Working collaboratively to find solutions to global health challenges
Dr Liz Grant worked in Kenya as a Community Health Adviser at Chogoria Hospital during the 1990s when HIV came to the fore. While the focus on the deadly disease and the number of lives it claimed was acute, far less attention was paid to the act of dying, she observed.
“So few people in Africa actually get adequate palliative care. It has been one of the awful things that everybody does die and so everybody does actually need palliative care at some stage.
It is not a near unique thing that only 1 per cent of the population need – 90 per cent of the population need palliative care and particularly in the African situation where so many people are dying of HIV or TB or a number of chronic diseases. They are dying in absolute misery. Very few people have adequate morphine, adequate care of bed sores, adequate care of breathing. It is pretty upsetting.” Grant manages the project team for the University of Edinburgh’s new Global Health Academy, where one of her keen interests is international palliative care.
She recalls one woman she met in Kenya whose final days have stayed with her.
“When I was in Kenya I was setting up a palliative care programme at the hospital because there wasn’t one. I visited a number of people but one woman stuck in my mind. I had visited her a few times but she was deteriorating rapidly – she had cervical cancer – and she had a wound that was the size of a football that was just open. She didn’t want to go to hospital and wanted to stay where she was because it turned out she didn’t have any money, and she was terrified that if she did go the family would have to sell the tiny bit of land that she had. She had a very badly disabled son as well who had a very severe learning disability, so she was really not wanting to go.
“I was trying to wash her and I was struggling to manage her. I tried to turn her and there were maggots under her and there were faeces because she couldn’t get to the toilet. Her family couldn’t help her. She couldn’t get up. She hadn’t had any morphine for ages – she’d just been chewing Paracetamol as a pain relief – so the nurses gave her some right away.” That woman should never have been allowed to suffer in that way, Grant states firmly.
“People shouldn’t be living and dying in those circumstances in the 21st century. That shouldn’t happen.” There are ways of making very immediate differences, she says, such as ensuring staff have the basic equipment and the right skills and knowledge to offer the necessary services and support. Grant says she returned to Scotland “very committed” to looking at what support systems could be put in place here to help.
The University of Edinburgh has grasped the thistle by establishing the Global Health Academy (GHA), which, it proudly explains, will provide a framework for collaborative, interdisciplinary research and training that will contribute to strengthening the health resource base, globally. GHA is open to all those working towards finding solutions to our global health challenges, and brings together experts from areas as diverse as medicine and the biomedical sciences, public health, social sciences and engineering to share their resources and knowledge.
GHA has been built on three pillars, Grant explains: offering world-leading educational qualifications in the most appropriate way for the individual; supporting collaborative research, particularly in low-income countries; and building a community of practice.
Together, this community will put its collective mind to finding solutions to a broad range of global health challenges, explains Sue Welburn, the Director of the Global Health Academy. As well as the usual suspects, Welburn is also keen to see neglected infectious diseases, such as sleeping sickness, also given some thought.
“These are the diseases that don’t hit the headlines. They are not like TB or malaria or HIV, and yet hundreds and thousands of people are disabled or die or their crops and livelihoods are destroyed as a result,” says Welburn, who has 20 years’ experience working on human sleeping sickness and other zoonotic diseases.
Like Grant, she is a passionate advocate for her specialist subject, and would like to see far greater attention paid to the contribution a ‘One Health’ approach – linking human, animal and environmental health – can make in combating disease and alleviating poverty.
However, while Scotland has a great deal of expertise to share on many of these issues, Welburn believes that one area where Scotland can make a significant contribution is by sharing its knowledge of non-communicable diseases.
“Where Scotland can have a very large impact in the next ten years is with our experience of non-communicable diseases,” she says.
“We have faced tremendous challenges in Scotland across the economic spectrum in terms of dealing with chronic diseases like diabetes, cardiovascular disease, COPD, and cancers. And this is a huge tragedy, really, that is waiting to hit the developing world.”
While some “very strong inroads” into infectious disease have been made, she says we are still waiting for the “magic bullet”. And as if that wasn’t challenging enough: “Now, at the same time we have the sort of tsunami of noninfectious, non-communicable diseases coming on top,” she adds.
Such conditions were once considered to be “western” or “luxury” diseases, explains Grant, and it has only recently been recognised that countries in Africa and Asia are also seeing huge numbers of people develop them “China has the highest diabetes burden, probably now in the world and it is because there has been this globalised trend in fast food, and marketing from the tobacco industry to target lower-income countries, particularly as our bans are in place. The epidemic that is lying behind tobacco and also alcohol use is phenomenal,” she says.
“That is the terrible tragedy,” continues Welburn, “to survive childhood malaria only to get diabetes. And we don’t know yet what the dual burden of these diseases – from living under these stressed conditions and the infectious disease and then the impact on the noncommunicable disease – means.”
However, Scotland has “led the way” in dealing with these diseases, especially at a community level, she says. “So we need to look at how do you translate that and take that knowledge and learn from these practices.”
Grant shares Welburn’s confidence of the contribution Scotland can make, arguing we have the right mindset for the task.
“Scotland has the opportunity to do this as well. Scotland is outward looking and I think it is that zeitgeist and the sense of security in Scotland that allows people to move out and think wider.” And they are both hopeful that the GHA can also play its part by bringing such issues to the forefront and challenging people to step out of their silos and work together.
“I suppose what the Global Health Academy is attempting to do with these really quite crossdisciplinary, multidisciplinary problems that can’t be solved from silo working – and I think that is what we are seeing more and more in global health if you don’t have teams working together and connecting together, we can’t solve these problems because we just don’t have the individual skill bases to do it – and it is instilling that in the students as they come through,” says Welburn.
Students, past and present, need to understand that working together is “the right thing to do”, she says.
She continues: “It is a sort of paradox, really because we are always taught not to copy each other’s homework and not to look over each other’s shoulders, so the driver in education is to do something yourself. So we need a paradigm shift in that to say, actually, working in a team, and a team of people who are not all necessarily from the same field, is good.
“And that, I think, is the opportunity that the Global Academy and the university is establishing,” she adds. “That is, to break down any barriers between students, staff, disciplines and units to get this cross working and develop a community of practice of people trying to solve a common problem together. ”