Me, Marmite, mosquitoes and malaria

It was the German scientist, Justus Liebig, who in the late 19^th century discovered that brewer’s yeast could be concentrated, bottled and eaten. Brewer’s yeast is a waste product from the brewing industry and is the basic ingredient of Marmite. Now regular readers of this blog may know that I’m a big fan of Marmite, but I wonder how many of you like it too? Research in 2022 (presumably incredibly important to enhance scientific knowledge) found that just under half of the UK population liked Marmite, a quarter didn’t and a quarter didn’t have an opinion one way or the other. I regularly eat Marmite for three reasons. (1) it stops me from getting cramp at night, (2) it helps prevent me getting bitten by biting insects and, (3), the vitamin B complex additions are good for my general health.

On our recent trip to India and Nepal, J was constantly getting bitten, whereas I didn’t get bitten once. I’m not sure how Marmite protects, but I do know taking regular Vitamin B complex supplements can have the same effect. However, I’m not recommending it as a complete protection. When I went to Uganda a few years ago, a country where malaria is endemic, I naturally took additional precautions. This included taking the antimalarial medication, Doxycycline (every day a week before, during my stay and for four weeks after returning to the UK) and using a DEET-based spray on exposed skin. The spray had a smell that I grew to loathe by day three of my trip. That said, I didn’t come down with malaria.

Malaria is a dangerous and indiscriminate disease. Across the world it kills more than 1 million people each year. People become infected through mosquito bites. And it only takes one bite to become infected. Indeed, almost 700 million people contract a mosquito-borne illness each year. Perhaps not surprising when you know that mosquitoes outnumber humans 160,000 to 1. They are tough little critters, who continually develop resistance to the insecticides used and so are very difficult to get rid of as well. Not impossible however, and it is certainly possible to eradicate malaria given the right commitment and approach. It is what happened in China in 2021, see here, and the Bill and Melinda Gates Foundation continue to work across the globe in the fight to make malaria a disease of the past.

There was a malaria vaccine developed by the pharmaceutical company GSK in 2021, but its cost was prohibitive for worldwide usage. Certainly, in those countries where malaria is prevalent - countries such as Uganda, Nigeria and Tanzania - the per capita health spend is very low. In Tanzania for example it is just £12 per person per year; to put that into perspective, in the UK it is over £4,000 per person per year. Even critical medication like the GSK vaccine can become impossible to provide at a population level with such low per capita spend.

So, it was great to read last week the preprint paper in the Lancet (a paper that has yet to be peer reviewed) of the work undertaken by a team working at the University of Oxford, who have successfully developed a malaria vaccine (at the moment called R21). I was amazed that anyone could write a paper that has 28 authors, but  here it is. The evidence presented in the paper suggests that the vaccine can protect children aged between three and five years old. Up to 96% of all malarial deaths in Africa are children aged five or under. It is as effective as the GSK vaccine, but can be made available at half the price, thus making population wide use possible in low-income countries. The vaccine has already been approved for use in a number of such countries.

Now, you might be thinking why is the Prof writing about malaria when it’s not something to be found in the UK. Well, you would be wrong. The last known case in the UK occurred in 1957. It was a consequence of troops returning home in 1915 from fighting in the Balkans during the First World War. They had been garrisoned in camps on the Isle of Sheppey, in Kent. Malaria was endemic in the Balkans, so many of the returning troops were infected. The Isle of Sheppey was an area where mosquitoes lived in abundance. The unintended consequence was a mass outbreak of malaria that took until 1921 to control.

As the world climate changes, and it feels like we are experiencing rapid changes to the climate, it is easy to envisage a much greater risk of diseases spreading in ways previously unseen. The world is heating up and disease in one part of the world might, in the future, spread much more easily. And we are already seeing this happen. In 2010 the Culex modestus mosquito was detected in large numbers in the Thames estuary. In 2016 the Aedes albopictus mosquito was first detected in England. Neither of these are native mosquitos, and both are responsible for life-threatening tick-borne diseases elsewhere in the world. It is Halloween time and if you want a real fright, have a look at the latest report (2021) published by the UK Health Security Agency, and just think about the Isle of Sheppey story… …I for one am glad that we now have the R21 vaccine in our national medicine cabinet.    

