare system. In other words, how much gender bias is there in healthcare?

Across the spectrum The Institute of Medicine’s landmark publication Unequal Treatment describes gender bias as unequal access or treatment that is not justified on the basis of an underlying health condition. In a healthcare setting, bias against women may be manifested when women are diagnosed, counselled, treated, or otherwise managed not just differently, but to a lesser degree of adherence to established standards of care than men with comparable health status, it said. Scarily, the bias has potentially lethal effects such as higher complication, morbidity, and mortality rates.

Gender bias is not the same as gender disparity, where there are fundamental anatomic and

physiologic attributes that result in differences to exposures and risks, and it is necessary to effect appropriate treatment adaptations and outcomes for each gender.

Worryingly, for over 20 years, researchers have found widespread differences between the way men and women are treated. One study found that critically-ill women aged 50 years and older were

out-of-hospital cardiac arrest or implantable cardiac defibrillators when indicated for congestive heart failure, or to be admitted to an acute care hospital and receive coronary revascularisation procedures when presenting with coronary syndromes than men.

Female trauma victims with life-threatening injuries were less often triaged by emergency medical service personnel to trauma facilities and less often Some think gender bias is an expression transferred by non-trauma of prejudice that is believed to be implicit, physicians to trauma centres.

In fact, gender bias appears to operating at an unconscious level on the exist across a wide spectrum of clinical practice areas, basis of situational cues ranging from management of cardiovascular risk factors, less likely than critically ill men to be admitted surgery, and orthopaedics to behavioural health, to an intensive care unit (ICU) and to receive acute and critical care. And it is worldwide. potentially life-saving interventions, and they were more likely to die in ICU or in hospital.

Unconscious prejudices?

More studies suggest women with strokes were less Bias happens not only within emergency care, likely to receive appropriate diagnostic imaging, but to primary care appointments, referrals for antithrombotic therapy, or carotid revascularisation investigations, diagnosis times, and starting as inpatients. They must wait longer after they procedures such as dialysis, say researchers. One arrive in the emergency department and receive study looked at German GPs who examined both less aggressive treatment and therapeutic workup men and women for chest pain. They were more following their admission too. They are less likely likely to refer men to the hospital for exercise >> to receive implantable cardiac defibrillators after an tests, assuming more frequently that men had

FEATURE female but not the male patient.

Most interestingly, the physicians’ professed attitudes related to the role of gender in these decisions were contradicted by their actual practise.

Underestimating or misunderstanding a woman’s risk for health problems or complications may be down to the differences in how diseases affect men and women. “I don’t think people do it consciously. It’s more that a disease may affect men more than women or women more than men.

These kinds of thoughts are not bias, they are the truth. It’s hard to differentiate sometimes,” said Dr Haut.

Researchers suggest that women tend to describe what they experience as a more personal, narrative commentary compared to men, who typically describe symptoms in a more straightforward, factual manner with fewer comments. In fact, women’s narrative presentation style has led to physicians making more diagnostic errors in their evaluations of chest pain in women.

Of course, some of it may be down to unconscious prejudices among physicians and some might even be overt discrimination based on sex. Some physicians take women’s symptoms less seriously, attributing symptoms to emotional rather than physical causes.

That is true of chronic pain, which is thought to affect tens of millions of people around the world.

Professor Joanna Zakrzewska, of the Eastman Dental Hospital, who specialises in the excruciating burning mouth syndrome and trigeminal neuralgia, says the conditions are not taken seriously and tend to affect women more than men. They are often dismissed by doctors. “It’s mainly middle-aged women and they get chucked out of the surgery,” she said.

Mitigating bias Luckily, there has recently been some evidence that bias can be mitigated by the use of checklists. These coronary heart disease.

One medical journal editor expressed shock at the growing body of research in a review last year. When patients enter any healthcare system, especially with life-threatening health conditions, it’s implicitly assumed that the care they receive is dictated by sound clinical judgement and objective evidence-based parameters derived from reliable research, said JoAnn Grif Alspach, Editor of the journal Critical Care Nursing. “Nowhere in that scenario do we anticipate that clinical decision making will be influenced by patient attributes such as religion, nationality, socioeconomic class or any other feature not relevant to their specific clinical situation,” she said.

Dr Elliott R. Haut, a trauma surgeon and expert in quality and Associate Professor of Surgery at The Johns Hopkins University School of Medicine, has looked at bias within his own department. He believes bias is generally an unconscious decision.

“I wouldn’t expect there to be a bias, because as a physician you don’t think you are biased. You don’t think you are doing anything differently. But there

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If you know you have a bias you may make a more conscious decision to try and overcome that bias. Nobody goes into medicine thinking I’m going to treat men better than women.

That’s not why we are in medicine are many things you may not know you are doing.”

Some think gender bias is an expression of prejudice that is believed to be implicit, operating at an unconscious level on the basis of situational cues.

Look at one study on total joint arthroplasty (TJA). It’s a procedure that is underused by more than three times as many women as men with qualifying knee osteoarthritis. So researchers sent one man and one woman with moderate knee osteoarthritis and otherwise identical clinical backgrounds to visit 71 physicians (38 family care and 33 orthopaedic surgeons). Results showed that 42 per cent of physicians recommended TJA to the male but not the female patient, whereas eight per cent of physicians recommended TJA for the

are aids for doctors, when diagnosing or treating patients, and help them to remember the various checks and considerations they must keep in mind when approaching their patients.

