How can health services keep pace with the rapid growth of cities? | Richard Vize

The relentless growth of urban populations is driving city and national governments to increase access to healthcare while tackling the root causes of poor health.

According to Oxford Economics [pdf], the world’s largest 750 cities will be home to 2.8 billion people by 2030 – more than a third of the global population. They will account for almost a third of the world’s jobs and more than half its consumer spending. More than a dozen cities will have populations greater than 20 million.

Rapid, uncontrolled urbanisation strains many aspects of city life that determine health. Traffic, factories, generators and construction poison the air, meanwhile water supplies can become contaminated, poor housing harms the health of children, and food supply and quality can be compromised.

Unplanned urban growth drives poverty. About 900 million people worldwide live in urban slums, where overcrowding encourages the spread of infectious diseases such as tuberculosis, dengue fever and cholera. The United Nations estimates that by 2030, roughly 60% of city inhabitants will be under the age of 18, which puts huge numbers of children at risk from illnesses such as diarrhoea and pneumonia, the leading causes of global childhood death.

Health services, particularly in developing countries, are concentrated in cities. As Mark Britnell notes in his study of global healthcare, many developing countries such as China, Indonesia and India suffer from a chronic shortage of health workers. This creates big disparities in care between cities and the countryside; doctors are reluctant to work in rural areas because pay is poor, career choices are limited, hospital facilities are often inadequate and primary care tends to be underdeveloped.

Meanwhile, in the cities, hospitals become overcrowded because patients know that is where the best doctors, research and technology are found. The dominance of hospital care in cities often means primary care is neglected, which according to the World Health Organisation (WHO) [pdf] can lead to unregulated, unsafe and ineffective private services. In some African cities, public primary healthcare has almost disappeared.

Britnell highlights some of the efforts being made to bridge the shortfalls. Brazil has announced new medical schools to train thousands of additional doctors, and training is being extended to include two years working in public service posts. This could add up to 36,000 working students to the system by 2021. Compulsory training in public hospitals was inspired by the NHS.

In addition, Brazil has recruited at least 10,000 doctors from Cuba to work in the poverty-plagued favelas on the peripheries of cities, as well as in remote areas.

The chronic shortage of clinicians is encouraging countries to make better use of volunteers and community workers. India is trying to boost its services in slums through the National Urban Health Mission, which emphasises reproductive health and works with women’s health committees.

Toronto [pdf]has been trying to bring together its primary and hospital services to provide joined-up care for patients with several health conditions. This includes individual care plans, one point of contact, and multidisciplinary teams supporting high-risk patients after they have been discharged from hospital. The city’s Ageing at Home programme aims to make it easier for older people to continue to live at home after illness.

Toronto also provides impressive support for people living on the streets with mental illness. Its Streets to Homes programme includes incentives for private landlords to offer accommodation. Several thousand people have moved into their own home since 2005, and about 80% of them remain there for at least a year.

Yet for many people, access to healthcare depends on the ability to pay, which excludes swathes of the population. Increasingly, countries such as China, Thailand and Indonesia are addressing this problem by pursuing universal healthcare. At present around two in five countries have some form of universal healthcare.

Britnell argues that its expansion is being driven by two opposing forces: capitalism and globalisation have grown a middle-class demanding more from governments, while about 1 billion people lack access to basic healthcare and 100 million are impoverished every year through catastrophic healthcare costs. Providing more equal access to health services strengthens social cohesion and promotes economic growth.

But while developing countries are increasing the proportion of their wealth spent on healthcare, urban populations are expanding so quickly that it is all but impossible to provide the health infrastructure and staff to keep pace.

Faster progress can be made, however, in improving the environment, such as providing cleaner air and water. For this reason, the WHO believes local government – and particularly executive mayors – are central to improving city health.

Beijing and Shanghai, for example, have introduced tough anti-smoking laws. In 2013 Mexico City became the first in the world to levy a tax on sugary drinks, which had been a factor in Mexico having among the world’s highest obesity and diabetes rates. Kuwait City has reduced salt content in bread to tackle high blood pressure. London and Paris were among the first cities to attempt to cut traffic pollution and increase exercise by offering free bicycle use.

