Lord Ribeiro
To ask Her Majesty’s Government whether they will support the strengthening of emergency and essential surgical care and anaesthesia by the World Health Organisation to reduce the global burden of disease.
Lord Ribeiro (Con)
My Lords, I thank the Leader for making the allowance for me to get in and start this debate. I shall open by quoting from a paper in Lancet Global Health in 2014 from the surgical departments of Massachusetts General Hospital, Boston Children’s Hospital and Stanford University, California. It states:
“Global health efforts, guided in part by the Millennium Development Goals (MDGs) have focused mainly on the prevention and treatment of malnutrition, obstetric disorders, and communicable diseases. With the exception of a few surgical procedures—eg, caesarean delivery and male circumcision”—
the latter because it reduces the transmission of communicable diseases—
“surgical interventions have been largely ignored”.
The purpose of this debate is to raise awareness of the value of surgery as a means of delivering effective public health.
In 2010, road traffic accidents accounted for 75.5 million disability-adjusted life years, or DALYs, up by 20 million since 1990. Cancer is on the increase, as are other non-communicable diseases, as life expectancies in developing countries increase with the reduction of HIV/AIDS and deaths from malaria and other infectious diseases. The perception of surgery as an expensive intervention may itself be a barrier to its acceptance as a means of reducing the global burden of disease. There is good evidence from Professor Haile Debas and others that surgical conditions, especially trauma and injury, obstructed labour and congenital anomalies such as club feet and cleft palate are all public health problems. Yet attitudes to surgery—that it is only affordable for the rich in developing countries and lower-income countries—mean that it does not appear on the public health radar for the poor.
Let me give some facts. I thank the Library for its excellent briefing documents, which I hope all noble Lords have received. There are 234 million surgical operations performed globally every year, but the poorest one-third of the world population receive 3.5% of all surgical operations. Approximately 2 billion people have no access to surgical facilities, and this is a global crisis. In high-volume countries—the haves—we have more than 14 operating rooms or theatres per 100,000 of population. In sub-Saharan Africa there are fewer than two operating rooms per 100,000 of population. Globally, 77,000 operating theatres have no pulse oximeters to diagnose hypoxia, or low oxygen levels, during surgery. Here I declare an interest as the patron of Lifebox, a charity which delivers pulse oximeters globally. In all, this amounts to more than 30 million operations worldwide without basic safe monitoring. It takes us back to the old days, when one felt the pulse and estimated the condition of the patient purely on feel.
In 2012 the noble Lord, Lord McColl, and I hosted a meeting of surgeons determined to bring these concerns to a wider audience. We and others cofounded an organisation called the International Collaboration for Essential Surgery, or ICES. The concept is not new and it has been debated for more than 40 years, but the problem is becoming acute in developing countries as more of them suffer a brain drain of their doctors and highly qualified nurses. The definition of essential surgery is the provision of basic intervention which will prevent premature death and long-term disability. Evidence suggests that there are 15 basic surgical interventions which will deal with approximately 80% of basic surgical need and the commonest urgent pathology in a community, particularly in rural areas where doctors are scarce.
Because of the loss of traditionally trained surgeons, who migrate to the private sector in cities, work for NGOs or emigrate to other countries, we need to train up a new cadre of non-physician clinicians, or NPCs. In 1963 Tanzania started to train NPCs, commonly known then as barefoot doctors, as the idea came from China. Malawi’s first medical school began by training clinical officers to carry out general surgery, obstetrical procedures and others in 1980. Similar programmes have developed in Niger, Zaire, Burkina Faso, Ethiopia, Senegal, Somalia and South Sudan. I believe that this paradigm shift is happening right across most of sub-Saharan Africa; it is just that the rest of the world needs to recognise it and catch up with what is happening. There are currently some 47 sub-Saharan countries using non-physician clinicians or clinical officers.
As chairman and vice-chairman of the All-Party Parliamentary Group on Global Health, the noble Lord, Lord Crisp, and I wrote to DfID, pointing out the benefits of surgery in the public health arena. We posed two simple questions. How will DfID raise the profile of essential surgery as a public health priority, and how will the department help to frame surgery as a crucial and affordable public health intervention? The response was both disappointing and bland and suggested to me that the department’s focus remained on communicable diseases and the well-being of mothers and children. I am not saying that that is not an important priority, but that appeared to be its continuing stance. However, let us contrast that with the way in which the Department of Health and the then Chief Medical Officer, Sir Liam Donaldson, promoted the surgical checklist as part of the patient safety agenda in developing countries. This is now a must-do exercise in all NHS hospitals in the UK, and is gaining traction in sub-Saharan African countries.