They have been championed most notably by Dr Atul Gawande, a surgeon in general and endocrine surgery at Brigham and Women’s Hospital, US, in his 2009 book The Checklist Manifesto. Dr Gawande has written broadly on modern medicine and ways to improve it. He posits that the idea that no matter how expert an expert is, well-designed check lists can improve outcomes (even for Gawande’s own surgical team).

But they’ve been shown to make a massive difference to bias too. In 2005, Haut’s group at Johns Hopkins discovered a discrepancy in the

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way trauma patients received appropriate venous thromboembolism (VTE) prophylaxis to prevent blood clots. They discovered 31 per cent of male trauma patients did not receive VTE prophylaxis, whereas in female trauma patients, that failure rate was 45 per cent, making women nearly 50 per cent more vulnerable to blood clots.

The hospital had already introduced checklists to improve the quality of services across all patients. But, when they identified how the data had affected outcomes, they realised that there had been a bias that was removed by using the checklist.

The checklist works something like this: when a doctor enters medical orders for such patients, the automated checklist recommends evidence-based best treatments for each patient’s needs, usually the regular administration of low-dose blood thinners or the use of compression devices to keep blood flowing in the legs.

The researchers say this new system worked far better than previous methods, which included handing out laminated cards outlining best practices or lectures presented on the topic of preventing venous thromboembolism (VTE), a term that covers dangerous clots in the legs and lungs. That’s because the electronic system prevented doctors from progressing in their

work until they had considered everything on the checklist.

The results were startling. There was nearly a twofold improvement in prophylaxis orders among patients who had no contraindications to receiving the low-dose blood thinners. The rate of deep vein thrombosis (DVT) in legs dropped nearly 90 per cent, from 2.26 per cent of trauma patients to 0.25 per cent of trauma patients in the final year of the study. Now, checklists are the standard of care throughout the hospital.

Highlighting discrepancies Many hospitals around the world use checklists already. In fact, special checklists have been developed for use in surgery, and are also used in low- and middle-income countries to save lives around the world.

However, Haut says checklists are more likely to be used to improve quality – which has been a big trend in recent years – rather than to remove bias. Tackling gender bias, unfortunately, is in its infancy. “The world of quality is about 10 years ahead of the world of studying biases in healthcare,” he said. “There is now more interest in the bias piece.”

In the future, hospitals may be able to use electronic checklists to pinpoint just how well

individual doctors are doing, in terms of gender bias. That would help identify those doctors who are more likely to miss certain symptoms, and treatments. However, determining that may not be as easy as it seems because so many doctors tend to work in medical teams.

Haut believes making people aware of the bias will make a difference. “If you know you have a bias you may make a more conscious decision to try and overcome that bias,” he said. “Nobody goes into medicine thinking I’m going to treat men better than women. That’s not why we are in medicine.”

Maybe tackling gender bias is down to education, too. The University of Pennsylvania’s Blewer said that it’s imperative to look at the way people are trained to do resuscitation in first-aid courses.

She notes resuscitation dolls are always male, for example, and maybe they need to be female. Or perhaps there should be more training to highlight the discrepancy, so it is brought to the conscious mind. “We’ve found disparities in terms of race and socioeconomic status, now gender, in terms of CPR, maybe we need to think about ways to address some of these attentional biases in training courses, either through how we communicate or how we train people in a stimulating environment,” she said. l

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Director of the GAUZE: Unravelling Global Healthcare documentary and founder of Gauze, a company that digitises information on global hospitals, Suzanne Garber, highlights her dream of a healthcare system that provides full transparency, quality outcomes, and a fair price, and reveals how she is seeking to fulfil this Could you tell us about your background?

Having grown up in seven countries on four continents and having had the opportunity to learn and practise various languages, I always knew I was destined for a career in the international sector. That came to fruition during my tenure at FedEx – where I spent almost 15 years – culminating in the role of Managing Director, South America based in São Paulo, Brazil.

From there, I became the chief operating officer at International SOS, which enhanced my skills and desire to make a difference in the world of international healthcare.

Fast forward five years and I directed and produced a documentary about international healthcare (GAUZE: Unravelling Global Healthcare), and set up a company that digitises information on global hospitals to be accessible to the 1.2 billion international travellers who may find themselves sick abroad, also named Gauze.

What led you to found Gauze?

I got sick abroad. Of course, that was bound to happen, given that I’ve lived outside of my home country almost half my life, as well as travelled to more than 100 nations. In most cases, I received excellent care and, in a few, not so excellent care.

One of the more concerning moments for someone sick outside of their home country is the inability to communicate, as well as the lack of knowledge surrounding quality – where should I go, what should I do?

I wanted to create an easy-to-use service that would provide information immediately to those who may not know where to go or what to do when sick in a foreign country. The current modes of accessing care abroad use antiquated telephonic connectivity; today’s traveller wants access to information and care at their fingertips. That means an app for immediate, confidential and accurate information.

What do you find most exciting and rewarding about your work?

Knowing exactly the thoughts that go through someone’s mind when they are in a land where they do not speak the language or have knowledge of the healthcare system, I can totally place myself in that person’s shoes. Being able to help alleviate someone’s fears about whether the quality of care is adequate or finding translation services, or worrying about cost and payment is quite extraordinary.

I find being able to save and enhance lives in a small way to get them the care they need to be very

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gratifying. We had one case where an ultra-high-net worth individual asked us to put in place a report listing all of the hospitals for an upcoming vacation by chartered yacht that detailed facilities that had a doctor on staff who spoke English and, for a developed nation, it was surprising to see that none of the facilities on his itinerary met his requirements.

He was able to hire multi-lingual staff to assist him throughout his holiday; being prepared gave him and his family great peace of mind. We were delighted to have facilitated a successful journey.

