Stopping Smoking in SSA: where is the evidence?

It would be nice to celebrate World No Tobacco Day with a piece of evidence from SSA countries about how we can help people quit. But I can't find it, anywhere. On the other hand, 17 of the 27 countries in the world in which smoking prevalence is rising are in Africa, where big tobacco is flexing its lobbying muscles. There are important public health interventions in the WHO's Framework Convention on Tobacco Control (FCTC), including raising taxes and these are being implemented in some African countries. The triple, half, double tactic has an effective ring to it (triple the cost, halves the number of smokers and doubles the tax revenues).

In 2005, Cape Town was one of the sites of the Burden of Obstructive Lung Disease (BOLD) study. In it, 22% of men and 17% of women aged > 40 years were found to have at least moderate COPD, compared to an international average of 10%. A similar high prevalence of COPD to Tanzania and Uganda. The most common risk factors were smoking, biomass fuel (moreso in women) and TB. In this weeks featured article, the original cohort of patients of 189 persons with COPD were followed up 12 years after their enrollment in the BOLD study, at which point the authors found 45 (23%) had died, an outcome associated with age and severity of COPD. Reflecting this years World No Tobacco day, the majority of deaths that were of a known cause were from cardiovascular disease (10/24, 42%). In those that could be followed-up (107 persons), there was a strong link with pulmonary TB, with 37% of patients previously being diagnosed with PTB, and 10 persons (9%) having received treatment in the interim period, reflecting double of the national incidence of TB. As expected, the majority of persons were current (56%) or ex-smokers (32%), unfortunately biomass fuel exposure and passive smoke exposure were not measured. Interestingly, in country were HIV prevalence is 12.6%, none of the patients had HIV and all were from the mixed-race community, making the sample non-representative of the country as a whole. Finally, the majority of patients were symptomatic whilst having low coverage of treatment (<1/3 on any inhalers).

This prospective observational study adds outcome and treatment gap data to evidence of a high prevalence of COPD in South Africa and other SSA countries. The Cochrane Tobacco control library features multiple excellent reviews but the majority of studies are based in developed countries. Now would be an excellent time for a stop smoking intervention study, based in SSA. In the meantime, the next time you have a consultation with a patient who smokes, for any reason, why not ask them – “have you ever thought about stopping smoking?” – even a brief intervention will help.

Azithromycin and Quality Care

This is my first blog that hopes to distill and appraise some of the recent relevant and practical research for training and practicing medics in developing countries. In it, I will try and select just a couple of recent papers and pick out some of the key areas of discussion. It goes without saying – anything not open access will not be discussed.

I will kick off with one of the more high profile studies of recent weeks, a cluster-randomized, double blinded control trial of azithromycin, given every 6 months for 2 years, to children aged 1 month – 5 years in Malawi, Tanzania and Niger, published in the New England Journal of Medicine.

To start, what a huge undertaking, almost 200,000 children across 1533 communities were identified  in the baseline survey. Why the need for such a large sample size? Essentially, a mixture of factors – reduced child mortality means a lower rate of primary outcome, relatively large variation between clusters, and an estimated effect size of 10%.

The results show a statistically significant reduction of 13.5% in under 5 mortality, with the majority (and indeed only significant) benefit seen in the largest site – Niger. In subgroup analyses of different ages, the youngest (especially aged 1-5 months) have the greatest benefit. Interestingly, as time progressed over the 2 years, there appeared to be an increasing effect of azithromycin.

Facing the current global antimicrobial resistance threat and evidence from trachoma mass drug administration of azithromycin resistance (as described in the trial), the concept of mass antimicrobial prescription is tricky to reconcile. Furthermore, outside of specific subgroups, the only real benefit was seen in Niger, where child mortality is highest and pneumococcal outbreaks common with limited (as yet) vaccine coverage. In Malawi and Tanzania, only a modest trend was seen (perhaps with greater numbers significance would have been reached). Finally, data collection was census based and relatively minimal, not providing enough information about to understand how and why the intervention seemingly worked. Do we change practice because of the trial? I would argue not without more information; better vaccination may be more targeted and longer term benefit may be more likely with a health systems approach. This intervention seems like a temporary bridge to quality care.

On the subject of quality care, a vaguely defined evidence synthesis (non-systematic review?) joint effort by the World Bank, Harvard University and the BMJ, found that universal care does not automatically equate to quality care. Citing examples such as 90% of angina cases misdiagnosed in Nairobi, they argue that improving quality should be a pre-requisite for access, as without it – what is the point in access? Qualification do not equate to clinical knowledge – a large proportion of nurses in Kenya outperform doctors on clinical vignette testing, and finally, that often even though staff know what to do – because of short consultations and perverse prescribing incentives – they don’t do it. Despite the limitations in methodology, the authors make an important point, we need new approaches to tackle low qualitt training, under-motivation and under-utilization of healthcare professionals. But do they need to be “new”? Globally, there is a wealth of experience on these areas, we just need to implement it.