The World Health Organisation initiative is making a difference not only in this context in terms of patient safety but in other areas as well. The WHO pulse oximetry project, to which I referred earlier, run by Lifebox, is a case in point. Similarly, the WHO global initiative for emergency essential surgical care and guidance for essential trauma care is also something that is developing apace. I noticed the criticism of DfID by the House of Commons International Development Committee in March, when it accused DfID of,
“raiding bilateral development programmes in low income countries”,
to,
“support disasters in middle income countries”.
It noted that,
“expenditure on low-income countries is … significantly lower than in 2010-11”,
and suggested that,
“DFID staff spend less time writing the perfect business case and more”,
time on the ground.
The International Collaboration for Essential Surgery, or ICES, has produced a powerful film entitled “The Right to Heal”, which was shown here in Parliament. This film identifies seven conditions which cause the vast majority of preventable surgical deaths and disability. They are quite simple; they are hernia, club foot, cleft palate, injury, cataracts, appendicitis and obstructed labour—which inevitably, in very young girls with underdeveloped pelvises, can go on to cause urethral fistulae. Surgery can relieve the suffering from many of these common conditions and return people to normal lives.
Will the Government support the resolution on emergency care, agreed by the 67th World Health Assembly, attended by 42 countries, including the United Kingdom, to be submitted at the 2015 assembly meeting? Secondly, the post-2015 sustainable development goals present an opportunity for the Government and DfID to support the role of surgery as a public health measure. Will they commit to doing so? Thirdly, will DfID examine the extent to which global surgery represents a component of its programme and expertise? What assurances can DfID give that it will review the development goals in respect of surgery and anaesthesia post-2015, when the millennium development goals end? Finally, I hope that the Government will make strong representation after this debate at the 13th working group of the UN sustainable development goals on 14 to 18 July, as this is a member state.
Baroness Brinton (LD)
My Lords, I declare an interest as a past trustee of CBM UK, of which I am a current patron. I thank the noble Lord, Lord Ribeiro, for initiating this debate, which will cover a very great area of experience and expertise. Having listened to the noble Lord, I am even more aware of my extensive ignorance in this area, so I hope that he will allow me to focus on just one thing that he mentioned. I want to talk about a multi-partner club-foot initiative which started in Africa, and in which CBM has been involved over the past decade. It acts as a model for surgeons and aid agencies working together in the future.
CBM is an overseas disability charity, founded more than 100 years ago, which has worked in Malawi for many years. For some reason, Malawi has the highest incidence of club-foot in the world, and CBM has worked for a long time with local hospitals, the Global Clubfoot Initiative and, more recently, the Royal College of Surgeons on supporting young patients born with this disability. This work typifies the hope that my noble friend expresses in the title of this debate.
Steve Mannion, a consultant surgeon in the NHS and senior lecturer on surgery, is the orthopaedic adviser to CBM. All orthopods know that treatment for club-foot should be started early; diagnosis at birth is ideal, rather than later in life, especially for cases that require surgery. He used the Ponseti treatment, which is a physiotherapy technique not well known but which has become the gold standard in the last decade, mainly because of this innovative work. It can be provided effectively and economically. The club-foot medical community also wanted to manage the care of others who had not been treated as young children, and for whom the damage to their feet, legs and ligaments would take longer to treat. The noble Lord, Lord Winston, who cannot be in his place this evening, filmed this project in Malawi in 2008.
The Ponseti method uses corrective manipulation and then keeping the patient in a plaster case. In most cases, this will avoid surgery. The surgeons have also found a cost-effective method of producing the Steenbeck foot abduction brace, which young patients have to wear full time for two to three months, and then at night for two to four years, to ensure that the foot grows into the correct position. The NHS version of this brace is a bit like Ford motor cars—you can get them in one colour only. It is effective, expensive and dull. This surgeon, working with local craftsmen in Malawi, developed a brighter and much cheaper arrangement, which he brought back with him to the UK and which, if my memory serves me right, cost around one-fifth of the UK equivalent. Suddenly, UK parents were asking for it in preference to the NHS version. So here is an assistive technology product from the developing world, saving the NHS money—good news. For £12 million, the cost of one advanced surgical robot in the UK, one-quarter of a million children can be treated and taught to walk.
The work in Malawi progressed well. Diagnoses were made early, but Steve Mannion told me four or five years ago that Malawi Ministers had expressed real concern to him that there were more Malawian doctors in Manchester than there were in Malawi and, helpful as medical aid and support was, there was a serious brain-drain problem. This is where the Royal College of Surgeons comes in. It has developed a local project training surgeons in-country under their own auspices, so there is no need to leave their home to learn the leading techniques. It has worked well. The Royal College of Surgeons developed this further and hosted an international conference on global surgical frontiers in January 2012, bringing together surgeons and aid organisations. The editorial in the Lancet on 21 January 2012 says:
“The greatest burden of surgically treatable diseases falls on people in developing countries, but the poorest third of people receive only 35% of operations and have the lowest numbers of surgeons per head of population. These statistics, combined with the emphasis on reducing global deaths from infectious diseases, make surgery feel like a neglected specialty in the current global health arena. But, as the conference showed, reducing the disparities in surgery between developed and developing countries will take a massive, coordinated, worldwide effort”.