Poor road safety takes many urban lives. Fatal traffic accidents [pdf]cost about 21 lives per 100,000 population annually in Brasilia and 18 in Nairobi, compared with 1.3 in Tokyo. Cutting road deaths depends on many factors – higher population density actually reduces deaths compared with sprawling areas. São Paulo (Brazil), Bogotá (Colombia) and Accra (Ghana) are among cities pursuing safer road design.

The health of city populations is becoming a central concern of local and national governments and international institutions. Affordable access to health services is just part of the story. Local government in particular recognises that improving the health of city populations depends on everything from ensuring water quality to designing safe roads and controlling air pollution.

But there is a chasm between cities where growth is controlled and those where the relentless quest to find work is creating polluted, overcrowded slums.

• Richard Vize provided editorial support to Mark Britnell for his book In Search of the Perfect Health System, which won the health and social care prize at the BMA Medical Book Awards 2016.

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How can health services keep pace with the rapid growth of cities? | Richard Vize

Portable brain-scanning helmet could be future for rapid brain injury assessments

A transportable brain-scanning helmet that could be used for rapid brain injury assessments of stroke victims and those felled on the sports pitch or battlefield is being tested by US scientists.

The wearable device, known as the PET helmet, is a miniaturised version of the hospital positron emission tomography (PET) scanner, a doughnut-shaped machine which occupies the volume of a small room.

Julie Brefczynski-Lewis, the neuroscientist leading the project at West Virginia University, said that the new helmet could dramatically speed up diagnosis and make the difference between a positive outcome and devastating brain damage or death for some patients.

“You could roll it right to their bedside and put it on their head,” she said ahead of a presentation at the American Association for the Advancement of Science’s (AAAS) annual meeting in Boston. “Time is brain for stroke.”

Despite being only the size of a motorbike helmet, the new device produces remarkably detailed images that could be used to identify regions of trauma to the brain in the ambulance on the way to hospital or at a person’s bedside. The device is currently being tested on healthy volunteers, but could be used clinically within two years, the team predicted.

Despite being only the size of a motorbike helmet, the new device produces detailed images that could be used to identify regions of trauma to the brain in the ambulance on the way to hospital or at a person’s bedside. Photograph: Stan Majewski

Rapidly diagnosing stroke patients, who often wake up unaware of what has happened, is crucial as every passing minute without treatment can result in more extensive and permanent brain damage.

In the hours after a stroke, the brain tissue surrounding the main injury hangs in the balance as it is starved of oxygen due to blockages in the brain’s blood vessels. A rapid surgical intervention, within two to four hours of a stroke, can salvage neurons in the so-called “penumbra” area. After that the risks of brain surgery tend to outweigh any potential benefits to the patient.

“The more you wait, the more that penumbra area gasps and dies,” said Brefczynski-Lewis. “If you can see there’s a bit of activity you might say let’s do an intervention.”

Depending on the brain region affected by stroke, a patient’s speech and language abilities could be saved or paralysis prevented.

In the future, the team said it may be possible to diagnose sports concussion “within minutes”.

“If one can determine quickly whether a head injury is a concussion, then one might be better able to assess if the player, or the soldier, should continue or take time to heal,” said Brefczynski-Lewis.

The device, which can be worn while walking around could also enable scientists to study people’s mental patterns as they move about, socialise and respond to threats in their day-to-day environment. Photograph: Stan Majewski

The helmet was developed in the lab and Brefczynski-Lewis describes it as the equivalent of “going from a big computer to a smartphone”.

The wearable scanner works on the same basic principle as a conventional PET scan. The patient is injected with glucose that has been tagged with a radioactive tracer. Radiation emitted by the tracer is captured by sensors on the helmet, allowing scientists to pinpoint which brain regions are metabolising glucose most rapidly, providing a heatmap of brain activity.

The team were able to miniaturise the scanner by using much smaller detectors fitted with crystal arrays designed to turn PET radiation into measurable electrical signals with a high degree of efficiency.

The device, which can be worn while walking around could also enable scientists to study people’s mental patterns as they move about, socialise and respond to threats in their day-to-day environment. Brefczynski-Lewis said it could also be useful for understanding addiction, where people can respond very differently in a lab setting to in their day-to-day lives where environmental triggers suddenly set off cravings.

