DEPARTMENT OF PRIMARY HEALTH CARE

Research as a route in to Global Health - personal reflections

Dr Merlin Willcox MRCGP DTM&H

GP and Clinical ResearcherDepartment of Primary Care Health SciencesUniversity of Oxford

Plan

� Why research global health?

� How I got involved in Global Health research

� Opportunities

� Challenges

Why research global health?

� It’s interesting!� It’s fun!� You can make a real difference� More than just by working in the UK� Not just to your own patients but to others� You can learn new ideas and skills which can

benefit your patients wherever you work� You can leverage funding

Scenario

� You’re on an aeroplane� Call for a doctor� Patient collapsed in the central aisle� Airway OK, breathing OK, circulation OK� Unresponsive to pain or voice, GCS = 3� No fit witnessed� Nearest airport / hospital is 90 minutes away.� What would you do?

Blood sugar level

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0 5 15 20 30 40 50 60 80 100 120

Time (minutes)

Gly

cem

ie (

mg/

dL)

sugar

Is sublingual sugar effective for the treatment of hypoglycaemia?

Is sublingual sugar equivalent to i-v glucose for the treatment of hypoglycaemia?

� 151 children with severe malaria screened at hospital

� Definition of hypoglycaemia?� 26 had glucose <3.3mmol/l� Randomised to sublingual sugar or i-v

glucose� Outcome measure?

Impact

� Personal: Useful emergency first-aid measure� Global: Sublingual sugar is now included in

MSF guidelines for the treatment of suspected hypoglycaemia, e.g. in patients with severe malaria

How I got involved in global health research …

Elective in Uganda

Parasite counts in patients taking “AM”

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0 2 7 14Days of Treatment

Parasite Count

(geometric means, 95% CI)

Madagascar trial of chloroquine resistance-reverser� CQ + SM extract vs

CQ + placebo� SM is safe� No significant

difference� ? Insufficient dose� Increasing levels of

CQ resistance

Literature reviews

Do the DTM&H!

Plasmodium falciparumPlasmodium vivax

Research Assistant at Liverpool / WHO

� Literature review of measures to prevent HIV in young people

� Contacting NGOs to obtain reports

� Helping to coordinate a meeting

Mali

� Using local resources to improve management of malaria

� Collaborating with traditional healers

� Aiming for sustainable results

Village level

� Understanding life in a rural African village

� Primary care with few resources

� Prospective study of patients using herbal decoction for malaria

� RCT of herbal vs ACT

Hospital level

� Improvement in quality of care for children with severe malaria

� Aim to encourage referrals by traditional healers

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25

Jun Jul Aug Sep Oct Nov Dec

Month

All-

caus

e in

patie

nt m

orta

lity

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2006

Average 2002 - 2005

All-cause inpatient mortality (Hospital statistics)

Pre-hospital risk factors for inpatient death from severe malaria

� a wide variety of pre-hospital treatments were used, both modern and traditional.

� None had a consistent impact on the risk of death

� Girls were twice as likely to die as boys (AOR 2.00, 95% CI 1.08-3.70)

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1.0

Number of Hours After Hospital Admission

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viva

l Pro

babi

lity

MaleFemale

P<0.01

Health system level

� Pilot of Confidential Enquiry on Maternal and Child Deaths in Mali and Uganda

� Adapting UK methods to African context

� Identifying avoidable factors at every level

� Making recommendations

� Designing intervention(s)

Lessons learnt

� The longer you are involved in one area or project, � The more you will learn

� The more ideas you will have

� the more you will achieve

� You will become an “expert” in your area

� Good working relationship with local staff is probably THE most important factor

� Aim for sustainability – what will happen when you leave?

How to get involved

� Training opportunities:

� Volunteering for an NGO

� DTM&H

� MSc courses, some can be distance-learning e.g. MSc in Clinical

Trials at LSHTM

� PhD

� Network

� Conferences

� http://tghn.org/

� Join a team!

Opportunities for GPs in Global Health Research

� Most health problems are most efficiently dealt with in primary care

� Most research on global health is done by ID / hospital specialists or public health specialists

� There is very little research done in primary care

� A GP perspective is important� Simple interventions can make a big difference

We know what diseases are killing children …

We know which interventions will prevent most childhood deaths…

But how to deliver those interventions…?

SS Africa N&S America

% of world’s pop 11 14

% of global disease burden

25 10

% of global health workers

3 37

% of world health spending

1 50

Where are children dying…?

Example: Effect of training TBAs on perinatal mortality

� Wilson et al 2011, BMJ 343

Challenges

� Finding funding

� Finding good collaborators

� Understanding local culture and traditions

� Bureaucracy

� Logistics

� Communication

� Local politics