As the world’s first and only global database of hospitals outside of the US that is vetted by professionals, can you discuss the importance of Gauze?

With over 1.2 billion international travellers, and determining that between 10 and 45 per cent of them become ill while travelling, we knew that our idea would make a huge impact to a large number of the global population. Our focus is on the international traveller, although organisations that are trying to vet and source information on foreign hospitals can also utilise our system. We focus on three key areas that differentiate us from other organisations that also place patients in hospitals.

1) Confidential. What that means is that individuals can access our database of more than 20,000 hospitals and determine the nearest centre of medical excellence or adequacy that meets their needs.

2) Immediate. There’s no need to ring a call centre in California when calling from Cartagena. Patients can simply look up the app for hospitals within a certain distance from them. They will never be placed on hold, receive a busy signal or voicemail, or be told someone will call you back with a vetted provider.

3) Accurate. With over 20,000 hospitals in our system, the information provided on hospitals has been vetted by academics in each country.

We detail information on nearly 40 categories including specialities, languages spoken, clinical trial availability, board certification, staff trained abroad and more. We know that giving access to information is one of the most empowering tools someone can have.

How does your company connect patients with hospitals around the globe and why is this important?

Individuals and organisations can access the Gauze network of hospitals via an app download, as well as tailored, written risk reports. Our goal is to put the power of information in the hands of those outside their home countries in need of access to healthcare, when they need it. The best way for me to summarise the importance of having confidential, immediate and accurate information is by giving an example of a case study recently completed.

‘Kelly’ travelled to China for a business trip.

Having been there only once prior and speaking no

Chinese, ‘Kelly’ knew the importance of having a risk mitigation tool like the Gauze network as she had once before fallen ill in a foreign setting but waited to return home in order to seek treatment.

She had requested a written report with a number of reputable hospitals in the cities she was to visit.

Incidentally, ‘Kelly’ succumbed to food poisoning while on her trip and handed the taxi driver the written report she’d received from Gauze. There was no way she would have been able to correctly pronounce the hospital name or address of where she needed to go in order to be seen by an Englishspeaking doctor and was thankful to have both the written English name and Chinese characters to hand to her driver. She was immediately seen and discharged; no one from her company knew she was sick and she was able to carry on her professional duties. Upon her return, she sent a thank you note to Gauze for letting her continue with her trip without interruption or concern from her employer.

This confidential and immediate access to care is certainly important to patient consumers of any age; it will become even more so with the millennial population who prizes privacy. Furthermore, there is no need for your employer to know when you have visited a hospital when you are at home; why should they know when you are abroad? Gauze facilitates the access to care by helping patient consumers make educated decisions.

What do you see as the key challenges facing the healthcare sector and, in particular, crossborder care?

Transparency in healthcare is a major challenge that affects many healthcare systems, and not just those in countries that are deemed politically opaque. For example, the New York Times newspaper ran a recent article citing that Singapore’s healthcare system could not be a best-in-class system due to its lack of transparency with regards to overall population health numbers as reported by the government.

Similarly, the US lacks transparency with pricing and quality outcomes. In fact, a 2016 study by Johns Hopkins stated that the third leading cause of death, if death certificates were coded correctly, would be, ‘medical error’. Other systems, particularly those in Latin America, lack transparency in terms of hospital bed availability, wait times and quality. >>

INTERVIEW

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INTERVIEW In terms of cross-border care, access to accurate information is key. Where does one look for objective, current, and relevant information?

Whether seeking placement at a healthcare facility for a medical evacuation or evaluating providers for an elective procedure, there is truly no panacea in healthcare transparency. Hospitals have become adept at marketing and those with the best websites and business development personnel may reap the rewards of increased international patients who both self-pay and pay list price.

What tools do you think internationalists require to make informed decisions about healthcare abroad?

I once collaborated with a woman who was spearheading a project on the dangers of travelling to Mexico after she lost her son who travelled there for holiday. I’ve lived, worked, and spent many a holiday in Mexico. I have many friends there and feel very at home there. But, the first time I went, I was very much on my guard and on the lookout for possible dangers.

Internationalists are a unique breed – and I count myself among them – for we have been everywhere and seen it all. Sometimes we become complacent about our travels, letting down our guards in areas we know are crime-laden and thus falling victim to

armed with key information with which to make an informed decision will help an internationalist who finds himself needing healthcare in any country around the globe.

For you, what does the ‘best in healthcare’ mean?

In filming my documentary, GAUZE: Unravelling Global Healthcare, I was able to interview over five dozen international healthcare experts. I asked this question and found that the responses, although varied, really came down to three areas: quality, affordability and accessibility. This can best be summed up by a healthcare journal editor from Portugal, who stated: “I think the best healthcare system in the world is still yet to be created. But overall, the best healthcare system would be one that would offer transparent healthcare, high levels of patient safety and quality all at a good price.

That is still waiting to happen.” I completely agree with him.

In your experience, where can this be found?

The utopian healthcare system does not quite exist.

However, there are a number of better systems out there. I point to the leaders in Switzerland, Germany, France, Singapore, and South Korea as offering a smorgasbord of options for their citizens.

One of the questions I asked every interviewee

My vision has taken on a more public healthcare policy footprint in lobbying US government officials for more transparency in healthcare pricing, improving access to care (and methods of financing) for more Americans, and educating others on the risks and rewards in cross-border care scams we would have otherwise been alert to if we were experiencing a locale afresh. This complacency can spread out into our own health as well. I know many people who will spend hours researching restaurants, shopping and shows prior to embarking on a trip but never once think about if there is a lifeguard on duty at the hotel pool or beach, if the hotel has use of a defibrillator, how far the hotel or meeting venue is from an emergency room or if the hotel or meeting site is serviced by ambulance.