“You could put [addicts] in a room similar to where they’ve used drugs before and ask what allows you to have the willpower to walk away,” she said.

A potential limitation is that the helmet is cumbersome, weighing nearly 3kg (6.6lbs) in its current form and up to 9kg (20lb) in an upgraded version designed to give full-brain coverage. The scientists have developed a counterweight system that is pushed along on a stand or carried in a rucksack to avoid the patient being crushed, but Brefczynski-Lewis acknowledges: “you’re probably not walking down the street in Manhattan wearing it”.

Portable brain-scanning helmet could be future for rapid brain injury assessments

British doctors and health professionals call for rapid coal phase-out

Groups representing Britain’s 600,000 doctors and health professionals say it is “imperative” to phase out coal rapidly to improve health and reduce NHS costs.

The doctors and nurses say tackling outdoor air pollution from traffic and power stations would cut climate emissions, reduce air pollution, and deliver a powerful boost to the nation’s health.

“Climate change and air pollution are both major health threats,” says the UK Health Alliance on Climate Change in a report. “They share a common driver: the combustion of fossil fuels. Pollution from coal plants alone costs the UK as much as £3.1bn each year in human health impacts.”

The group of 15 health bodies includes seven royal colleges of medicine and the British Medical Association.

Pollution from coal plants causes many serious health conditions including stroke, coronary heart disease and lung cancer. It disproportionally affects children and kills more people than road accidents , says the report.

The government has said it intends to phase out coal power plants by 2025 but the doctors say they are alarmed that no consultation papers looking at how this could be achieved have been published in more than a year.

“Ending the use of coal is a simple, no-regrets public health intervention. The rapid phase-out of coal fired stations is an imperative first step. Coal is the most carbon-intensive source of power generation, and is a key focus for reducing the risks of climate change.

“In the UK, burning coal is linked to 1,600 premature deaths, 68,000 additional days of medication, 363,266 working days lost and more than 1m incidents of lower respiratory symptoms,” says the report.

It urges politicians not to tackle air pollution and climate individually, as has been done in the past. “The UK has witnessed … policies that encouraged the use of diesel cars which inadvertently worsened air quality. Considering air pollution and climate change together can limit adverse health effects.

“Some strategies can be good for both air quality and climate change, for instance wind, solar and tidal energy. Acting on ones that are beneficial to both is advantageous to health. Indeed, joining up policies on health, air pollution and climate change can offset the costs of climate mitigation policies through the health benefits that they bring.”

Air pollution is the second biggest public health threat in the UK after smoking and kills 40,000 people a year in Britain, said Prof John Middleton, president of the Faculty of Public Health. “Coal-fired energy is particularly damaging through its invisible particulates and because it is a driver of climate change,” he said.

“The phase-out of coal use is an essential step towards creating a sustainable energy policy for the UK,” said Dr Richard Horton, editor-in-chief of the Lancet medical journal. “It is also a vital co-benefit for health – ending coal use will deliver long-lasting health and dividends for the British population. Life expectancies will be prolonged, disease and disabilities reduced, and future risks to health diminished. This is an opportunity to be seized.”

Jonathan Griggs, professor of paediatric respiratory and environmental medicine and fellow of the Royal College of Paediatrics and Child Health said that children were particularly vulnerable to burning coal.

“Air pollution from burning coal has been linked to low birth weight and pre-term delivery as a result of maternal exposure during pregnancy,” he said. “The phase-out of coal is a double win for tackling the twin health threats of air pollution and climate change.”

“Tackling air pollution and climate change will have numerous health benefits but it requires a joined-up approach from government to ensure the health impacts are better recognised and fully realised,” said Janet Davies, the Royal College of Nursing’s chief executive and general secretary.

British doctors and health professionals call for rapid coal phase-out

A Rapid Guidebook To The Mediterranean Diet regime

Objective: about four tbsp/day
The quantity of olive oil contains oil utilised for cooking and salads and oil consumed in meals eaten outside the home. In the group assigned to the Mediterranean diet regime with extra-virgin olive oil, the purpose was to eat 50 g (appx. four tbsp.) or much more per day of the polyphenol-rich olive oil provided, as an alternative of the ordinary refined assortment, which is minimal in polyphenols.

A Rapid Guidebook To The Mediterranean Diet regime