Presentation given by Dr Merlin Wilcon on Friday 13th April 2012 to the 4th RCGP Junior International Committee Annual General Meeting in Croydon, London

1. DEPARTMENT OF PRIMARY HEALTH CARE
Research as a route in to Global
Health - personal reflections
Dr Merlin Willcox MRCGP DTM&H
GP and Clinical Researcher
Department of Primary Care Health Sciences
University of Oxford

2. Plan
Why research global health?
How I got involved in Global Health research
Opportunities
Challenges

3. 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

4. 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?

10. Blood sugar level
200
180
Glycemie (mg/dL)
160
140
120
100
80
60
40
20
0
suga
0 5 r 15 20 30 40 50 60 80 100 120
Time (minutes)

12. Is sublingual sugar effective for
the treatment of hypoglycaemia?

13. 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?

16. 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

17. How I got involved in global
health research…

18. Elective in Uganda

19. Parasite counts in patients taking “AM”
12000
10000
Parasite
8000
Count
(geometric
means, 6000
95% CI)
4000
2000
0
0 2 7 14
Days of Treatment

21. 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

22. Literature reviews

23. Do the DTM&H!
Plasmodium vivax Plasmodium falciparum

24. 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

25. Mali
Using local resources
to improve
management of
malaria
Collaborating with
traditional healers
Aiming for sustainable
results

26. 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

27. Hospital level
Improvement in
quality of care for
children with severe
malaria
Aim to encourage
referrals by traditional
healers

28. All-cause inpatient mortality (Hospital statistics)
All-cause inpatient mortality
25
2006
20
Average 2002 - 2005
15
(%)
10
5
0
Jun Jul Aug Sep Oct Nov Dec
Month

29. Pre-hospital risk factors for inpatient
death from severe malaria
a wide variety of pre-
1.0
hospital treatments were
0.8
used, both modern and
traditional.
Survival Probability
0.6
None had a consistent P<0.01
impact on the risk of
0.4
death
0.2
Girls were twice as likely Male
to die as boys (AOR 0.0
Female
2.00, 95% CI 1.08-3.70) 0 20 40 60 80 100
Number of Hours After Hospital Admission

30. 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)

31. 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?

32. 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!

33. 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

34. We know what diseases are killing children …

35. We know
which
interventions
will prevent
most
childhood
deaths…

36. But how to deliver those interventions…?
SS Africa N&S America
% of world’s pop 11 14
% of global disease 25 10
burden
% of global health 3 37
workers
% of world health 1 50
spending

37. Where are children dying…?

38. Example: Effect of training TBAs on
perinatal mortality
Wilson et al 2011, BMJ 343

39. Challenges
Finding funding
Finding good collaborators
Understanding local culture and traditions
Bureaucracy
Logistics
Communication
Local politics