TOPSHOT - Health workers carry a coffin containing a victim of Ebola virus on May 16, 2019 in Butembo. - The city of Butembo is at the epicentre of the Ebola crisis, the death toll of the outbreak to date is now over 1000 deaths. The Red Cross warned that critical underfunding could force it to cut vital work to rein in the deadly Ebola virus in the Democratic Republic of Congo at a time when case numbers are soaring. (Photo by JOHN WESSELS / AFP)JOHN WESSELS/AFP/Getty Images
Health workers carry coffin of Ebola victim in Butembo, the epicentre of the DRC outbreak © AFP

I dedicate this to the WHO's Carlo Urbani and Richard Valery Mouzoko Kiboung, who died serving their communities and who represent the selfless and brave healthcare workers around the world who put their lives at risk to make all of us safer. 

In the past decade there has been huge progress in improving health worldwide. But that incredible advance is fragile and easily reversed by the impact of climate change, the spread of antimicrobial drug resistance, the rise of non-communicable and preventable diseases, and vaccine hesitancy.

Public health and clinical medicine remain chronically underfunded, and with some regions in almost continuous conflict, the challenge is ever greater.

The frightening Ebola epidemic in the Democratic Republic of Congo is something I dwell on often. Epidemics start and end with communities. We now have Ebola vaccines and treatments, but public health efforts cannot succeed without the ownership, involvement and consent of those affected. 

And not just in DRC. Daily news reminds me of the many who are unconvinced of the value of vaccines. Negative imagery of terrified children and looming needles does not help. 

These are among the issues under discussion at the World Health Assembly, which I will attend next week.

Global ill health often paints a bleak picture, but we should remember the hope too. Walking to work, this wonderful image struck me.

These challenges are too big and complex for any one organisation or country to handle alone. Solutions depend on international collaboration. That cannot be achieved with a return to a nationalistic world, where we care only about ourselves and those like us.

Research can, and does, change humanity. We must ensure it continues to flourish, that it is embedded in clinical care and public health, and that innovations reach all who may benefit — wherever they call home and regardless of ability to pay.

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Three questions

Jeremy spoke to Prof Tim Cook, consultant in anaesthesia and intensive care medicine at the Royal United Hospitals NHS Trust Bath and director of the national audit project programme at the Royal College of Anaesthetists.

What is the greatest challenge you face as clinician working in the National Health Service today?

The greatest challenges are managing increasing healthcare demand, limiting capacity, and amazing clinical opportunity. The success of healthcare has enabled more of us than ever before to live longer (although often with chronic diseases) and to have the opportunity of almost limitless new therapies, which are offered to us at almost any age. In the coming decades, challenges arising from ageing populations, antimicrobial resistance, and global warming may dramatically reduce the quality and extent of healthcare we can expect to receive or offer.

What can we do to facilitate clinical/public health research within the NHS?

The administrative burden associated with planning and performing research needs to be addressed. We need to turn back the research governance ratchet that has made research less accessible for most clinicians and dramatically impeded nimble reactive research (eg during pandemic flu) that addresses real public health challenges in clinics and hospitals. This could re-energise and democratise NHS research and create opportunities for clinical/public health and citizen science. 

What advice would you give to a funding agency like Wellcome?

Research needs to be brave and innovative — accepting that much will fail and some will go down blind alleys — inspire and back young researchers from diverse backgrounds, encourage innovative methodologies (accepting the many limitations of randomised controlled trials), ensure equal access based on merit, and shift research from ivory towers to where front-line clinical care and public health can address common high-burden issues.

Books I’m reading

Five Go on a Strategy Away Day — Bruno Vincent

King Leopold’s Ghost — Adam Hochschild

News reports

Snakebites: Like having my hand smashed by a hammer As Kofi Annan once said: “Snakebite is the biggest public health crisis you have likely never heard of”. This report and the accompanying WHO strategy bring into sharp focus the enormous burden of snakebite, the loss of life and disability to so many people. Treatment is possible, but it relies on many techniques which were invented in the 19th century and which are simply not available to most of the people who desperately need them. A new initiative is bringing together partners — including the WHO, MSF and Wellcome — to reduce the number of deaths and disability by 50 per cent over the next decade. (BBC, WHO)

The death of antibiotics Modern medicine depends on the ability to control infection. We are losing the most precious group of drugs ever invented — antibiotics — as infections become increasingly resistant and common ones become deadly. The issues are complex, but solvable, needing investment, behaviour change, different economic models, stewardship of what we have now and protection for any new antibiotics we develop. Above all, it needs political support at the highest level. (Newsweek) 

A mystery illness killed a boy in 1969 Years later, doctors learned what it was: Aids. In my very early career as a young doctor, I witnessed the fear and prejudice before we knew what caused Aids and before there was any treatment. We watched helplessly as mostly young people died, with public health and clinical medicine impotent to intervene. It was devastating. And then over 10-15 years, through science, research, and engagement of the HIV community, we slowly worked out the cause and could provide public health advice. Then came the start of the era of treatment, which turned a death sentence into a long-term manageable condition.