Working towards a more diverse, equal and inclusive world

This week’s blog comes from the blustery and very wet Fylde Coast. Our trip to India and Nepal, although wonderful, is sadly over. After most days where the temperature was 26 - 30c the change in the weather came as a shock. We made some new friends along the way, both fellow travellers, guides and hotel staff. We had a great time, and thankfully, through avoiding ice cubes, salad and only drinking bottled water, we had none of the potential health problems!

In fact, we had no problems along the way at all except operating the TV in the various hotels we stayed in. As we were travelling without any young people, operating the controls appeared to be beyond our ability. The consequence was until the last day, when someone from reception came and showed us how to access the TV, we were largely cocooned from the outside world. Yes, we had picked up some of the news from the Middle East, but it was only when we were able to see the news reports on the various news channels did we get a sense of the enormity of the unfolding conflict in Israel and the Gaza Strip.

Back in 2022 J and I took a Holy Land pilgrimage by way of a belated Honeymoon. Due to family connections, I had long wanted to visit Israel and it had always been a must-do on J’s bucket list. We decided that we didn’t simply want to be tourists and so chose a company that specialised in religious pilgrimages. I’m glad we did, as our guides brought the Bible to life and it was one of the most spiritual experiences of my life. There were so many good memories; perhaps one that stands out for me, was taking holy communion literally on the shores of the Sea of Galilee.  

Our guide was a chap called Bassam. He is a Palestinian Christian, and one of the most generous men I have ever met. His kindness, tolerance, biblical knowledge and historical insights were amazing. One of the places he took us to was a small orphanage in Bethany or in Arabic, Al Eizariya, a small town in East Jerusalem, the West Bank. If the name sounds familiar it might well be that it has been consistently one of the most popular girls’ names in the English speaking world. It could also be that you remember it as the place that Jesus stayed during the Holy Week before he was crucified.   

To get to it, we had to pass through an Israeli checkpoint, which was a little unnerving to say the least. The orphanage was a day school for Palestinian girls and a residential school for boys. Most of the boys had been abandoned by their families for one reason or another. None of the children had ever been through the checkpoint and sadly never seen Jerusalem, which lies on the other side of the Separation Wall only 2km away. They had very little in the way of material possessions, and although the rooms and building were clean and tidy, they were very drab and had an institutional feel about them.

On our return to the UK, we contacted the orphanage to ask if there was anything we could do to help make the boys lives better. After a while, we got an email back which said perhaps we could help pay for one or two of the bedrooms to be repainted. They gave us a suggested cost, for a couple rooms. However, based on these costings, we decided we could fund all of the 26 bedrooms being decorated, and paint the corridors and banisters too.

The boys were told and they were given the opportunity to choose colours and their own design and so on. We were sent photos and messages during the entire process, and it was wonderful to see the delight and hear the excitement of the boys as their choices became a reality over that summer. We had hoped to go back this Christmas to see for ourselves, but that now feels unlikely.

This blog is not the place to argue about the rights and wrongs of this long-running conflict in the Middle East, other than to say I absolutely condemn any act of terrorism, wherever this occurs and whoever is responsible.

Our pilgrimage coincided with Palm Sunday. We were able to join thousands of others, waving palm fronds and singing hymns, as we walked from Bethpage on the Mount of Olives descending into Old Jerusalem. It was a hour or two that brought together so many folk from different beliefs, religions, cultures and races in celebration and remembrance. It was an occasion to show peace, love and not hate.

I was surprised therefore, on Friday to see a copy of a letter from Steve Barclay, (Secretary of State for Health and Social Care) to all England’s Integrated Care Boards instructing them to stop local NHS provider organisations from employing ‘standalone’ Equality, Diversity and Inclusion (EDI) post’s. If we persist, then we are to justify why these roles are more important than employing doctors or nurses instead with the money. In our Trust, we have a so called standalone EDI lead, and she provides excellent leadership in our ambition to develop a more inclusive organisational culture. If I’m called upon to defend our decision to employ someone in this capacity, I will draw upon the evidence-based open letter penned by the excellent Roger Kline on diversity in the NHS – you can read it here. 

During our pilgrimage, Bassam our guide noted that the future of Israel and Palestine will only be secured when the rivers of blood spilled over the years become water under the bridge. Wise words indeed. We all need to work together to ensure we create a more inclusive, diverse and equal world. This might be a nation world, a community world, or even, an organisational world. And, maybe, just maybe, our Steve could learn a thing or two from Bassam.

