My RCPCH 2017- Day 2
Lord Dub’s and giving Teresa May the eye
Lord Dubs arrived in the UK in 1939 as an unaccompanied refugee on the Kindertransport and therefore was ideally placed to kick off international day with an overview of how we can best provide care for refugee children in the UK today. Unaccompanied minors are particularly at risk and a study completed by Save the Children last year identified that there were 95000 unaccompanied asylum seeking Children in Europe but that 10000 of these had simply disappeared from sight. He warned of the vulnerability of these young people in the absence of official routes to safety especially in relation to human trafficking.
He outlined the government’s response to the current challenge of caring for these unaccompanied minors including section 67 of the immigration act which states that;
The Secretary of State must, as soon as possible after the passing of this Act, make arrangements to relocate to the United Kingdom and support a specified number of unaccompanied refugee children from other countries in Europe and that the number of children to be resettled shall be determined by the Government in consultation with local authorities.
In addition to this, the EU derived Dublin Free Regulation means that young people seeking asylum should be able to join family members already resident in the UK. It may all be written in legislation but it doesn’t sound like we’re doing our bit yet. He’s locked horns with Teresa May on more than one occasion both as home secretary and prime minister regarding the above and even told us about ‘giving her the eye’ as she attended parliament to let her know he meant business. Unfortunately it sounds like the distraction of Brexit and the recent election means that the exact number of child refugees that will be accepted by Britain is still being argued in government. As a college he asks us to speak up nationally and continue to raise awareness of this issue as some European countries such as Germany and Sweden have certainly done a lot more for these children than the UK at present.
What can micro finance initiatives have to do with paediatrics you may ask? I did too…However Shalini Ojja presented her work on ‘Roji Roti’, a micro finance initiative in Bihar, India. This system in which groups of women have shared savings which they can organise and manage to ensure their families receive adequate nutrition led to a reduction in child malnutrition. As half of all death in the under 5’s is secondary to undernutrition and this is a critical public health issue, this was pleasing to hear. It seems the key features of this scheme were that it was women centered, peer controlled and involved small financial loans only.
Early intervention in HIE in a low resource setting
Childhood disability is recognised as having huge emotional, social and financial implications for families and mother’s of disabled children are often subject to stigma and social isolation especially in developing countries. Dr Karen Martin spoke about a study from Mulago hospital (A government hospital in Kampala, Uganda) where life births affected by birth asphyxia and children with cerebral palsy were identified from age 6 months and an early intervention education programme (getting to know cerebral palsy) was delivered with significant improvements noted in the quality of life for these families.
Referral characteristics and clinical findings in child sexual abuse
Dr Sarah Al Jilaihawi then presented her findings in a population of children referred for concerns about child sexual abuse. It was helpful to recap the definition of an acute or ‘forensic’ case as I often receive phone calls during my child protection on calls and need to consider whether an urgent examination is required. In Pubertal girls; forensic assessment may be indicated up to 7 days from the suspected abuse (the earlier the better). In Prepubertal girls or boys it is only indicated up to 3 days' post abuse.
She also highlighted that those children < 12 years often present with abnormal behaviour or physical symptoms prior to concerns about abuse being raised. However these examinations are more likely to be normal whereas increased age is associated with an increase in anogenital findings.
Life Course Approach to Non-Communicable disease prevention
The George Frederick Still Lecture was given by Professor Mark Hanson and focused on non-communicable diseases such as type II diabetes and cardiovascular disease.These account for 2/3rd of all deaths and DOHAD (International Society for Developmental Origins of Health and Disease) identifies this focus as the greatest area for public health intervention since germ theory and hygiene.
He highlighted the importance of intervening in the adolescent population prior to the onset of peak reproductive age. 50% of our population are overweight or obese by age 24-39 years but the adolescent population are often unaware of the risky health trajectory which leads them down this route. Increasing research into Epigenetics tells us that DNA methylation occurs as a result of these unhealthy lifestyles which in turn passes to the next generation increasing their risk of obesity.
Adolescents are generally fit and well so not on the radar of health care professionals yet postpone adopting healthy lifestyles and do not realise the risk of transmission of non-communicable disease to their children. However they are at an age where they may begin to to understand this risk if appropriate education was given. Two examples of such resources include Life Lab, an educational project in Southampton that educates young people about the science behind health and ‘The Gift’ a public initiative in conjunction with RCPCH and Southampton University highlighting that life is a unique and precious resource for healthy development given by one generation to the next.
The Inspiring Professor Molyneux and the Global Health Workshop
This was a fantastic workshop that highlighted not only global health opportunities abroad but what those of us without the freedom to fly off for 6 months could do to experience global health. Although going overseas with the global links programme and taking an OOPE (out of placement experience) sounds appealing, so does getting trained in delivering ETAT teaching and spending short sessions overseas or fitting things in in the UK such as the CHiLS course (Child Health in Low Resource Settings) run by the college or the RCPCH e-learning ETAT+ module.