We were far too slow to appreciate the impact on low-income countries, particularly in Africa and Asia, and far too slow to make treatment available independent of the ability to pay. This superb article traces back to a mystery illness in the 1960s (in fact HIV probably first appeared in the 1930s) and reminds us all just how important it is to remain curious in medicine. (Washington Post)

Rwanda could be first to wipe out cervical cancer Most cervical cancers and an increasing number of the head and neck are caused by the human papilloma virus. There has been a vaccine against HPV since 2006 and many high-income countries now offer the vaccine to young teenagers with remarkable results. However almost 90 per cent of the deaths from cervical cancer occur in low and middle countries where access to the vaccine is limited. Rwanda, emerging from the horrors of civil war, has prioritised vaccination, and in particular HPV vaccine, as part of its universal health coverage. This article shows just what can be achieved with political leadership, commitment to health for all and ensuring evidence informs policy. (Mosaic Science)

Breaking through the glass ceiling Dr Tshidi (Matshidiso) Moeti is an inspiration. She has transformed the Africa Regional Office of the WHO, providing vision, leadership and amazing diplomatic and people skills alongside her brilliant technical knowledge as a public health expert. (Telegraph)

Welcome to the Departure Lounge Death and dying are issues few of us can talk about with comfort or confidence. This project, led by the Academy of Medical Sciences, provides a safe space for all to explore these difficult and challenging issues, and deal with them with sensitivity, humility and even humour. (Guardian)

Incubating innovation We are lucky to live in a golden era of science and culture and yet also one of tremendous uncertainty. To address the great challenges of our time we will need to be ever more creative and innovative, and yet with changing incentives, geopolitical shifts and growing inequity, it can be difficult to see where critical innovation will come from. This article serves as a wake-up call and a clear argument for sustained investment. (WGBH News)

Research and academic identity Many key breakthroughs will be made by early career researchers in social sciences and humanities. Yet the career pathways for these individuals and teams are poorly developed and under resourced. (LSE blogs)

Leonardo da Vinci — lessons for 21st century cities With more than 55 per cent of the world’s population now living in cities, the impact of the built environment has never been more important. But those who do not learn from history are doomed to repeat it. (The Conversation)

Infant mortality in Africa Inspirational for just what can be achieved when science is linked with innovation, development, policymaking and implementation. (Robert Wilson, Twitter animation)

The rise of ‘populism’ is damaging public health . . . and a warning of just how fragile progress is and how we cannot take it for granted. (The Economist)

Supporting the ailing antibiotics market The most honest, brutal assessment of the crisis in research and development for antibiotics and the impact of antimicrobial drug resistance. (Forbes)

What's it like to be a woman scientist in India? Gagandeep Kang is the first Indian woman scientist to be awarded a Fellowship of the Royal Society. I have had the privilege to know Gagandeep (Cherry) Kang as a collaborator and friend for many years — it is wonderful to see her unique contribution recognised in this way. (The Hindu)

Scientific journals

Measles and the path to elimination The number of measles cases in the first three months of 2019 quadrupled compared with the same period last year, surging in many regions and reappearing as major public health issues in countries, including the US, where it had been eliminated in 2000. 

Measles is highly infectious, can cause severe disability and death and yet is entirely preventable by a safe, affordable and available vaccine. To eliminate the disease, a very high proportion of the susceptible population must be vaccinated. But as some have questioned its value, vaccination rates have fallen and the disease has returned with more than 100,000 deaths a year. This paper demonstrates how countries can develop policies to achieve elimination. (Science)

Contagious cancers: A ‘devil’ of a problem We have known of the link between infections and cancer for many years but, thankfully, cancers cannot be passed from one person to another. The Tasmanian devil — nature's largest carnivorous marsupial — suffers from a contagious form of cancer called devil facial tumour disease, passed between them as they bite each other during territorial fights. As so many emerging diseases in humans originate in animals, it is crucial that we learn from this in case such a cancer emerges in humans. (eLife Sciences)

Global chemotherapy demands Demographic shift, lifestyle and environment change are having a profound impact on the nature of health and disease. This superb paper outlines what we can expect over the next twenty years in cancer and the demands on public health, the clinical workforce, prevention and treatment. 

Prevention, universal health coverage and equitable access to treatment are key, but planning for that, training the next generation for the demands of tomorrow and using technology to support that growing demand is critical. This is the sort of paper that health and finance ministers around the world need to read, appreciate and plan for. (The Lancet)

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Final thought

Please watch this: the one in red is all of us at some point in life. It has to make you smile . . .

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