Further, does the healthcare system in that particular country offer care for foreigners and, if so, do they demand to be paid in cash up front or would the hospital even dare reject treatment if payment could not be made? These are realities of healthcare in many countries.

One’s view of healthcare while travelling can mirror both our lackadaisical attitude toward our own healthcare whilst at home, or our cavalier impression of travel overall. In either case, healthcare should not be taken lightly, nor should choosing a healthcare facility or physician be determined by a third party.

While insurance and assistance companies have networks primarily comprised according to the discounts they have been extended by healthcare facilities, Gauze lays bare all possible facilities, along with information that is important to an international traveller such as languages spoken, insurances accepted, specialities, and more. Being

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during filming was exactly this question. The head of benefits for the AFL-CIO, the largest union of mostly government employees in the US said it certainly wasn’t the US, for how can a country be considered the best when one-quarter of its citizens (at the time of filming) were without access to quality care? But, I would be remiss in simply lumping entire countries as ‘best’ or ‘worst’ when, in fact, high-quality care can be found in many individual hospitals, departments, or physicians in some – what others might consider – surprising locations.

What will be the key goals for yourself and Gauze in the coming five to 10 years?

We continue to add hospitals to our database and hope to ultimately be the authority in objective healthcare rankings. We refuse to take money from hospitals, in order to retain our fair approach and make a plea for hospitals to be transparent in their information reporting as well as to become more transparent in their pricing and quality outcomes.

The triangle of quality, accessibility and affordability really does determine the definition of ‘best’ in healthcare.

We will also partner with other companies who may focus on a more complete view of healthcare – we only catalogue information on hospitals – or those who take a more in-depth look at hospital data

apart from those categories that are important to an international traveller. There is no truly global data repository for healthcare systems and we know that it will take a lot of collaboration amongst various parties to achieve it. This will be for the betterment of global healthcare as a whole.

More broadly, can you share some of your hopes and dreams for healthcare?

I initially began my journey in creating Gauze – both the documentary and the company – with the goal of helping those who found themselves in need whilst sick overseas. I was creating a solution to something that didn’t exist when I found myself in that exact situation. Today, my vision has taken on a more public healthcare policy footprint in lobbying US government officials for more transparency in healthcare pricing, improving access to care (and methods of financing) for more Americans, and educating others on the risks and rewards in crossborder care.

Currently, I am working on gaining 10,000 signatures on a Change.org petition to mandate transparency in US healthcare pricing so that the patient receives an estimate for total costs prior to undertaking a procedure. US hospitals require patients to sign financial responsibility forms that put the entire burden of cost on the patient consumer and yet give no estimate for how much those costs might be. In any other industry, one knows the cost of an airplane ticket, a new or used car, a cup of coffee or even a stock trade on the NYSE; why is American healthcare any different?

It is time to give the patient consumer full visibility into the true costs along with the risks in order to make a well-rounded decision. I dream of a healthcare system that provides full transparency, quality outcomes, and a fair price. It will take some work to get there but it can be accomplished.

On a personal level, which country have you enjoyed visiting most and why?

Such an unfair question when I’ve been to over 100, worked in 42, and lived in eight! There’s no clear ‘winner’ although I have to say living in Brazil spoiled me. The people are lovely, the cuisine is so fresh, and the scenery is just breath-taking.

Although, most of my dearest friends are from when I lived in the Dominican Republic or worked in Mexico; I am partial to Latin America. From a purely touristic standpoint, I was awe-struck with Antarctica and brought to tears by the haunting majesty of its vastness. I also loved Iceland, Egypt, Thailand, and the Galapagos Islands … although, truth be told, I’ve loved most places I’ve visited!

Every place has its own special qualities. l To participate in Gauze’s upcoming campaigns to make healthcare more transparent and accessible, sign up to its newsletter at www.gauzethefilm.com. Clips from the film and commentary on global health policy can also be viewed at www.pbs.org/video/gauze-unravelingglobal-healthcare-tsesgt

INTERVIEW

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FEATURE

Leeches, maggots and spider webs have been used by healers since antiquity. In the 21st Century, researchers are discovering that treatments such as maggot debridement therapy can be effective. Robin Gauldie investigates the claims made for some seemingly outlandish remedies Watching a medicinal leech swelling as it sucks blood from a recently sutured abrasion isn’t for the squeamish. Think of maggots, leeches, roundworms, ants and spiders – if you can bear to – and you see them as pests or parasites. But hospitals and medical researchers are finding new applications for creepy crawlies.

‘Leech: An aquatic or terrestrial annelid worm with suckers at both ends. Many species are bloodsucking parasites, especially of vertebrates, and others are predators ... a person who extorts profit from or sponges on others’. So says the

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Oxford English Dictionary. It’s fair to say that the leech doesn’t have a great media profile. But the dictionary offers a second, more positive definition: ‘(archaic) a doctor or healer’. All the way back to Hippocrates, the medicinal leech (Hirudo medicinalis) has played its part in medicine and pharmacology, and in the 21st Century they – and other creatures more commonly thought of as parasites or pests – are making a medical comeback.

Not many years ago, a visitor to Istanbul’s famous bazaar, the Misir Carsisi, might see vendors selling jars of wriggling medicinal leeches, used to ease all manner of ailments. No longer. Medicine in Turkey has moved on into an era of high-tech hospitals and 21st Century treatments and procedures that can be billed to private health insurance providers.

