Then there are religious questions that have slowed the expansion of human milk banks in settings with large Muslim populations. The Islamic faith includes the concept of milk kinship, where the sharing of breast milk creates familial ties and, as a result, marriage prohibitions. Human milk banking, where breast milk is often pooled from a variety of donors, creates clear challenges for Muslim families, who worry that an infant might end up later married to a milk kin.
By Dr Tedros Adhanom Ghebreyesus
BEIJING, JULY 16, 2018 – As I travel this week to meet China’s state leaders in Beijing, I’ll fly over a number of nations where China is dramatically changing economic landscapes. With its “Belt and Road” development initiative, China is promoting global economic integration by building infrastructure and broadening trade with countries such as Kazakhstan, Russia and around five dozen other nations on multiple continents.
Pakistan, for example, is gaining new railways, power plants and highways courtesy of $60 billion of Chinese funding and infrastructure expertise. But the partnership also extends to health. China and Pakistan launched last year a new emergency medical center in the southern port city of Gwadar, aiming to expand healthcare to those in need.
China’s aim in Pakistan is to improve health conditions in an area where access to healthcare and basic sanitation are needed to prevent future disease outbreaks. WHO commits millions to projects in Pakistan each year, focusing on the expansion of polio vaccines and responding to outbreaks of diseases such as dengue and hepatitis. Yet—as China recognizes— there is more to be done.
There was a certain kind of quiet hopefulness when, in late April 2016, the last Ebola patient of the West African epidemic – a two-year-old boy – walked out of a treatment facility in Monrovia, Liberia. With the smouldering embers of the outbreak fading, there was cause for celebration. But there remained the impotent fear of the unseen: Ebola was still out there, lurking. We just didn’t know where it was hiding or when it would be back.
It’s now resurfaced in the Democratic Republic of the Congo, emerging in the country’s rural north-west before spreading to Mbandaka, a city of nearly 350,000. The threat of a new epidemic looms.
Ebola is a zoonotic disease, meaning that it can spread between animals and humans. It burns hot and fast through people. Its ruthless nature means that we are often the end of the line for the virus: a host like us that gets too sick too fast, that dies too quickly, cuts down the virus’s ability to jump into a fresh body. To remain a threat, Ebola needs a safe house in which to lie low and hide.
Such a long-term host, the quiet refuge of a pathogen, is known as a reservoir species. If a reservoir species is Ebola’s safe house, we are its luxury retirement property, a place for it to live out its last days with a bang. The trouble is that we aren’t sure where the safe house is. If we are going to be vigilant against Ebola’s re-emergence, we need to find it.
Medical negligence costs in the UK National Health Service (NHS) are reaching new unsustainable heights. Earlier this month, a 9-year-old girl was awarded a settlement that could amount to over £19 million (US$25 million) after she was born with severe jaundice, resulting in brain injury. The NHS spent £1·8 billion on negligence claims in the 2017–18 financial year and the annual cost has doubled since 2010. Estimated total liabilities for 2017–18—the cost facing the NHS if all claims against it were successful—is £65·1 billion, up from the 2015–16 estimate of £56·4 billion.
In the future, the number of lawsuits looks set to increase still further. The latest computer glitch, which was responsible for 450 000 women failing to receive an invitation for breast screening, might have existed in the system since 2004, 5 years earlier than the date given by Health Secretary Jeremy Hunt—as described by Shama Sheikh and Peter Sasieni in a Correspondence published online today in The Lancet.
Medical negligence has been the subject of detailed, repeated examinations. In 1999, the US Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System, estimated that avoidable medical errors contributed to up to 98 000 deaths every year in US hospitals. Hospital-based errors were found to be the eighth leading cause of death nationwide and legal liability worries discouraged health staff from reporting errors. In 2004, then Chief Medical Officer Liam Donaldson told a conference looking at patient safety: “To err is human, to cover up is unforgivable and to fail to learn is inexcusable.” In the UK, the issue was extensively examined in a public enquiry that led to the publication, in 2013, of the Francis Report in the wake of events at the Mid Staffordshire NHS Foundation Trust, where up to 1200 people died between 2005 and 2009 due to substandard care.
More recently, the strategy document, Delivering fair resolution and learning from harm, published in April, 2017, by the NHS’s litigation authority—NHS Resolution—stressed the need for candour as early as possible in potentially litigious situations. Additional insights have come from an examination of cerebral palsy or brain injury cases in which a legal liability had been established between 2012 and 2016. Claims related to obstetrics and potential neonatal harm represent 50% of the total value of claims for all specialties. The NHS Resolution report Five years of cerebral palsy claims, published in September, 2017, found that families were only involved in 20 of the 50 investigations in which a serious incident had occurred. It also concluded that enquiries into the cases focused on the individuals to blame rather than on the systems. Interestingly, the need to avert “the risk of harm before it happens” is a recommendation in a letter published in The Lancet by Terence Stephenson, whose leadership of the General Medical Council was instrumental in getting junior doctor Hadiza Bawa-Garba struck off the medical register after she was convicted of gross negligence manslaughter. She was granted leave to challenge her erasure in the Court of Appeal in March.
Several solutions are now being employed to chip away at the problem. For example, a mediation service was launched in December, 2016, after a pilot of the scheme, investigating 47 fatal and elderly care claims, managed to settle 81% of the cases without going to court. And to ease the burden of rising general practitioner insurance premiums, a state-backed indemnity scheme will be introduced in England and Wales in 2019.
Additional measures currently being examined are the introduction of fixed-cost schemes for claims up to a value of £25 000, the use of one expert per case acting jointly for both plaintiff and defendant, and the capping of the expert’s costs to a maximum of £1200. The Civil Justice Council has set up a working group to consider the proposals, and it is due to make its recommendations in September this year. Opponents to the plans fear access to justice will be put at risk, as claimants might not be able to find a solicitor prepared to work within a fixed fee arrangement. Concerns about patient safety have also been raised: respondents to the consultation document outlining the proposals argue that if access to justice is impeded and cases with merit are not brought, then the NHS will be unable to learn from the event.
No single measure will unravel the unsustainable problem of rising medical negligence costs. However, several key activities—in the context of a continued requirement to increase expenditure—might help: the promotion of candour, the advocacy of a problem-solving culture rather than one based on blaming the individual, and the improvement in quality of a service that has, for 70 years, been crucial in delivering equitable health care for millions of people. In medical negligence, there are no winners.