Some 30 months on from that conference, orthopaedic surgeons such as Steve Mannion and the Royal College of Surgeons are training large numbers of local surgeons and physiotherapists in club-foot and other techniques, with the College of Surgeons of East, Central and Southern Africa, and now elsewhere in the world. As the Lancet says:
“The move away from the paternalistic approach of parachuting in Western surgeons on brief missions and towards teaching skills to local surgeons needs to continue, although the need for skilled surgeons to take part in sustainable programmes is still great. Coordination needs to exist between surgical institutions in developing and developed countries so that skills taught are appropriate to requirements. In addition, coordination between and within countries needs to increase to ensure that qualifications have no borders … It is also essential that efforts continue to plug the brain-drain from developing countries”.
The treatment of club-foot is life-changing for patients. Disabled children are often at the back of the queue for medical support and education, and as they grow up they are the last to get employment opportunities in their communities. This simple surgical and non-surgical intervention and treatment is not only benefiting thousands of children across Africa, in Laos, in Papua New Guinea and in other countries; it is providing local craftsmen with work—and local surgeons are being trained in world-leading surgical and physiotherapy techniques. Perhaps most importantly, it is changing the centuries-old view of the West parachuting experts in to solve problems. The surgeons from the UK say that they are learning as much from their colleagues in-country as they are teaching them.
To conclude, I have one simple question to ask my noble friend the Minister. What can the Government, both in DfID and in the Department of Health, do to ensure the dissemination of successful projects like this, and to encourage more in the future?
Baroness Chalker of Wallasey (Con)
My Lords, I begin by apologising—particularly to my noble friend Lord Ribeiro—for my lateness, which was caused by inattention to the annunciator screen. I also make the declaration that I am president of the Chalker Foundation for Africa, and we assist in the training of basic medical workers in Africa for Africa. That is often assisted, as my noble friend Lady Brinton said, by teaching skills in Africa. That may be done by people from other countries, but increasingly Africans are teaching Africans, which is a very worthwhile advance.
I wish to concentrate on two aspects of the need for surgery across the developing world. I support all the comments that I heard my noble friend Lord Ribeiro make, and thank him for initiating this debate. The two aspects that I am most concerned with are fistula repair—which is essential for maternal health, under millennium development goal 5—and cleft palate and lip surgery.
We all know that fistula is an abnormal channel or passageway in females, usually caused by the lack of prenatal and obstetric care, as well as by poverty, malnutrition, early marriage and childbirth, harmful sexual practices and violence, and a lack of quality and accessible maternal care and healthcare. There are also traditional practices like encouraging women to drink water to aid a baby’s birth. That does not help: it increases the risk of fistula, because a full bladder during childbirth is a bad thing. As was said earlier, obstructed labour and obstetric fistula cause 8% of maternal deaths worldwide, but a much higher percentage in the developing world—and it is clear from the statistics on very hard and prolonged labour that about 80% of the problems result from that cause.
I have mentioned many times in this House the fact that the problems are also caused by poverty: the distance that people must travel and the uncomfortable travelling conditions; the lack of nutritious food and the cost of care; and the lack of access to healthcare, particularly in rural areas, which are most deprived in terms of transport. Above all, there is the lack of trained midwives and doctors. We also know that, as my noble friend said, malnutrition causes stunted growth in mothers, which makes giving birth much more difficult.
About 63% of those on a Nigerian fistula programme needed surgery. About 37% had, fortunately, had access to a catheterisation programme within 75 days of the birth—but that can be implemented only where people have been trained to do it, and in rural areas that is just not going to happen.
There are also cases in which a caesarean operation is critical, when a surgeon can see that there is likely to be a real problem. But how can we possibly take that on board when we are not preventing the problems in the first place? That, too, needs the sort of surgery that my noble friend spoke about. The advantage of a caesarean section, if it can be done, is that it can prevent fistulas recurring in later births. But the cost is somewhere around $300, and the aftercare may be as much as $150. It is vital that that surgery be available, and I commend the work of the Addis fistula hospital, and the surgery carried out by Marion Sims, and by Reg and Catherine Hamlin. That is the largest fistula repair centre in the world. We now also have the Niger Danja centre, operated by the Worldwide Fistula Fund.
I now turn to the need for surgery for cleft lip and palate. In the developed world, although the causes are mainly unknown, a cleft lip is usually detected between the fourth and seventh week of pregnancy, and a cleft palate between the sixth and ninth week. It is highly unlikely that that will be diagnosed in developing countries, and so the surgery needs to be done in the first few months of the life of the child. I have been much impressed by the fundraising done by the Smile Foundation, which, through its donations to hospitals and its support of doctors, is carrying out a large number of operations every year, which can prevent children being disfigured for the rest of their lives.