Dan Magnus (Chair of the International Child Health Group) told us about his experiences setting up HealthStart an education based programme in primary schools. Read more about it here at child.org.
His key messages were that:
1) Global Child Health does not have to involve travel
2) Doing global health does not have to mean using a stethoscope in a hot country but could involve research, advocacy, humanitarian work etc.
3) There are many many pathways into global health!
I had never heard Liz Molyneux speak before but her achievements speak volumes; having been one of the founders of APLS as well as ETAT (emergency triage and assessment), She’s spent most of her working life in Malawi and had lots to tell us about how we could all become doctors of the world!
She spoke of the importance of considering what you as an individual can best offer when applying to work in low resource settings and approaching all new experiences with sensitivity, not making assumptions that one knows better. It takes time to learn about a different system and therefore wading in, in our ‘know it all’ boots is never a good idea. Her advice was that on arriving in new work settings, when we see opportunities for improving care it is best to take that thought and put in a drawer for a few months whilst gaining a better understanding of the local system and it’s limitations. When we take that thought out of that drawer and re-examining it with better insight several months later we may be glad we didn’t express out thoughts initially.
In terms of accessing global health opportunities she mentioned VSO (Voluntary Services Overseas), DFID (Department for International Development) and the infamous MSF (Medicins Sans Frontiers. Whatever your path it seems that you often learn much more from these experiences than you could ever give. She also talked about the current MTI and visiting fellows programmes that have been set up by the college to allow doctors from overseas to work here in the UK for a period before returning to low resource settings with the hopefully beneficial experience of working in the UK health system. Unfortunately, it sounds like the MTI programme has currently had it’s funding withdrawn due to visa issues.
Parents as Educators- A great idea
Following this I attended the paediatric education special interest group forum where Dr Borges Da Silva told us about their experiences of a parent educator programme in which they had taken ‘expert parents’ and asked them to teach medical students. This provided a much more family-centered experience of child health for the students and I left wondering how we could apply it in my trust.
Post traumatic stress disorder in UK trainees
For those of us who have been involved in the death of a child it was reassuring to hear that we are not alone in reliving the event over and over in our minds. Avoiding reminders of the event, emotional numbing and hyper-arousal are all symptoms of post-traumatic stress disorder and indeed 81% of trainees on questioning were recognised to have at least 1 symptom of PTSD following a child’s death with 5% meeting the full PTSD criteria. 32% felt that they had returned to clinical duties too early following an event and 17% felt unsupported by their seniors. This is clearly an area in which we need to improve.
Ready Steady Go and transition…
Southampton hospitals then shared their experience of the ready steady go ‘transition’ programme that they had developed for all those patients over 11 years who were likely to require transition to adult services at some point. Read more about it here. There are some great resources identifying how we can help these children prepare for independence at a much earlier stage and prevent a very quick and frightening transition to adult services at age 16-18. There is also a focus on taking ownership and understanding one’s medical condition
A bit more Global Health
I finished my afternoon by skipping back over to the Global Health forum (couldn’t resist…) We watched a video about a young women called Cynthia who struggling with asthma as a child moved to the United Kingdom age 5. However she was not granted indefinite leave to remain and later told she was not entitled to the education she dearly wished for (see here). We heard from other unaccompanied child refugees about specific challenges faced when arriving in the UK such as the health care system not being explained and frequent changes in support workers. Through their honest accounts it was clear that immunisation guidelines were not necessarily being met.
However hope exists and Project London (run by Doctors of the World) is an organisation that helps all asylum seekers/ register with GPs and access health care.
Liz Molyneux then took to the stage again and gave the David Baum Lecture about doing more with less (a concept we could all learn from). She highlighted the benefits of kangaroo care in preterm infants, reducing the need for expensive incubators, getting babies home quicker, reducing infection and improving weight gain. Have a read about the work of NEST (Newborn essential solutions and technologies) who are helping design other innovative and cost efficient ways to provide neonatal care. She also discussed the benefits of task shifting e.g. doctor to clinical officer, nurse to mother, junior doctor to specialist nurse etc. in maximising our use of resources.
She again talked about the college’s work in advocating for overseas aid (although not an aid organisation) and promoting humanitarian law as well as its current involvement in training the global work force in countries such as Myanmar, Sierra Leone, Rwanda, Palestine (see here).
Several speakers then gave examples of their overseas work linked with the college including the use of the ETAT system to improve management of gastroenteritis in district general hospitals in Kenya (which unfortunately fell at the time of the Kenyan doctors strike); introducing quality improvement teaching in Myanmar where there was little awareness of this formal concept prior to training, and measures taken to help reduce deaths secondary to Neonatal Sepsis in Kenya.
As usual it was all very inspiring and I do recommend trying to attend the conference at least every couple of years in order to put a spring in your step. I am certainly now again looking with enthusiasm towards the years ahead and the opportunities that are available in global health.