Monthly Archives

March 2016

by Dr Rooney Jagilly

By | Our health system in the Pacific islands: a deadly storm | No Comments

Sustainable fisheries, ocean conservation, climate change and economic development are important issues our Pacific Island leaders are discussing at the UN General Assembly as well as other regional meetings. We would like to add to this discourse the health challenges the people of Pacific Island nations are faced with. The alarming rising tide of chronic diseases throughout our Pacific region must be addressed as it adds another layer of stress to health systems already taxed by infectious diseases such as malaria, dengue, tuberculosis and childhood diarrhea. Health aid is currently regionally distributed throughout the Pacific, and while this collective approach may be efficient, it might actually be harming some of our least developed countries in the region.
Cancer deaths in Melanesia are projected to increase by 43 per cent by 2030. These projections underestimate the problem in countries like Papua New Guinea and Solomon Islands, where cancer reporting is only just being established and where many of our people succumb to their diseases in their rural villages without ever knowing what killed them. Screening programs are underdeveloped, leaving our healthcare providers limited options to treat patients once they present with advanced, incurable diseases. The distribution and risk factors related to the cancers we treat may be unique to our region and merit comprehensive epidemiologic investigation.

Increasing numbers of chronic diseases are not the only health threats Pacific Islanders are vulnerable to. Climate change impacts such as extreme weather events, heat, and rising sea levels also adversely affect our health. The recent WHO Climate Change and Human Health conference highlighted the inextricable link between human health and climate change. It also affects our economies. The downward revised GDP growth rate in our country, Solomon Islands, on the heels of a recent deadly flood is one such example. Disease outbreaks following extreme weather events not only tax already short-staffed and under-supplied health systems, but they also turn diarrhea and influenza-like illnesses into killers.

Infectious diseases, until now, have been our greatest health challenge. Human papillomavirus, Hepatitis B virus, Helicobacter pylori and Epstein-Barr virus contribute to 18 per cent of our cancers, and outbreaks of infections like dengue fever have challenged our systems. The unfolding deadly Ebola outbreak in Western Africa has many lessons for us in the Pacific. Ebola virus reminds us that weak public health and health care systems allow infectious agents to flourish unchecked due to the inability to diagnose, contain, and treat them in a timely fashion. It also highlights that despite billions of dollars spent on disease-specific treatment programs, the public health and health care systems remain inadequate in many developing countries. Public health laboratories are the mainstay of infectious disease control, but at present Pacific Island laboratories can only perform a limited catalog of diagnostic tests. Current responses to significant outbreaks like dengue rely on the external assistance of expatriate specialists. While valuable, this is not a sustainable solution to our problem. In 2011, WHO’s Laboratory Strengthening for Emerging Infectious Diseases Program was initiated in the Asia-Pacific Region in order to address the need to develop national public health laboratories. But as of 2014 most Pacific Island nations have been unable to establish these vital laboratories in contrast to our Asian counterparts.

Pacific Island nations are not all at the same level of development and for this reason we advocate for an individual as well as regional approach toward health development aid. The 2014 UNDP Human Development Report ranks the majority of Pacific Island nations in the medium to high developed category, but Papua New Guinea and Solomon Islands are ranked in the least developed category along with Sub-Saharan African countries (PNG and Solomon Islands rank 157th of 187 countries). The Intergovernmental Panel on Climate Change AR5 uses this same development data to predict vulnerability to climate change impacts. The lower the rating, the more vulnerable Solomon Islands and Papua New Guinea are. The World Risk Report Index further supports this notion. Of the 15 most at risk countries in the world in 2013, four of them–Vanuatu, Tonga, Solomon Islands and Papua New Guinea–are Pacific Island nations. The percentage of GDP spent on health care varies widely among Pacific Island nations: from 4.3 per cent in Solomon Islands to 10.6 per cent in Palau. This results in disparities among our region’s hospitals and clinics, medical supply chains, trained healthcare workers and in measures of health outcomes. These are valid reasons to tier aid in our region.

Strong public health services and health care delivery systems with the capacity to respond to injuries and infectious disease outbreaks, while maintaining care and prevention of chronic diseases, are needed in the Pacific in order to maintain a civil society, foster development, and prepare for future climate change impacts. Overlays of country specific programs tailored to address health development needs using stratified aid should be added to current aid schemes. We need educational partnerships with developed country healthcare professionals, administrators and technicians, as well as sector leaders, in order to put in place a broad health infrastructure that protects our people.

It is time to take a hard look at the way health aid is currently delivered in the Pacific and determine if it is resulting in better, sustainable care based upon improved outcomes. Is the program building health system strength from its foundation upward? Can we craft a new agreement on how to best facilitate this in countries like Solomon Islands by merging the current piecemeal aid into a comprehensive multi-national partnership with the host nation overseeing the program? This approach requires multinational cooperation in order to form a “health coalition” that uses political, humanitarian, economic, scientific and medical capital to meet its goals. International coalitions are employed in response to worldwide threats to freedom. We should employ the same approach in order to confront the health challenges our people of the Pacific face. Today the battle fields throughout our Pacific Islands are the hospitals and clinics where there are not enough resources to diagnose and treat increasing numbers of people with diabetes, cancer and heart disease, which have come from Western influences and the inexorable push of globalisation. Without the capacity to respond to chronic diseases, the health impacts of climate change and outbreaks of new infectious diseases, it will not be terrorism, China, or over-fishing that poses the greatest threat to our security in the Pacific region, it will be this “perfect storm” of multiple health threats that will overwhelm our underdeveloped health care and public health systems.