That is why I wanted to speak in support of my noble friend in this debate. I believe that it would be right for DfID to support the role of surgery as a public health measure. There are some occasions when it actually happens, but it happens by default, not because we have made it happen by our policy decision. I also believe that, as my noble friend said, we need to find a way to review the development goals in respect of surgery post-2015. I am pleased to have been able to contribute a little in this debate. These areas of work are absolutely vital, alongside treatment for club foot and the many other surgical procedures that can make all the difference between a mere existence for somebody, and a real life.
Lord Crisp (CB)
I, too, congratulate the noble Lord on securing this debate, on his excellent speech, which laid out the issues extremely well, and on continuing to keep this issue live. He is right to choose this moment to seek to use the United Kingdom’s enormous prestige and influence in the world of international development to press the point home even further.
The noble Lord described the problem well, and I shall pick up some of his points. First, there are just 15 interventions that will, between them, cater for about 80% of surgical need. That relates to the other point that he and the noble Baroness, Lady Brinton, made: the fact that those interventions need not be carried out by surgeons who are physicians. They can be done by non-physician surgeons—and we now have the evidence about where that can work and where it cannot work. I declare an interest as chair of Sightsavers, which works on avoidable blindness and in preventing blindness. In Africa almost all cataract surgery is done by nurses with additional training, and it is done to the same standards and with the same outcomes. As has already been said, we have seen that pattern in other disciplines too.
I also totally agree with both the noble Lord and the noble Baroness that this is a two-way street. We can learn, and some of the things that are happening in Africa can be imported back to the UK; indeed, the Ponseti technique can be reimported back to the UK. The noble Lord made the further point that seven conditions which can be prevented by surgical intervention amount to almost all the medical conditions that need to be tackled to prevent disability and death. We know what to do—that is the simple point here.
This problem is becoming more visible. The noble Lord and his noble friend Lord McColl have pressed for measures to resolve it, as have others around the world, and the issue is now on the agenda of the World Health Organisation. It has been picked up by the Lancet Commission on Global Surgery, and there is a real opportunity here for the UK to take a lead on this issue on a practical level and in policy. Sometimes just pushing the policy is fine but offering practical support is also important. Indeed, the UK is already doing that but it could do more. Noble Lords may not be surprised to hear me talk specifically about partnerships in this regard—that is, partnerships between UK organisations and African organisations or, indeed, Asian organisations. The All-Party Parliamentary Group on Global Health, which I co-chair, recently produced a report entitled Improving Health at Home and Abroad, which argued strongly that if our doctors, nurses, managers and others spent some time working in Africa they would learn new skills, abilities and flexibility which they could reimport to this country, thus providing scope to improve health at home and abroad at the same time, which would be fantastic.
I wish to reinforce that concept with some related points. It has been stressed that the brain drain is very important, but even more important is the need to offer people education and training. The UK has a fantastic tradition of education and training in health which we can offer to others and thus put it to more effective use. Put simply, if every African who acquired some medical or nursing training before they emigrated went home, it would deal with about 10% of the problem. Therefore, a big increase in training is needed.
I congratulate DfID on extending the partnership scheme and hope that it will continue to extend that scheme, as one would expect. However, it is not just a question of our people working and training in Africa and people from Africa coming here; British surgeons have been innovative in this field. I think of people the noble Lord, Lord Ribeiro, will know such as Bob Lane, a retired surgeon, who has developed a programme to enable doctors to deal safely with a few general surgical procedures—I hope the doctors present will forgive me for describing those procedures in non-technical terms—and one can train trainers to deliver that programme in a relatively short time. This is a real gift to the world. I also think of people such as Professor Chris Lavy, professor of trauma at Oxford University, who has trained orthopaedic clinical officers in Malawi. Therefore, we have a lot to offer in terms of training.
Getting from where Africa is today to where it needs to be cannot be achieved in the short term by training alone. A lot of young doctors take a year out of their training but many of them go to Australia and other places where they are not necessarily needed. I hope that we can find a way to encourage more of them to work in rural African hospitals when they have received enough training in the UK to enable them to provide general medical services and undertake general surgery. There is an organisation based in South Africa called Africa Health Placements and, if a doctor wants to work in Africa, that organisation will find him or her a placement. It is a not-for-profit job agency, as it were. The young doctor from the UK—it could, of course, be an older doctor—will receive a wage paid by the South African Government, which is enough to live on while they are there, and return to the UK at a later stage.
I think that Africa Health Placements is on the verge of persuading the Americans that if a young doctor takes up a placement in Africa for a year at the end of their training in America, they should get some money taken off their student loan. I ask the Government to consider that initiative. That is a very neat, interesting and relatively cheap way to incentivise people to work as surgeons or doctors in rural hospitals which lack such personnel. As I say, they are paid by the South African Government, the Zambian Government, or whichever Government are involved.