Passage from India and into Nepal

Last week's blog was posted from India. This week's blog comes to you from Kathmandu, and what a beautiful place it is too. A mere two hours’ flight from Delhi, yet a world apart. The India leg of our trip was brilliant, even if you were reminded every moment of every day of the contrast between the lives of the rich and the poor. More of which later.

 

I have been to India before, but only on work business, presenting at conferences and so on. Despite perceptions to the contrary, this usually meant flying in, staying in a hotel, presenting a paper in a conference hall, with maybe just a day or two of sightseeing. So for this trip I was determined that J and I would do all the tourist bits, and more, so we hired a guide for our stay and did just that. And there was so much to see. We chose to do the Golden Triangle – Delhi, Jaipur, Agra and back to Delhi. This meant we were able to take in many of the sights India is famous for including The Palace of the Winds, The Am(b)er Fort, Fatehpur Sikri, Agra Fort, Jantar Mantar Observatory (one of my favourites), the Palace of the Maharaja and of course the Taj Mahal. 

 

We had to get up at 04.00 to visit the Taj Mahal, and even then, we had about 40 people in front of us while we waited for the 06.00 opening time. It was worth the early morning start and the wait. The Taj Mahal is everything you expect it to be. J and I got to sit on the famous Princess Diana bench for the ubiquitous photo (it had to be done). We watched the sunrise and stood in awe as the Taj Mahal was revealed in all its glory. The whole site is some 17 hectares in size and yet it was all proportionate, symmetrical and stunning. It took 20,000 men 22 years to complete during the 17th century. To put this feat into perspective, the Grand Mosque in Abu Dhabi took 3,000 men 13 years to construct in the 20th century, and that is with all the benefits of modern construction techniques, materials and machinery. 

 

I can now say that I have been to both places. They are both wonderful, but I think I preferred the Taj Mahal of the two and can absolutely see why it is now a UNESCO World Heritage site and still one of the seven wonders of the world. 

 

What wasn’t so wonderful was the traffic. It was unbelievable, terrifying, literally death defying and the noise, a constant cacophony of horn blowing. Drivers constantly jostled for position; an inch gained was a reason for celebration, more horn blowing. However, in the whole time we were there, and we covered many miles, we did not witness one collision, or accident. It was simply remarkable. As was crossing the roads on foot. You had to take your courage in both hands and step out into the face of oncoming traffic and resolutely keep walking. The first time I did it my heart was in my mouth, and I had this fearful thought that someone would knock me down. 

 

As you are reading this week’s blog, clearly that didn’t happen. I survived. Possibly it is just as well I wasn’t involved in an accident, as no-one takes any notice of the emergency vehicles even with their ‘blues and twos’ going. It’s just more noise to add to the general melee, and they have to fight for that all important inch forward like everyone else. The traffic was also a window into the wider inequalities across Indian society. There was everything from Range Rovers to rickety bicycles and everything you could possibly imagine as a form of transport, including camels, elephants, oxen and horses, in-between.

 

I found it very difficult to get information on the average income here, so don’t want to quote figures that might be widely wrong. However, doctors are paid considerably more than nurses, and like in the UK, the cost-of-living crisis appears to have hit India – see here. I did discover though that for every 100 rupees paid to a man, women were paid 112 rupees for the same role. What is difficult to understand is why so many families chose not to take advantage of the many government services that are provided free. There are fantastic education services available, free of charge, and where everything from school uniforms, school meals and bus pick ups are included, yet many families choose not to send their children to school, with the inevitable consequences for the child in terms of life chances.

 

Health is another area where there is state funded, free at the point of contact, services available. Whilst the government has a statutory responsibility to make free health care available to all, the actual public services available are underfunded and can be very patchy, particularly in the more rural areas. The public health care services experience massive workforce shortages and care is often provided in poor facilities (doesn’t that sound familiar). However, there is a thriving private health care system in India. The private sector offers services at a fraction of the cost of most developed services, and every newspaper carries full page advertisements of what is on offer. Whilst we in the UK would find it relatively cheap to access, and India is fast becoming a medical tourism hotspot, many low paid folk in India would struggle to access the private sector. Ensuring good population health appears to be as big a challenge here in India as it does in the UK 5000 miles away.