Traditional, do-it-yourself remedies like the leech are a thing of the past.

Ironically, just as Turkey has abandoned such age-

old treatments, medical science is rediscovering them. Hospitals in Europe and the US are increasingly interested in the potential benefits of the humble leech as an aid to post-surgery recovery.

In the UK and more and more frequently in other countries, leeches are used in microsurgery, where they have been shown to be useful in the prevention of post-transplant necrosis. Natural anticoagulants that they inject at the site of their bite have been found to increase blood flow to newly transplanted body parts. “Even as late as 1896, some hospitals were still ordering stocks of leeches, and they continued to be used in some parts until the Second World War,” said Dr Alun Withey, an academic historian of medicine at the University of Exeter, UK. “After centuries of emphasis upon medical progress, and the ignorance of patients and practitioners in the past, it is interesting to see the ways in which past practices and beliefs are again beginning to find their way

FEATURE

into orthodox medicine.”

Meanwhile, in the UK and the US, surgical staff are using leeches, which have been cleared for use as ‘medical devices’ since 2004 by the US Food and Drug Administration, to drain blood from sutured wounds and simultaneously prevent

also sells its wares in the US, Italy, Scandinavia, China, Japan, Korea and South Africa. The South Wales-based company has been in the bloodsucker business since 1812. “Biopharm is the first leech farm of its kind and we are innovators in the cultivation of the medicinal leech, currently producing the majority of leeches used in modern Hospitals in Europe and the US are medicine worldwide,” said Biopharm’s Carl Peters-Bond. increasingly interested in the potential The potential of leeches in benefits of the humble leech as an aid to post-surgical treatment began to be recognised with the post-surgery recovery astonishing advances in microattachment surgery over the further clotting, allowing faster healing after plastic last 30-50 years, he said. “We were among the first surgery. A thoroughbred medicinal leech from to recognise that potential.”

Biopharm Leeches, which supplies UK National Biopharm, based in Swansea, Wales, has nurtured Health Service medical establishments such as the renaissance of leeches in modern plastic and the Royal London Hospital costs £12. Biopharm reconstructive surgery worldwide, rearing and

selling up to 50,000 medicinal leeches a year.

Around 20,000 of those go to hospitals in the UK. The rest are exported to Biopharm’s network of partners worldwide. At £12 per leech, and considering that leeches live in any old pond, that sounds like easy money.

However, it’s not as easy as getting out there with a net and a bucket. Raising medicinal leeches is ‘quite a long and difficult process’, said Peters-Bond. “They need to be kept in a sterile environment while growing. We feed them three times over about a year; when we despatch them they are between three and four years old. It’s quite a difficult and lengthy process, and exporting them internationally involves lots and lots and lots of red tape.”

Cut-price Russian bloodsuckers For Biopharm, that could be a blessing in disguise. >> In Russia, leech treatment remained in

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common use in the Soviet era and is still popular.

Hospitals and clinics still use around 10 million leeches each year, as they did in Soviet times, to relieve conditions ranging from back pain, liver disease and high blood pressure to glaucoma, though their efficacy in treating such ailments is questionable. More recently, Russian medicine has seen leech therapy’s main benefits as deriving from the natural anti-clotting agents found in leech venom used in the prevention of cardiac conditions and stroke, and delivered directly by live leeches much more cheaply than pharmaceutical anti-coagulants. The International Medical Leech Centre in Moscow sells its leeches for less than £1 each (minimum order 10,000, cash up front) but bureaucratic obstacles have so far prevented it from breaking through into UK and European Union (EU) markets, so these are unlikely to be flooded with cut-price Russian bloodsuckers any time soon.

Like treatment using leeches, maggot debridement therapy (MDT) was well known historically. Some military surgeons reportedly noted that maggotinfested wounds healed more quickly, with a lower mortality rate. In the 1920s, an American surgeon working at Johns Hopkins Hospital in Baltimore, William Baer, conducted research into MDT with hopeful results, and the technique was widely used until the 1940s. It fell from favour with the advent of antibiotics, but is being re-examined as hospitals seek alternative forms of treatment. “The first modern clinical studies of MDT were initiated in 1989 at the (US) Veterans Affairs Medical Center in Long Beach and at the University of California,” according to Dr Ronald Sherman, a founder and board chairman of California-based non-profit organisation the BTER Foundation, which aims to improve access to maggot and leech treatment and other biotherapies. “By 1995, a handful of doctors in four countries were using MDT. Today, over 3,000 therapists are using maggot therapy in 20 countries.” Sherman, who began treating patients using MDT in 1990, claims ‘miraculous results’ from the treatment in healing stubborn wounds.

Precise and selective The US Food and Drug Administration and the UK’s NHS both authorised the use of maggots as ‘medical devices’ in 2004. In UK hospitals, NHS surgeons working in fields such as podiatry say MDT is cheap and cost-effective. It is also more selective than conventional debridement surgery, which involves cutting away dead flesh, but can

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also involve cutting away healthy tissue to ensure removal of the whole infected area. Fly larvae, however, eat away only dead tissue, so debridement is precise, and treatment does not require patients to stay in hospital to recover from surgery. Some proponents of MDT say they have observed that maggots not only remove dead and infected tissue but also help to disinfect the wound and speed healing by exuding natural antibiotic substances.

technique, infection could be prevented over weeks or months by the controlled release of antibiotics.

At the same time, tissue regeneration is accelerated by silk fibres functioning as a temporary scaffold before being biodegraded.”