That measure is significant but not as significant as some of our other development initiatives. I merely ask the Government to consider that, in the short term at least, by which I mean 10 or 15 years, there will be a need for more non-African doctors in Africa. There is also a need for some doctors from other countries to come to this country to acquire more specialist training. There is a programme, which I believe is called the international medical training scheme, and I hope that the Minister will comment on it, or write to me on the numbers that are involved. Therefore, we can offer practical measures and we should make the most of them because they are impressive. Indeed, the UK is already doing a great deal in this regard, but it could do more.
However, we also need to introduce measures at the policy level. I echo what the noble Lord, Lord Ribeiro, said about the Government’s commitment to the resolution that he mentioned. I congratulate the Government on their disability-inclusive programme in international development. What better way is there for the Government to signal that they have such a programme than to do something which prevents disability? It is very much of a piece with the great announcement the Government made on that last week.
What are the Government doing to promote partnerships? Given that I suspect that the noble Baroness who will reply to the debate will speak from a Department of Health perspective as well as from a government perspective, what is being done to encourage the NHS to be more active in this field, as this issue is about improving health at home as well as abroad? Will the Government allow me to bring personnel from Africa Health Placements to meet government officials to consider ways in which we can persuade more of our young doctors to work in Africa? Will the noble Baroness write to me or let me know how many people are involved in the international medical training placement scheme?
Lord McColl of Dulwich (Con)
My Lords, I thank the noble Lord, Lord Ribeiro, for initiating this debate on a subject which I have always thought is of great importance. I ought to declare an interest because over the past 40 years I have worked in about 14 African countries doing operations, teaching various surgical techniques and helping to enhance surgical care and anaesthesia in realistic ways that they wanted and which were within their financial means.
I always tried to emphasise that organisations should be sustainable, especially in the sense that those they trained would not promptly emigrate to more lucrative climes. Some while ago, I was asked to devise the curricula for two medical schools in Libya, one in Tripoli and the other in Benghazi. I inquired whether they would like a system tailor-made for Libya or whether they just wanted to copy the West. Of course, they said that they wanted something tailor-made for Libya, which was very welcome. I took a team from Guy’s Hospital—there were about five or six of us—to help them to devise suitable curricula. When we presented it to the deans, the first question they asked was, “Will this be recognised by London University?”, and, of course, it would not, so it was rejected and they reverted to the usual western pattern. Needless to say, on graduation many of the students from those medical schools promptly emigrated.
People were very suspicious of me going to such a place as Libya. Indeed, the then Prime Minister, Margaret Thatcher, asked me, “Where have you been recently?”. When I replied that I had been to Libya, she retorted, “You what”?, so it was not a very popular thing to do. People became even more suspicious when I had to operate on Gaddafi’s father. It was the middle of the night. He was 103; I know that they are all 103 out there, but this chap looked much older than that to me, like a dried-up old prune out of the desert. At the end of the operation, we were standing around the old man’s bed, watching the pulse meter; it would go fairly regularly and then stop so that there would be a gap, and then another gap. I thought that this would be the moment where the pulse stops and the dictator takes his gun out and shoots the doctor—although I thought he would probably shoot the anaesthetist first. Gaddafi asked me, “How is my father?”. I said, “I have good news for you; your father is indestructible”. He laughed, and everyone relaxed. In any case, I have always liked to live dangerously.
Our next project was for people dying of AIDS in Uganda. We went out to set up a hospice at the invitation of President Museveni, because he had been impressed with the one that we had set up in Hackney for people dying of AIDS. The wonderful Minister for Overseas Development, Lynda Chalker as she was then, gave us enormous support to do this. We set up this hospice six miles outside Kampala on the road to Entebbe. As you all know, my noble friend Lady Chalker is much admired and respected in Africa; they always take her advice. She advised us not to have any in-patient beds. I think she must have known that the word “clinician” is derived from a Greek word meaning “bed”—that is why doctors are so obsessed with beds; clinicians are bed people. She advised us instead to concentrate on out-patient treatment. She said we ought to become a teaching centre for the whole of Africa, teaching people how to look after those who are dying at home. How wise she was. I returned to this hospice in Uganda recently and I was delighted to find that it was running extremely well, and run entirely by Ugandans, apart from one lady who was a Scot; she was the finance adviser. By the way, the word “economy” is from the Greek and implies housewifery, which is why ladies are the ones who understand finance.
The next project that I got involved with was a charity called Bridge2Aid in Tanzania. This is an amazing charity that has trained more than 300 emergency dental technicians. They are trained in two weeks to take teeth out; you may think that that is not adequate, but when we were medical students we only had three lectures on how to take teeth out, so in Tanzania they go a bit further. They become expert at taking out teeth and therefore relieve a great deal of dental pain and dental sepsis, which can kill. We give them a pressure cooker and a paraffin lamp to sterilise the instruments. Of course their skills are not recognised abroad so they do not emigrate. This is rather reminiscent of President Nyerere’s barefoot doctor scheme, mentioned by the noble Lord, Lord Ribeiro.