 

Normal service resumes and hopefully the changeable font situation will be resolved. Next week's blog will come just North of Blackpool. 

 

Memories of bears, pigs, and a great Slovakian nurse

It is funny what can stir a memory. General Elections in Slovakia don’t normally cause a stir, and yet the result of last week’s election made it into most of the UK media and, as a consequence, caused a stir in my memory. For the media, it was the election of Robert Fido as Prime Minister. He is a pro-Putin politician, and part of his election manifesto was to stop providing aid to Ukraine. I cannot believe that would be a good thing. However Slovakia is very dependent on EU monies, so maybe he will be slightly curtailed in what he feels able to do. 

My stirred memories of Slovakia are many. Pigs are one memory. On my very first visit to Slovakia, I spent two hours in an intensive pig unit formerly run by the Russian communist occupiers. Now if this was smelly ‘So Me’, you might appreciate my dilemma. I love pigs, and once upon a time had a small herd of Vietnamese Pot Bellied pigs – possibly the first person in Wales to do so. But they had names, and as we were all vegetarian, we were never going to kill them for `Sunday lunch’. It was a dilemma, as we eventually sold the piglets to others and of course, you had no idea what they might do with them.

Bears are another memory. Until going to Slovakia I had never seen a real live bear in the wild. On my second trip there, I did. I had been invited to a dear colleague’s summer cottage for the weekend. I would have moved there in an instant. It was a small cottage; two bedrooms and a downstairs that was lounge, kitchen, dining room and bathroom. Some might say it was crude, me, I thought it was perfect. Best of all was seeing the little black bears coming out of the forest opposite the garden to steal the plums off their tree. I had never been up close and personal with a bear before. It was an intimate moment never to be forgotten. 

The colleague I was visiting at that time was what I thought of as the almost indefatigable Alzebta Hanzlikva. She was a lady about whom I used to think, if I could be half as good as her, I might be able to make a bit of a difference.  I met Alzbeta in a pre J world and I was stunned by her purple hair. Many years later I married a lady who doesn’t just have purple hair, but multi-coloured rainbow hair. It is her thing. Wherever and whatever J is doing, she does it with her head held high. J has taught me the power of authenticity, and she is one of the most authentic persons I have ever met. 

Back to Alzbeta. In 1995, the first ever conference I attended as a speaker was an ‘international’ nursing conference in Martin, Slovakia. I say international, but essentially, myself and my boss, were the only non-Slovakian folk in attendance. It was held at the Jessenius Faculty of Medicine - the medical and research division of the Comenius University. For many years after that first conference, I attended each subsequent conference and enjoyed some fun times travelling to and from Slovakia over those years. 

Those early post communist days were wonderful and so different from life in the UK. Back then they really didn’t know what a vegetarian was, and thought I was completely foolish for not wanting to eat meat! They had never seen anyone wear clogs before, let alone brightly coloured ones. Eventually, I became part of the scientific committee that organised the conference. Every year it grew in terms of the number of papers being presented and started to attract several more academic colleagues from outside of Slovakia. Although I had to participate through an interpreter, it was a great community of nurses to be a part of. 

As with all things, I eventually stopped attending the conference, so I was surprised in 2015 to be invited to attend and present a paper. At first, I didn’t want to attend, but was persuaded by one of my old PhD students from Hungry and also a long-time supporter of the conference, that I should go. So once more I took the overnight train from Prague and pitched up at the conference. What I didn’t know was I had been asked to attend for a special reason. I was there to be part of a memorial conference that celebrated the life and work of Alzbeta. She had died in 2012. Her life’s work was in promoting the profession of nursing and she was passionate about ensuring the education of nurses was evidence-based, and scientific in orientation. Alzbeta was an inspirational lady, who really had a 'can do' approach to life. She started to learn English aged 50, as she realised that English was the ‘official language of science’ and she needed to get her research papers published in English language journals. The memorial conference acknowledged her impact on nurse education, not just in Slovakia but much further afield. She championed the advancement that research could bring and tirelessly worked at enabling nurses to gain their PhD. 