Dr Sara Goodacre, Associate Professor at the University’s Faculty of Life Sciences, says the work is likely to lead to ‘a very exciting range of studies’.

“Some of the future work will be supported by

After centuries of emphasis upon medical progress, and the ignorance of patients and practitioners in the past, it is interesting to see the ways in which past practices and beliefs are again beginning to find their way into orthodox medicine However, peer-reviewed research carried out in 2009 at three UK universities and published in the British Medical Journal indicated that while maggots are indeed better at debridement, there was no significant difference in healing time compared with treatment using hydrogel dressings.

Patients in the groups using larvae also reported more pain than those in the hydrogel groups.

The research, which was carried out at the University of York, University of Warwick, University of Leeds and Coventry-based Micropathology Ltd and funded by the UK National Institute for Health’s Research Technology Assessment Programme, was based on a controlled study of 267 leg ulcer patients and provides the strongest evidence to date about the effects on larval therapy on leg ulcer healing, according to the NHS. “Future treatment decisions should be fully informed by the finding that there is no impact on healing time,” the researchers said, adding that further study was needed.

Silken scaffolding It sounds like something straight out of Marvel Comics, but scientists at the University of Nottingham’s SpiderLab, in the UK, have developed a recombinant (artificial) spider silk that can be used to create a biodegradable mesh that can be used to accelerate growth of new tissue and for the slow release of antibiotics. “There is the possibility of using the silk in advanced dressings for the treatment of slow-healing wounds such as diabetic ulcers,” said Professor Neil Thomas of Nottingham’s faculty of chemistry. “Using our

other, neat ideas from the world of spiders and their silk, which the SpiderLab is currently trying to unravel,” she said.

Meanwhile, a group of scientists in Rio de Janeiro, Brazil, inspired by an ancient Sanskrit medical text, have developed plans for a surgical clamp based on the jaws of a large South American ant species. The use of ant mandibles to close wounds is described in the Charaka Samhita, written in India almost 2,000 years ago and the Brazilian team’s research suggests natural biopolymers such as fibroin and chitosan could be used to build absorbable clamps that mimic the action of ant mandibles. There seems to be no end to the new applications that medicine can find for ancient biomedical techniques. l References: 1. www.nhs.uk/news/medical-practice/maggots-clean-ulcersquickly 2. www.bmj.com/rapid-response/2011/11/02/maggot-therapyapparently-good-treatment-despite-poor-study-andinadequate 3. www.wales.nhs.uk/sitesplus/863/news/22870 4. David Harvey, Philip Bardelang, Sara L. Goodacre, Alan Cockayne, Neil R. Thomas. Antibiotic Spider Silk: SiteSpecific Functionalization of Recombinant Spider Silk Using “Click” Chemistry. Advanced Materials, 2016; 1604245 DOI: 10.1002/adma.201604245 5. www.sciencedaily.comreleases/2017/01/170104103533.htm 6. www.scielo.br/pdf/mr/2017nahead/1516-1439-mr-19805373-MR-2016-1137.pdfeceived: December 30, 2016; Revised: June 19, 2017; Accepted: July 21, 2017

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INTERVIEW

Making guesswork a thing of the past

Co-founder and clinical ambassador Daniel Shaw discusses how GCR strives to ensure clinics deliver the best patient experience possible Can you provide a brief outline of your role as clinical ambassador of the Global Clinic Rating (GCR)?

I’m privileged to have to role of representing GCR internationally, including its mission and vision, so that an increasing number of patients, clinics and hospitals begin to make their decisions by putting treatment outcome data first.

What do you enjoy most about working at GCR? I’m proud to know that we are able to tell anyone within 60 seconds which clinics and hospitals that work with GCR perform are the best in their chosen specialisations. For example, which dental clinic has done work that lasts the longest, which fertility clinic can give the highest chance of having two male twins, or which cancer hospital has proven to increase current life expectancy after diagnosis by a factor of 10. This saves days of tiresome research online and, in the end, simply guessing which clinic will give the best results.

What is your professional background?

I came into healthcare completely by accident.

When my grandfather suddenly lost control of his legs early in life and was diagnosed with a rare neurological disease, I was unable to find a local clinic that treated his illness. And when I did find a clinic online hundreds of miles from his home, I had no idea of the expected success rate if he had

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treatment in that clinic, as opposed to another clinic in another part of the country for example.

When discussing this issue with other patients facing major health conditions, I found that this problem still applies to everything from dentistry

I encourage all patient co-ordinators for clinics large and small to always find out what the patient expects from the clinic before treatment starts, and then do all they can to surpass that to cardiology , even in today’s digital age – there are no quality outcomes of medical facilities published for fair comparison. So, we built the global clinic rating – GCR.org.

Can you give an insight into the types of factbased action steps you provide for clinic owners and the impact these might have?

AID is an acronym we use at GCR to help clinics and hospitals understand the three factbased action areas that are involved in working with GCR: A - Assess/analyse how the clinic stands today compared to other clinics locally and worldwide in the areas of expertise, facilities, services and patient outcomes available.

I - Implement/improve on what we’ve discovered in A.

D - Demonstrate what’s been discovered in A and I to the clinical team, stakeholders and patients to improve the clinic’s reputation, transparency, quality outcomes and revenue.

There are three major differences that GCR has brought to international healthcare as opposed to traditional third-party accreditations and standards: GCR gives a simple quality one to five score understood in every language of the world, in every culture and by every patient. GCR started to rate clinics according to specialisation rather than as a whole. For example, a clinic may have great outcomes in cancer therapy but poor scores paediatric care. A traditional accreditation will simply tell you that this clinic or hospital passes or does not pass their standards as a whole, which I believe is a misleading representation of quality for the patient.