Of course I have been associated with Mercy Ships for many years. We concentrate on teaching the local people various operations and anaesthetic techniques. It has been very encouraging to see how they flourish. On board we had an American eye surgeon, Glenn Strauss, a wonderful trainer who trained a Togolese surgeon to do cataracts. Within a week or two, the surgeon had done 30 cataracts beautifully. That surgeon then taught the next Togolese surgeon, who happened to be his professor. The professor became expert in that, and in turn taught the next one. So we ended up with three competent eye surgeons doing cataract operations in Togo, one in the north, one in the south and one in between. They come back for a refresher course every so often.
I want to tell your Lordships about Gary Parker, an American who trained in north Wales at a very good maxillofacial hospital for about five years. He came to work on Mercy Ships for two months, just to see what it was like, and he liked it so much that he decided to stay a bit longer—24 years longer. He must be the most experienced maxillofacial surgeon in the world and he has trained so many Africans in these techniques.
I ought to mention a most outstanding president in Africa, Ellen Johnson Sirleaf in Liberia. She is one of the best presidents out there and the first lady president. She is an economist, she is tough, and she is doing an extremely good job.
For seven years one of our anaesthetists on board has been doing a great job running courses for anaesthetic providers. In the past two years we have been very fortunate in having on board the consultant anaesthetist Dr Michelle White, who gave up a hard-won consultant post in Bristol to work on the ship for three years. She has been invaluable not only in looking after patients and children but also in teaching. She has made an amazing sacrifice. It is so heartening to see such dedication to help developing countries to improve their healthcare and produce something that will last.
Lord Hunt of Kings Heath (Lab)
My Lords, it is a great pleasure to take part in this debate. The noble Lord, Lord Ribeiro, has raised some very interesting questions on health in a global context, on which I hope that we will get some helpful responses from the Government tonight.
His argument essentially is that surgical interventions —focused, as the noble Lord, Lord Crisp, reminded us, on 15 common interventions—can play a very positive role in improving global public health. I thought that the argument was very persuasive and, as I said, I hope that the Government will respond. The comparison of access to surgery in the richest and poorest nations was striking. When we come to the core question of whether surgery is perceived by DfID as a public health measure, we must bear in mind this obvious inequality between the richest and poorest nations.
I would like to ask the Minister whether she accepts that surgery can relieve many of the most important health conditions that millions of people suffer from globally. It is very important that we get an affirmative response on that.
The comment made by the noble Baroness, Lady Brinton, using club foot as an example, was very striking. The example that she gave from Malawi seemed to be absolutely life-changing and very persuasive.
Of course the noble Baroness, Lady Chalker, speaks from great experience and is much admired in your Lordships’ House as well as internationally. She spoke of some of the major challenges in Africa regarding childbirth, including, as she clearly said, the need for surgery, and in particular of the problems in rural areas. She also mentioned issues arising with cleft palate: the challenge of early diagnosis and the problem of the availability of surgery. Again, it would be interesting to know whether that is a point that is recognised in DfID’s development plans for the future.
As ever, it is a great pleasure to hear the noble Lord, Lord McColl, whose personal contribution is remarkable. Politically correct perhaps he is not, but we are always entertained by his contributions. He mentioned the example of helping with the curriculum in a developing country, which, because it would not then be recognised by western universities and health systems, did not prove to be acceptable to the country itself.
It brings us to the difficult problems of both the emigration of doctors from developing countries and the fact that many students from other countries who come to the UK and other developed countries do not want to return. This brain drain is very worrying indeed. Can the Minister confirm whether it is government policy firmly to discourage such a brain drain? I would also like to ask her, given the example of the programmes training surgeons in the home country, whether the Government support that and will endeavour to give further support to bodies such as the Royal College of Surgeons in future.
The noble Lord, Lord Ribeiro, also raised questions about DfID’s priorities for low-income countries. He suggested that in terms of budgetary expenditure, middle-income countries—if I can call them that—were gaining at the expense of the poorest countries because of natural disasters. It would be good if the noble Baroness could confirm that.
The noble Lord, Lord Crisp, said that the issue was becoming more visible internationally, and mentioned the Lancet Commission on Global Surgery. I thought that one of his most telling comments was on the advantage of partnerships in which the NHS is a full partner but where it is acknowledged that enabling NHS staff to go abroad for a certain time and then come back to the UK can be a real advantage to the NHS. I am sure that that is right. My question to the noble Baroness is the one that the noble Lord raised. Inevitably at the moment, the NHS is under great pressure—and I know from my experience that when an NHS trust is under pressure, it worries about losing staff abroad. That applies to the services as well. Is there work to be done to help the NHS to recognise that there could be great benefits from encouraging young staff in particular to take advantage of these programmes? I doubt whether the noble Lord will get an answer to the question on whether student loans can be discounted, but it would be interesting to know whether the Government were at least prepared to talk to the noble Lord, as he suggested.