Nb. One acronym used for the needs of healthcare providers by the Health Information For All (HIFA) group is SEISMIC: 

- Skills
- Equipment
- Information
- Structural support
- Medicines
- Incentives
- Communication facilities.

Acknowledgment also goes to Dr B Sossen, for presenting the NJEM paper last week.

Small Differences

It seemed fitting that the day after the #Brexit vote I was astride the continental divide in Montana where one drop of rain, by the difference of a few centimetres could end up in the Pacific or Atlantic. Sometimes the differences can be so small yet the end effect so dramatically different. What would have happened if David Milliband had won the labour leadership contest, if David Cameron had taken the decision not to hold a referendum he was so confident of winning, and if Boris hadn’t gambled his future premiership on leading the Leave campaign? Nevertheless, this is the mess were are in.

Dillon, Montana

In the quiet 5,000 person town of Dillon, Montana, nestled amongst snow-capped mountains that seem to capture the twilight for the majority of the day, these questions can seem far away. Which would be true if it wasn’t for the fact that it is – and still pretty well remains 2 weeks later – the opening question of a conversation once it’s clear I am from the UK. Whether I am in a shop, restaurant or, as seems not uncommon here, just sitting minding my own business “So what’s going on with Brexit?”. These last 3 weeks we have been a showcase for the world. The night of the vote I watched on CNN as it was wall-to-wall coverage (interrupted only by adverts of overly sincere “honest, hard-working people” telling people that “I work for this company, they care about us – the people – and that’s why you should come and buy an RV from us”).

It’s easy to see the parallels to the Trump “Make [insert country] great again!” scenario, people want to exercise a desire for isolationism and control of immigration. I have found it surprisingly hard to draw many people into declaring their voting tendency on the trip so far. In a similar way to Brexit, as one very friendly man put it, “once they get into the voting booth it’s their “guilty secret” to vote for Trump”. Scarily, and only having been here a few short weeks and visited a few places, I think he might win. From people I speak to I don’t get the feeling people like or identify enough with Hilary, especially to compete against the bold, brash and proud Americans (who I have to admit have all been incredibly welcoming and kind to me all the way through the route) who want to “take back control” of their country and see Trump as the modern day hero who can do that for them.

Westport. Credits to Ed for excellent photo

The epitome of this feeling was in the fishing town of Westport, South Washington where Ed and I arrived, slightly damp after battling a headwind from Aberdeen, the suitably oppressive hometown of Kurt Cobain. On the road we had only passed “Trump for President” signs. One house in particular was entirely bedecked with Trump signs and the accompanying “Hilary for Prison” sign. We didn’t stop as the elderly man and presumably owner of the turf stood by and watched over his creation. The town of Westport stood like a chessboard on the end of a sandy spit at the mouth of the Chehalis river and was the culmination of ever more ragged, bearded and rundown settlements heading westward. From our campsite, we hitched into town for dinner where we fortuitously bumped into the only taxi-driver in town who offered to take us back when the time came. For a slap-up dinner Bennett’s fish shack managed to deep-fry everything in sight for us requiring us to head to the local bar to try and settle our stomachs. As we walked in conversation stopped but heads refused to turn, the quiet eventually punctuated by the end barstool being knocked to the ground. The bar lady (and the taxi-mans' last customer) sent out a controlling missive to the punter while the NBA play off’s game 6 ran silently in the background. Ed and I ordered and slank off to a table on the far side of the bar. Gaining in confidence we sidled over to the table tennis table where, after a few rallys we noticed the wiped bloodstain across the corner of the table and onto the floor. This was the Monday after the weekend before. I couldn’t imagine any of these residents of Westport having any time for the political elite that Hilary represented or the vague elements of social welfare that she stood for. For this American town, the men of whom were seemingly a mix of fishermen, veterans and jailbirds (or all 3) and a single one of whom we were yet to find without a speech impediment, Trump seems the logical option.

The beginnings of an acrimonious campaign

 At the centre of both Brexit and Trump campaigns is immigration. One fellow cyclist told Ed and I that, when Trump said he would build a wall between the US and Mexico and make Mexico pay for it, a friend (to his horror) had said to him “finally, I’ve been wanting to do that for years”. As we travel south, the Mexican influence becomes greater, but my favourite immigration story comes from back in Dillon where we started this blog and only 3% of the Montana state population are Latino. The story was actually covered in the LA times, but is now woven into history of the town. Los Koritas the local Mexican restaurant serves the entire community delicious (I can vouch for this) Mexican food including a weekly breakfast meeting held by Mayor George Warner and his colleagues. For the last 3 years the restaurant has been run by Yeni, who lives in the town with her 3 children. The article describes how Yeni’s and her children’s story of illegal entry to the country 10 years ago was told to this group. Their response? Illegal immigration is still wrong, but “as far as we’re concerned, she’s one of us”. In the time since the article was written nothing more has been mentioned at the breakfast table and Yeni continues to serve George and the rest of her customers.