Finally, GCR gives patients and clinics updated scores in real-time. This means that our rating algorithm is constantly updating itself and reassessing the clinics based on new data reported to us each day about the clinics. A clinic/hospital may improve or decrease rapidly in quality within a matter of months, so with the GCR a fair representation of the current state of the healthcare facility is reported, rather than a check of standards done every few years.

What are some of GCR’s proudest milestones to date?

What started as a simple comparison of a few hundred clinics on a spreadsheet in 2014, GCR has grown from a beta test rating 126,000

INTERVIEW world often express that they’d happily give their patient data to improve healthcare worldwide, and are much more wary of someone misusing their Facebook data as opposed to their blood pressure, heart rate and mobility scores.

Looking ahead, what will GCR be focusing on in the coming five to 10 years?

The next five years will bring a massive revolution in healthcare and GCR hopes to be a core part of that. With a medical issue 5,000 years ago, we prayed to the Gods to help us. Two thousand years ago, we started to turn to human doctors instead for suggestions and intervention. Ten years ago, we started to turn to data. If you go to a doctor today, you very often get blood tests, an MRI, an EEG, an X-ray or genetic tests that produce data by which a doctor or, more increasingly, algorithm, can interpret the data. Increasingly, which clinic/ hospital you should ideally visit will be data driven too. dental clinics worldwide in late 2015 to rating 432,000 clinics within 17 medical specialisations during 2017. We’ve very excited to see what will happen next.

How does GCR go about assessing a clinic?

We use a model that was developed by our advisory board of experts, which we call the four pillars of clinic excellence. We look at the level of expertise, facilities, services and patient outcomes available, and within each pillar we give the clinic a score.

This means that while a clinic might score highly in the level of expertise available, if they don’t have the technology available to support high clinical and patient outcomes this will be reflected in the overall score.

What advice would you give to a patient looking for medical care who is unsure of where and how to begin looking?

Doctor recommendations are still the safest bet. However, I recommend a patient asks their referring doctor to support their recommendation with data. Without that, while simple reviews of a hospital or clinic are a good place to start, they’re not enough to base medical decisions on.

Patients should compare as best they can the level of expertise, facilities, services and patient outcomes available of a handful of suitable clinics, then start communicating with them.

Communication with the clinic is often the best barometer of their professionality and creating a judgement of a patients’ expected treatment outcome with that particular medical clinic.

Our hope is that GCR will soon make all this guesswork a thing of the past.

I’m a firm believer that a positive patient experience always results in the patient experiencing better outcomes than expected in the patient experiencing better outcomes than expected.

That’s why I encourage all patient co-ordinators for clinics large and small to always find out what the patient expects from the clinic before treatment starts, and then do all they can to surpass that.

Do yourself, and GCR as a whole, face any particular challenges in your work?

Any company that collects patient data has to deal constantly with the issue of protecting patient privacy. While privacy is of course a necessity, it does create a barrier in collecting patient treatment outcomes, and improving healthcare globally.

Patients that I’ve talked to in many countries of the

What are your hopes for the future of crossborder patient care?

Clinics and hospitals with some of the best patient outcomes have been found in the most unlikely places of the world, and often don’t have the reputation to get the word out about how well they are doing. A better hospital or clinic is often closer than you think – and I trust that GCR will make that information available, while making the comparison of the quality of clinics between towns, countries and continents even easier.

On a personal level, do you have any exciting plans or goals for the coming years?

Since working with GCR, I’m increasingly aware of the masses of patients around the world who are in the closing years, months or days of their lives due to an unexpected accident, medical mistake or illness.

This makes me acutely aware of how precious time really is, so I’ve been creating a book and phone app designed as a personal ‘memento mori’, reminding us that we could die anytime – in order to live more and live wisely. l

For you, what are the ingredients of a positive patient experience?

While patient decisions are usually determined by three major factors – accessibility, cost and expected outcome – I’m a firm believer that a positive patient experience always results

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DESTINATION SPOTLIGHT

Small but mighty. By Tatum Anderson A small Latin American country that has become the byword for ecotourism, rainforests and wildlife – one-quarter of Costa Rica is protected area and national park – is also a destination for medical treatment.

Americans have known about Costa Rica for years.

US retirees have been heading to the country to get their teeth done since the 1980s. Although Costa Rica offers a wide range of medical treatment services; from physical checkups, to plastic surgery, orthopedic, spine, bariatric, IVF, stem cells and anti-ageing therapies, almost half of the medical travellers visit Costa Rica for dental procedures.

Although Costa Rica has heavily marketed itself as a dental service hub, it also relies heavily on word-of-mouth for international clients says Alberto Meza, who runs Meza Dental Care, one of many small clinics across the country able to carry a procedure at the fraction of the cost of the US. Although Meza says 95 per cent of its clients are American, he does receive visitors from countries like Italy, Germany, Japan, Australia, Canada. “We do not get patients from neighbouring countries,” he added.

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High-quality professionals But compared to many of the giants of medical travel, Costa Rica is a tiny country with a tiny medical travel industry. The Council for International Promotion of Costa Rica Medicine (PROMED), has estimated that 70,000 medical travellers visited in 2016 and brought in US$485 million. The industry has been growing 15 per cent per year since 2006. There are a few hundred private hospital beds in the country.