We come now to the crunch question. Do the Government accept that surgery has a key role to play in improving health globally, and, as the noble Lord, Lord Ribeiro, said, will they support surgery as a public health matter? That is a very important question. I yield to nobody in my admiration for public health doctors—indeed, I stand here as president of the Royal Society for Public Health—but beloved though public health doctors are, I sometimes think that the only interventions that they are concerned with are those that have absolutely nothing to do with medicine. This is because in the developing world inevitably they think about sanitation, access to water and all those sorts of things, which is entirely understandable. However, it is a question of global equality, too; and the evidence is that medical intervention, medicines and surgery can have a huge, positive impact on individuals. For that reason—the noble Lord’s point was persuasive—these should be regarded as public health measures and are as deserving of DfID’s support as what might be considered as the more traditional public health approach.
Baroness Jolly (LD)
My Lords, I am grateful to my noble friend Lord Ribeiro for raising this important issue and for his thoughtful and incisive comments based on years of commitment and experience. He and I went to Zambia two years ago in the summer, so I have seen him in an area in which he is hugely expert asking extremely pertinent questions of the Minister for Health, on the one hand, and the sister in charge of a hospital in the bush, on the other. I also pay tribute to the work of the noble Lord, Lord Crisp, and the All-Party Parliamentary Group on Global Health. We have heard the personal and local experience of my noble friends Lady Chalker and Lord McColl. As the noble Lord, Lord Hunt, said, this debate has been totally fascinating, and I hope that I can get through my speech and answer all noble Lords’ questions.
The noble Lord, Lord Crisp, and my noble friend Lord Ribeiro, through their work, have highlighted the importance of surgery across the whole world, and indeed it is a key part of disease prevention and treatment, and a public health good. We welcome the All-Party Parliamentary Group on Global Health’s recent activity to highlight this issue, including the film “The Right to Heal”.
We very much support the strengthening of emergency and essential surgical care and anaesthesia in developing countries as a component of universal health coverage, and see it as an issue of great importance. To answer a question of the noble Lord, Lord Hunt, on whether surgery can relieve many of those conditions, yes, indeed—we heard many examples in this debate, including treatment of cataracts, cleft palate and fistula.
The UK supports further consideration by the WHO executive board in January—I say that in response to my noble friend Lord Ribeiro’s first question. Action must be taken to help prevent avoidable death and disability as a result of surgery. Indeed, surgically treatable diseases are among the top 15 causes of disability worldwide. Speakers today have highlighted different examples of the appalling statistics and human suffering resulting from poor training and procedures. This position can be changed by working together. The WHO process is an important part of this work and will help commit the international community to making greater progress in raising awareness, improving data and monitoring, and increasing global collaboration on this issue.
The Government aim to improve the provision of basic health services for the poorest by strengthening health systems. Surgery is a key aspect of health service provision and is addressed in this context: the UK is supporting efforts in developing countries to increase the skills and availability of health workers, and to expand access to essential medicines and equipment. Increasing coverage, access and quality will strengthen health services in addressing all health problems, including those requiring surgical treatment.
In answer to my noble friend Lord Ribeiro’s question on DfID raising the profile of surgery, and the question of the noble Lord, Lord Crisp, on partnerships, we have a number of programmes that specifically improve access to surgical services. The UK is supporting partnerships between the UK and developing countries to improve health services in those countries through sharing skills and capacity development, and bringing benefits back to the UK through volunteer NHS staff returning with stronger skills—I underline the point made by the noble Lord, Lord Hunt—that can be useful when they come home. The health partnership scheme is supporting a range of programmes to achieve better outcomes following anaesthesia and surgery, such as supporting training for healthcare workers in surgical and theatre nursing skills in eight countries in Africa. By June 2014, the scheme had trained 26,600 overseas healthcare workers, and UK health professionals had spent 31,000 days volunteering overseas.
The noble Lord, Lord Crisp, inquired whether the Government would consider welcoming Africa Health Placements. The Government’s “Health is Global” strategy includes work on health system strengthening. Officials work with many organisations and will be happy to meet Africa Health Placements. Other work being undertaken includes the provision of and training in obstetric services, including the availability and quality of caesarean sections and episiotomy, where necessary, and eye surgery. In humanitarian contexts, we also support the UK International Emergency Trauma Register of deployable specialist staff—primarily from the NHS—and a deployable surgical field hospital.