If it started fittingly for Brexit, it ends ironically. As I write this article I’m sitting at Cape Arago on July 4^th on Independence day. The sun is setting over the Pacific and it’s warm bar the odd ocean breeze that brings with it a shiver. It’s a peaceful and stunning view, the sea-lions pop to the surface intermittently and gray whale’s rise infrequently in out at sea to let of steam. The couple next to me (predictably) began by asking about Brexit, which led us to their disenfranchisement with politics in general. But, they have found their solace here “last year on this day, we sat and watched 3 humpback’s breach and blow bubble nets in the bay in front us, I never realized the come so close to shore” the lady says “when you see things like that, politics seems less important."

Cape Arago: Sunset on Independence Day

Small, small to big, Big

The last week has been a comfortable and comforting settling of the dust. The last few weeks in Connaught have been – as ever – hectic and packed with action. 

For anyone lucky enough to chance upon this blog or have been redirected by a Nigerian email promising the riches of the late Prince Oleku. Sorry, this is another bike trip blog and the subject and content of the next few weeks is going to be just that – the journey and a few other bits. 

As I sit on the dock of Fulford Harbour, waiting for a ferry to take me to Victoria with a hippy couple who are perhaps getting a deeper appreciation of the beautiful deepening greens and blues of the evening than me, I’m wondering how did I come to do this trip? I can think of a few reasons. 

Fulford Harbour

 Firstly, I bloody love cycling trips. In fact, i’m a bike holiday evangeslist and if I get as far as this bible belt, those guys and girls are more likely to leave on a bike than I am with God. And the West Coast of the US is somewhere that’s long been on my list – amazing views and iconic cities – and not to mention now a few friendly faces along with way. 

Ron: A familiar face

Secondly, less than 48 hours after leaving Sierra Leone I was cycling (on the wrong side of the road – thanks the guy in the jeep for pointing in the right direction) out of the airport. I want to experience the extremes, the differences from a country a notch off the bottom of the World Bank Human Development Index to (arguably) the most developed and affluent in the world. As Saloneans would call me, I want to be the “JC” “just come” fresh of the boat and wide-eyed with wonder.  And so far – maybe obviously – the contrasts are stark and all pervasive. They exist in the accuracy, efficiency and safety of systems – I don’t think I’ve been on a ferry in 5 that has run late yet - and the scale of investment and quality of products and industry – as Ron and I cycled home from Seattle city centre, we docked at Pier 52, 20 mins cycling and 1 beer later we were at Pier 91 and still hadn’t reached the end. 

There are similarities as well as differences, people are people and they remain kind, cheerful and welcoming – the world is a better place than you think it is. Leaving Vancouver airport, a fellow cyclist and I took a bonding trip to the nearest bike shop, she has lost her bearings and I had forgotten my nuts. The area of Richmond we cycled through was entirely bilingually signed in Chinese, even down to the many decade old businesses – “Doug’s Collision Centre” had a Chinese version sign, huge development plots were owned by Chinese investment vehicles. This was an unexpected similarity to Sierra Leone, where acres of beach frontage are now Chinese owned and Chinese businesses pepper the busy Wilkinson road. 

The night before I left Vancouver, I sat in a bar chatting with an Aussie and a Canadian. They probed into these differences and the experiences. I found it difficult to verbalise  what Sierra Leone is like and some of the challenges and lack of freedom of opportunity of average person, without making it sound like I was making it up or some kind of deliberate act of trying to shame them. On reflection though, that’s just what it is – unbelievable, unjust and… unacceptable. And this leads me to the third reason I’m cycling: I am raising money for the King’s Sierra Leone Partnership (KSLP). KSLP are the London-based health partnership for whom I’ve been working for the past almost 18 months. If you want to find out a bit more about the great work they do, then please check out the website. If I was to try and summarise why I think they are worth supporting, I would say this: 

At their worst, but also in my limited experience relatively commonly, developed and developing country collaborations can be relatively extractive and with an unhelpful emphasis on a research focus. I think KSLP is different and to an extent novel as the focus is much broader, with aims to help our Sierra Leonean partners to directly improve services for patients, education for doctors, nurses and allied healthcare professionals and create an enabling environment and system to work in. Research is, of course, key but only in way that supports these other aspects of KSLP’s work. If we are looking for evidence about why this broad and systemic approach is important, I think we need look no further than the Ebola outbreak, which highlighted that it’s the system that needs improving, rather than one specific area. In the past year, I’ve also come to learn a little about funding and how challenging it is to find – especially when it is for something new and different. And how important it is to have money, which KSLP can decide (wisely) how to spend it best, rather than funds that come with tight donor restrictions.  So for these reasons, I want to support KSLP and I hope that you can help me do this.  The link to the just giving site is here. 