Rooney Jagilly MD is the Medical Director of the National Referral Hospital in Honiara, Solomon Islands. This article was written by Rooney Jagilly with help from Tenneth Dalipanda the Permanent Secretary for the Ministry of Health and Medical Services in Solomon Islands and Eileen Natuzzi an American public health surgeon working on health development in Solomon Islands.

by Dr Alex Cato

By | Musings of a Member | No Comments

Over many years I have witnessed much progress in all aspects of urology. There has been a vast improvement in equipment and the development of new and previously unthought-of gear. New drugs fix or ameliorate previously intractable problems. Patient management and practice has changed almost beyond recognition. Hospital organisation is completely different. Our training programme is now predictable, robust and reliable, producing better qualified practitioners.

There has been one area where the changes have been much less obvious but where there are still good grounds for optimism. I refer to 3rd world or developing country medicine and in particular urology. The way forward however is not set in stone nor even clear. There is plenty of scope for discussion and debate into the what, who, how, where and when to help these countries and communities grow their urology capabilities.

One area that underlies all development is the political will and economic state of the country in question. That is something we cannot alter at an individual level but must take into account when offering advice and providing training. Inappropriate support is not only wasteful but can also have serious adverse results.  A Dean of one of the Pacific Islands Medical Schools, when asked how we (Australia & NZ) could best support his health service, said “Stop pinching my graduates”.  Less aid may be required if he had more feet on the ground and more benefit may accrue from a few instructors than many specialist visits.
It has to be understood that any progress in the economies of these countries will be slow by our standards even with the best will in the world. This perception is especially strong given our very rapid changes in the last couple of decades. Nevertheless I have learned that there is enormous talent, ingenuity and dedication in the local populations that can be harnessed and these people have the most encouraging optimism.

“A Dean of one of the Pacific Islands Medical Schools, when asked how we (Australia & NZ) could best support his health service, said “Stop pinching my graduates”.

Some clinical aspects have changed so that the incidence of some problems has dropped to a fraction of previous levels. For the Pacific Islands (excluding PNG) the provision of surgical obstetric services has all but eliminated vesico-vaginal fistulae apart from the iatrogenic cases which are much easier to repair (this does not hold for SubSaharan Africa but their solution is to train technicians in caesarean sections capable of working in austere circumstances).
The treatment of other conditions has not moved with the times. Prostate cancer in the absence of regular PSA testing still presents late and on clinical diagnosis an orchidectomy is performed and the patient returned to his village. This is not likely to change in the mid term. It may seem rough to us but in the overall picture of their health service priorities it may be the most economical and culturally appropriate management.

Our urology community contains much goodwill but we must channel that in a productive manner. The recipients of our efforts are very capable of change and therefore what we offer must be relevant for the present but must change over time. We must also not forget that our improvements have come from the efforts of nurses and other clinical staff and these skills must also accompany our aid.

Currently these countries have excellent general surgeons(very general in the old-school sense – abdo, ortho, plastics, gynae, neuro, uro and paeds, often in the same day!) and the urology practices that we suggest must be tailored to their strengths. They each do more Millen’s prostatectomies in a year than we do in a career and as a consequence an abdominal approach to a vesico-vaginal repair is second nature for them. Reconstructive surgery with grafts and flaps is absolutely possible with training as there is no need for elaborate instruments.

The introduction of more sophisticated instruments e.g. rigid and flexible ureteroscopes with their attendant wires, baskets, access sheaths and stents as well as a working image intensifier may have to wait a little while until the local health services can afford the costs and ensure reliable supply. Nevertheless TURPs are a feasible first step into endoscopic urology and is already widely practised.
The above thoughts lead me to reflect on what our next generation will need to know to be of most value. Some of the aid may be intangible. Could some of our trainees spend 3 months (recognised) with one of these surgeons and get some skills in open surgery? This will acknowledge their abilities and strengths and thus they will become better practitioners and teachers of their own graduates.

They may be better able to instruct each other with occasional masterclass activities to upgrade their skills. Integration into our conferences will let them work out a way forward that takes into account their own needs and realistic capabilities. Our advice must be supportive but not gratuitous. Training opportunities for budding PI surgeon-urologists in Australia and New Zealand must be in concordance with their expected practice back home while still exposing them to new ideas and techniques.
On reflection of nearly 20 years observing these places and their people I feel that they can actually help themselves and can do so with enthusiasm and dedication. They have shown that they can accept and adapt to progress as we have had to do here. What we should now offer is something more collegial
The changes in these countries may have been subtle but they are there.

Dr Alex Cato was a VMO urologist at The Alfred Hospital in Melbourne for most of his career.  Dr Cato spent over 20 years doing volunteer work in the Pacific Islands and was instrumental in establishing urological services in the Pacific Islands, including the Solomon Islands.  Dr Cato received  the Member of the Order of Australia in 2009 for his services