Reappraising old friends: oxygen and primary careBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4594 (Published 01 November 2018) Cite this as: BMJ 2018;363:k4594
All rapid responses
Your editor's choices (Luke Allen and colleagues in particular - doi: https://doi.org/10.1136/bmj.k4469) are timely but, then, they would have been at any time since the Alma Ata Conference held at about the same time as the revolution in Iran and Margaret Thatcher came to power in the UK. 12 years later, and having done a medical rotation, I did the DTM&H course in tropical medicine and (international public) health and learned that our western teaching was narrow and, predictably, about western health. The most fascinating thing to discover was that the three most important drivers of health are GDP, clean water and sanitation. Within nations it is the spread of wealth that determines the health of the population (see The Spirit Level, Pickett and Wilkinson, 2009 for a read or Hans Rosling's Debunking third-world myths with the best stats. https://youtu.be/RUwS1uAdUcI via YouTube).
Health is predominantly socially and structurally determined. Alma Ata is both about structural change and less radical stuff like education and empowerment. The call to arms is there and the focus on women and children is admirable but we aren't, as an 'industry' really doing this are we? And not in the UK. Not meaningfully and early in life. We focus instead on downstream solutions or early intervention. What if people were able to share our understanding of a sense of normality which included illness as party of its breadth. And, in time, common medical concepts like inflammation, the immune response, normal variation, healing and ideas about mental wellbeing and resilience were inculcated into this teaching...(see The Inner Level, Pickett and Wilkinson, 2018)
I didn't travel abroad as a tropical physician but started a GP training course in inner city Bristol where the level of health illiteracy was profound. This experience brought home to me the link between poverty, poor education and lack of opportunity, ACEs etc and poor health outcomes. But across any population people are consulting in response to their felt need and having come to a conclusion about what needs doing. What they lacked was our medical insights.
Out of this came the Facts4Life programme which is all about helping children and parents take meaningful control of their health. We have now trained over 1000 teachers in a 6 year programme and have results from the evaluation of the last 4 (UWE, Innovation in health education helping children ride ups and downs of life, study shows, 24/10/18, https://info.uwe.ac.uk/news/uwenews/news.aspx?id=3876) showing we have altered attitudes in the population of primary school children exposed to Facts4Life teaching - we have trained over half the primary (and secondary schools) in Gloucestershire with CCG and Public Health funding. We have repackaged medical thinking - often focussing on the negative- into three key, positive realistic, messages: life is a series of ups and downs, we have to 'ride the ups and downs'; we live in balance (homeostasis) and we need to 'smooth the path'.
This is based on the sorts of insights more commonly found amongst GPs through whose door 90% of the footfall in the NHS is said to arrive. We often see people who are crying out for reassurance, information and help and not always prescriptions. That is, with experience, many will go away happy having been reassured, educated, enlightened and empowered. We could do this better if we worked in harness with the education sector turning GP into both assessment and treatment and education and sign posting patients to better knowledge sources (than, say Dr Google). To do this we need to educate children and adults to consult differently - so the change needs to be in us as well as in the 'public'. We should honour their quest for information and knowledge with better teaching.
The overriding and generally reassuring messages we can take from our experiences in general practice and give to people are these:
• Illness is part of normal life. We experience more or less of the time depending on a host of structural, social, political, environmental and inherited reasons. Luck plays a massive role. So does education and the choices we make.
• The Most ideas
o Most of the time most of us get better from most illnesses on our own
o Most of the time we are well
o Most illnesses are not serious
o Most of us want to know what will help us get better and stay well (but see last ‘all’ idea)
• The All ideas
o All of us get ill sometimes
o All of us live in a state of flux between health and illness from birth to death
o All of us have something positive to learn from illness, in general, and specifically from our own experiences
o All of us have a tendency to look for a quick fix (and this often isn’t available)
Our aim should be – less illness, less often, less severely with a quicker recovery and with better understanding.
Competing interests: No competing interests
This reappraisal based on objective observations/evidence certainly calls for attention and consideration and eventual translation into clinical practice; however, there is bound to be turmoil between science (evidence), the answerable actor (clinician) and the perceiving recipient (patient). For a long time, the precious drug oxygen has been the most elementary measure to convince and confirm that management has been 'initiated and delivered '. On the patient side, in those with a vascular catastrophe such as cerebrovascular stroke or myocardial infarction, with consciouness/ awareness intact and a mind shattered, oxygen may be perceived as the only link and thread between the earthly existence and the upward 'other'.
In acute care units, where the first 24 hours of aggressive treatment, monitoring and stabilisation matter (1), the rapidly changing clinical dynamics may make the clinician commit (act) rather than be conservative with the patient / attendant perception factor in mind. As such the 'disconnect' in clinical care both perceived and real has become more apparent in recent times. Depending on the clinical setting and situation, the population served and their human and cultural sensitivities, it appears prudent to tread slow and steady towards newer findings being implemented in clinical practice.
Reference: 1 Yeolekar M E , Mehta S .ICU care in India- status and challenges. J Assoc Phys Ind. 2008 .56 , 4 : 221-2.
Dr Murar E Yeolekar, Mumbai.
Competing interests: No competing interests