I want to pay tribute to the royal colleges and others for the work they undertake in this area, and the Association of Surgeons of Great Britain and Ireland, which is a member organisation of the International Collaboration for Essential Surgery. Governments, health professionals and the voluntary sector all have a role to play. An organisation that is trying to tackle the basic issues around lack of anaesthetist skills in many countries is Lifebox, mentioned by my noble friend Lord Ribeiro. Its purpose is to provide equipment and support services in low resource and lower-middle-income countries at no or reduced costs. UK hospitals, universities, health and international development third-sector organisations have well established and expanding relationships with healthcare institutions in lower and middle-income countries. These range from: training and capacity building for staff; providing practical skills; continuing professional development; supporting improvements within developing-country organisations; facilitating research; and, indeed, curriculum development. Those are all in line with points raised by many noble Lords.
In response to my noble friend Lord McColl, regarding the funding of Mercy Ships, I can say that DfID has indeed funded mercy ships in the past but currently is not so doing. The noble Lord, Lord Hunt, inquired about the brain drain. The Government are committed to the World Health Organisation code on ethical recruitment of health workers, which is designed to prevent brain drain from countries with a shortage of healthcare professionals.
British health volunteers have a key role to play in improving health in other countries, as highlighted by the all-party group last July in its report Improving Health at Home and Abroad. The noble Lord, Lord Crisp, will be interested to know that the Department of Health and the Department for International Development will shortly publish an updated framework for voluntary engagement in global health by the UK health sector, which will seek to bring greater clarity as to how these activities can contribute, in a sustainable way, to building capacity in low and middle-income countries. It also outlines the benefits and opportunities for UK employers, professional associations and, indeed, individual health workers in the UK.
The medical training initiative accommodates overseas postgraduate medical specialists to train in the UK for up to two years. Participants can return to their home country and apply the skills and knowledge developed during their time in the UK. I think the noble Lord, Lord Crisp, inquired about this; I am happy to give noble Lords figures in a letter.
I would finally like to focus on some priorities for the Government that are linked to this topic. First, as part of any progress in surgical interventions, if basic surgery is to have any chance of widespread continued success, I stress the importance of the need for access to and rational use of antibiotics. This has not been mentioned this evening, but it really is critical. It links to the work that the UK, along with international partners, is leading on tackling antimicrobial resistance, which is one of the biggest global health challenges facing us today. The World Health Assembly recently committed to developing a global action plan. As part of this wider effort, the Prime Minister has today launched an international commission to identify what action may be taken by the global community.
Secondly, we recognise that the rates of maternal and newborn mortality remain unacceptably high and further action is needed. The UK Government have made commitments to save the lives of 50,000 women in pregnancy and childbirth and 250,000 newborn lives. They also support the WHO and UNICEF global action plan, Every Newborn: An Action Plan to End Preventable Deaths, which was launched in Johannesburg this week. The links between newborn and maternal survival and access to quality surgery are clear. It is estimated that one in three pregnant women needs some intervention during birth and between 5% and 15% require a caesarean section. Improving the quality of maternal and newborn care is one of the strategic objectives of the action plan.
Finally, another area where the UK is working, both at home and abroad, is in eliminating female genital mutilation and supporting women and girls affected by this practice. The recent adoption of a WHO resolution on violence against women is a welcome development. Through our work on FGM and reproductive and maternal health, we are also working to prevent and manage obstetric fistula—a hole in the birth canal—which WHO estimates affects between 50,000 to 100,000 women worldwide each year.
All this links to our work towards a health goal in the post-2015 framework. The UK wants to ensure it includes commitments on key areas such as: newborn and maternal health; ensuring access to essential medicines; and universal health coverage—all issues identified in the course of the debate, and all linked to access to quality surgery and anaesthesia. We have been involved in these discussions through the High-level Panel of Eminent Persons on the Post-2015 Development Agenda, which was co-chaired by our Prime Minister, and remain involved through the deliberations of the open working group.
I am grateful for the opportunity to focus on these issues through the debate and will keep noble Lords updated on further discussions by WHO’s executive board. By taking action now at a global level, and by all sectors working together, we can truly make a difference to lives and tackle avoidable mortality and disability.
I will take what time I have left to pick up on a few points that came towards the end of the speech. My noble friend Lady Brinton asked about DfID and the Department of Health supporting successful projects, such as the one she outlined. Working with NGOs and civil society forms an integral part of the Government’s approach to reducing poverty. We will be happy to provide information on funding for NGOs and civil society organisations in a written reply.
My noble friend Lord Ribeiro asked about a stand-alone target on surgery. I hate to disappoint him, but the Government are not in favour of a stand-alone target on surgery in a post-2015 framework. Rather, we think it is more helpful to measure health outcomes, such as reductions in mortality. Surgery may be required in some cases to achieve those, but we also support the inclusion of a target on universal health coverage, which will help to expand the availability of essential health services.
I will write to all noble Lords who have taken part in the debate to answer unanswered questions, but I will also try to arrange a meeting with the relevant Minister to take up these points further.