(For anyone who wants to get involved, there will a Kilometer Competition - for each 20 pound donation you get one guess for how many kilometers the journey will be. There will be special 1,2 and 3rd prizes!)

The final, and obviously most important reason, is that my buddy Matt beat me on a bike ride in April, for the first time in to many years. Its time to do some training. 

So the title of the blog – Small, small to big, Big… In Krio “small, small” is a turn of phrase, “you have to start somewhere/little by little”. And that’s where we start with the bike ride, for the fundraising and for KSLP itself. My experience of Canada so far is BIG* – big cars and trucks (pic), big roads, big ideas, portions and people. Now as Ed joins the road in Seattle, lets see how much bigger it gets…

A big yoke

*Big in the Howlett family dictionary can be used for any form of exaggeration. A big car/horse – “that’s an awful big yoke”.  An important event/ - “this is big stuff”

Carnivals and Christmas: Looking back on a year in Sierra Leone

The dust is settling in Freetown as the dry, cooler Harmattan winds blow off the Sahara for Christmas. Each morning you wake to a fine layer covering the surfaces in the house and the previously expansive view across the 3^rd largest natural harbour in the world is shrouded and the waters still in the hazy sunrise. By contrast Freetown is vibrant and chaotic as Christmas approaches. Each day bring a new sign for a Carnival, most recently the Nurses of Connaught Hospital Carnival – tonight Friday 18^th December – and another street is festively adorned with bunting (where does it all come from?). One older Sierra Leonian Muslim proudly told me “no one does Christmas like the Sierra Leonians…”. An exciting prospect for the next could of weeks.

As I mentioned in the last blog this is an incredibly young national, in 2010 50% were under the age of 20 and it feels like it. At night the hum of music and bars, cheers from screened football matches and noisy streets drift through the air. Our street had a carnival (street party) in November. After a relatively gentle start it was only after midnight that things really got going – big sounds systems, dancing, eating and drinking... I thought, does no one on the street mind about the noise? Then you look round and can see – the street are all here, maybe one or two houses had some older members who may be at home with earplugs  (or dancing Dom) but otherwise the whole street was young and out partying.

I feel that the conical age distribution sometimes it gives the city the feel of an impetuous, sometimes cheeky 20-something year old, brimming with vitality to go places and do things, but lacking the outlets and opportunities. And with the energy and good humour that they carry, I guess it’s easy to forget what this generation has been through, and although war and ebola come to mind, these are in equal part the symptoms and cause of their issues. Many, many more have lost family members to systemic problems of childhood disease, childbirth, HIV and accidents than the headliners.

This year has been like no other, I have no misgivings and I chose it, but there is no doubt work in Sierra Leone can be an emotional rollercoaster. Arriving to Sierra Leone in the shadow of the Ebola epidemic was harrowing, moreso to hear the stories of others from the previous months although reminders still stung you from time to time. Honestly, I still sometimes have to pinch myself when I go to work, just to remind myself its all real – the global inequalities are so gross and so tragic. At the same time, I’ve met people for whom praise and admiration is the only thing they deserve – nurses, doctors and others that I hope will be friends for life.

One of these friends was a guy named Ivan. We ran together on the hash and partied away a few evenings (and mornings..?). And, although I knew him for a few months, we became good friends and he was one of those young people who was lucky to be given a break of a beneficial sponsor through school, an opportunity he grabbed with both hands. He worked for the UN, was learning languages and was energetic and full of ideas for himself and the country. Unfortunately, the night after the Street Child Makeni Marathon, he was killed in a road accident. For his friends and family it’s a tragedy, for many of us were there when he died it’s a memory that will stick in our minds and for Sierra Leone sadly I think it’s a loss that may never be fully accounted or realized.

On the wider context, I’ve been between African countries for the last 15 months and the wider context is of business and growth in a sea of ageing and grandiose leadership dotted with islands of governance. In Tanzania happily the future seems brighter with the recently elected Magufuli showing how it’s done. And in this vein, it remains clear to me now as ever that neither I nor any expatriate colleagues will ever, or should ever aim to, make the lasting changes to a country, that is the task of its people and will always come from within. But I'm proud that,in our work at KSLP, we are trying make a space for and support those who are willing and do want to. And so I’ll finish with something that Ivan told me. In fact, as we drove up to Makeni I asked him to remind of it because I’d forgotten from the last time.

If you go somewhere for a year, you grow rice, if you go for 10 years you grow trees and if you go for 20, you grow people.