People visit Costa Rica because it has good medical professionals and facilities said Alvaro Piedra Meléndez, of Procomer, despite not being the cheapest destination in the region, Costa Rica’s export agency. “It should be noted that the main success factors for Costa Rica as an actor in this industry is the high quality of their professionals,” he said. Importantly, Costa Rica, which has the oldest democracy in Latin America, also has political stability and high standard of living. That’s what sets it apart from its Central American neighbours according to the US’s Central intelligence agency.

Unsurprising then, that US citizens are still the largest proportion of Costa Rica’s medical travellers, by far. About 83 per cent came from the US and 11 per cent from Canada in 2016.

Costa Rica also receives patients from Central America and the Caribbean, who have tried the public health system at home but seek complex procedures not available in their countries; cancer treatments, liver transplants and radiotherapy for example.

Interestingly, there is very little contact with insurance companies, a feature of much of the industry in Costa Rica. “We are not making moves to work with insurance companies, just fill in forms for patients to make their claims,” said Meza. “All of our clients pay out of pocket.”

Great growth PROMED - and the government are trying to change that, however said Massimo Manzi, Head of PROMED. “Around 85 per cent of patients pay out of pocket, but Costa Rica is trying to develop corporate and institutional programmes where procedures are sponsored either by self-funded employers, an insurance company or a foreign Government,” he said.

Those companies prepared to pay for patients to seek health in Costa Rica have very specific programmes. “US corporations have focused their programmes in Costa Rica in orthopeadics, neurosurgery and weight loss surgery,” he said.

DESTINATION SPOTLIGHT Public hospitals are not permitted to receive private international patients either. So, medical travellers tend to visit one of three JCI-accredited hospitals in the country. Two of the JCI-accredited hospitals are Hospital Clínica Bíblica (HCB) and CIMA Hospital, owned by the International Hospital Corporation, which is headquartered in Dallas, Texas. Hospital Metropolitano, is based in San José downtown and is the newest hospital, opening eight years ago. It provides services to US veterans and accepts medical insurance under the Foreign Medical Program (FMP) and Tricare. The next largest private hospital, Hospital Hotel La Católica (HCC), is accredited by the Costa Rican Medical Tourism Associations.

Much growth is envisaged. Both CIMA Hospital and Hospital Clínica Bíblica are building new facilities in the Guanacaste Province, the area in northwest Costa Rica which attracts the greatest portion of tourists and has an international airport with direct flights from the US CIMA Hospital’s new site in Liberia and HCB’s facility is in the Papagayo area, but it plans an outpatient clinic in Santa Ana in the near future.

Juan Andrés Castro, Gerente Comercial at JCIaccredited Hospital Metropolitano in San José said his hospital targets mostly domestic patients, although many of those may be foreigners living in Costa Rica. “Our mission is to provide the best medicine care at the best price. It focuses very much on local,” he said. “We also have a large number of expats and veterans that live in our country that we serve regularly,” he said.

Hospital Metropolitano too has eyed growth opportunities and has opened two primary care branches in the main tourist areas of Quepos and Guanacaste. Those clinics report about a 5050 share among local and foreigners. “In time, we have seen an increase of request for more treatments in our main site in San Jose. We plan another two next fiscal year. One of which will have an OR and hospitalisation services. At the moment that’s only available in San Jose,” he said.

promote the industry, it seems they do not believe in it as a profit-maker for the country,” says Meza of Meza Dental. “There is lots to do – regulating the industry and then promoting it to make it sustainable”.

The fact is, Costa Rica has one of the best health systems in the region and investments in health infrastructure has impacted on service levels and health professionals. “The country is well prepared and now suffers of an oversupply of medical and dental professionals,” said Manzi. “So far, the private sector has been doing most of the effort but with the involvement of the Government we believe we can open new markets more easily.”

He wants the government to negotiate with the

Among the best As well as these hospitals, there is a wide range of smaller private clinics – the largest of which are Clinica Santa Catalina, Clínica Santa Rita, Clínica Santa Fe, and Hospital Clínica Jerusalem. Private patients can be seen quickly in these facilities, which are accredited by the Association for Ambulatory Healthcare (AAAHC).

Although the main hospitals are concentrated around the Central Valley, where the capital is, PROMED said it has been working with the German Cooperation Agency to create regional local medical and wellness travel clusters in other areas such as Guanacaste, Jacó, Los Santos and La Fortuna.

Recovery centres, too, allow patients to recuperate at a special ranch or accommodation centres with medical staff. They include CheTica Medical Recovery Centre and Paradise Cosmetic Inn in the mountains near the capital.

But, some within the industry say government could do more. “Local government does not

COMMON PROCEDURES AND THEIR AVERAGE COSTS (PROMED)

Ministries of Health of third countries to offer medical services and also medical professionals, for example. “We believe this is an opportunity to accelerate the growth of the industry with a stronger support from the Government.”

The Ministry of Foreign Trade, Ministry of Foreign Affairs, Ministry of Health are also thought to be on the verge of passing an executive decree to help boost the medical travel industry. Meléndez said that the government is active. “Procomer is reinforcing market studies, missions and fairs, and during 2017 the sector is participating in medical travel summits and a commercial mission in Guatemala and Honduras,” he said. l

Procedure

Cost in United States

Cost in Costa Rica

Abdominoplasty (Tummy Tuck)

$6,000–$8,500

$4,000 +

Breast augmentation

$5,000–$8,000

$3,000 +

Facelift

$7,000–$9,000

$4,500 +

Crowns

$1,000 + per tooth

$400 +

Dental implant

$3,000

$1,000

Porcelain Crown/Bridge

$1,050

$350

Root Canal

$800

$315

Teeth Whitening

$700

$250

Veneers

$1,250

$350

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