And at the conference, I was surprised to see my name appear in a presentation with many others whose work was being recognised by the award of a Gold Medal of Merit. I was duly presented with my medal for my contribution to university education for nurses in Slovakia. I was both immensely proud and humbled in equal manner. The last official act on that day was the unveiling of a memorial plaque in the entrance hall of the School of Nursing. I am not sure what Alzbeta would have thought about this very public recognition of her life and work, as she was a very modest person. My feeling was that it was a very appropriate, and somewhat affectionate, and a well deserved sign of how much her work meant to so many people. There will be others like her in Slovakia, and perhaps they will collectively work in promoting kindness, compassion and hope rather than hate

Talking chickens, a curate’s egg and an improving week

Some weeks are better than others. Last week was the proverbial Curate’s Egg; a very mixed week for stories for sure. Storm Agnes came and went, we didn’t notice, whereas in Ireland and Wales there was flooding, damage to buildings and much travel disruption. We heard the dreadful news from Iraq of the fire at a wedding reception that killed over 100 people and injured 150 more. And last week we heard about the conflict that has broken out in Azerbaijan with thousands of folk having to flee to nearby Armenia. I think, like many people living in the relative comfort and security of Britain, facing such an upheaval is hard to imagine. 

Also, hard to imagine, and very sad were two very different stories from last week. The first was the awful killing of 15 year old Elianne Andam in South London. It’s a parent’s worse nightmare. Your child leaves for school and never comes home again. As well as Elianne’s family who will now be trying to come to terms with this senseless murder, Elianne’s friends who witnessed her attack and death will live with that trauma for the rest of their lives. The police have a suspect in custody and if that person is eventually convicted of her murder, then they will have to live with the legal and psychological consequences of their actions for the rest of their lives too. Given the age of the suspect, that is likely to be a long time.   

The other unimaginable, inexplicable and equally sad story, but for very different reasons, was the cutting down of the Hadrian’s Wall Sycamore Tree. The tree had a special place in many people’s hearts and minds and, like me, many people will have seen it during their lifetime. The police have now arrested two people in connection with this apparent act of vandalism. True confession time, sycamore trees are the bane of my gardening life. Neighbours on both sides of me have large, mature sycamore trees. In the spring and summer, they drip a sticky substance (the result of greenflies). Throughout autumn, the tree scatters seeds to every corner of the garden. I spend many hours pulling up the tiny seedlings that grow as a result. I’m sure the Gap Sycamore stump will soon sprout new growth, but of course it will be many years before it regains its former glory.

There were, of course, some good stories last week. One that made me smile was about Joey the 82-year old tortoise. Apparently, tortoises are a very tough species, and just like many men, they don’t let you know there is something wrong with their health until it’s really bad. In Joey’s case he had a huge bladder stone, weighing some 150 grams. Veterinary surgeons were able to remove the stone, but reckon it will take up to a year for Joey to fully recover.  Just to put this remarkable tortoise’s situation into context, if the equivalent stone had been growing in a human it would have been the size of a basketball!

And there was another good news story last week that didn’t get a mention in the main stream news media, but for me was just as important. Last week, at my NHS Trust we held a celebration event for the service transformations that have been achieved over the past 12 months. It was a great celebration too, and a wide range of service improvements were showcased and presented by the teams involved. We do have an excellent ‘transformation team’, and their main role is to try and create the right culture at a local level that supports continuous improvement, innovation and of course, improved outcomes for patients.

Just like the recovery of the Gap Sycamore Tree, developing such a culture will take time. It also needs facilitative and committed leadership from the Board through to the Ward. One of the things I notice the most when doing my walkabouts and talking to colleagues is the ‘can do’ attitude many are proud to share. Given the often challenging conditions facing colleagues at present, this is an attitude that gives me great confidence that we are not content with the status quo, but will keep looking for continuous improvement.

In the summer NHS England launched what they have called NHS IMPACT (Improving Patient Care Together). It is a new approach that will help support organisations to develop the appropriate leadership behaviours, help create a widely shared vision of what is possible, and lead to the development of an improvement culture. You can read about the approach here. However, it does feel like we have taken the first bold steps in reframing how we approach improving patient care as an organisation.

The quirkiest story of the week? It has to be the how a recent study in Japan has used AI to understand what chickens are saying to each other. The researchers listened to the sounds made by 80 hens, which were then analysed, and which allowed the researchers to work out the mental state of the chickens. Their study hopes such understanding can help us create a better world for chickens everywhere. I share that hope. Maybe we can all help create a world where love, not hate triumphs.