• 

• 

The 24th Annual Pumphandle Lecture was delivered on 8th September 2016, by Dr Paul Spiegel, recently appointed Director of the Center for Refugee and Disaster Response at Johns Hopkins Bloomberg School of Public Health. Previous to this appointment, Dr Spiegel had spent 14 years as Deputy Director of the Division of Programme Support and Management and Chief of Public Health at the United Nations High Commissioner for Refugees (UNHCR) in Geneva.

Dr Spiegel began by referring to the large numbers of refugees and displaced persons in the world today – the
largest numbers since the Second World War, with the majority coming from Syria, Afghanistan and Somalia.
He commented on the history of such humanitarian crises in recent decades, from Biafra in the 1960s to Cambodia in the 1970s to the many states in crisis today. Circumstances have changed considerably over the years both in the nature of the crises and countries where they take place, and the various institutional responses. Much of the data come from refugee camps, and it has been difficult to quantify populations affected but not in camps. Crises have become protracted and health problems have shifted from a focus on communicable disease to a wide variety of health problems including those associated with middle income populations such as in Syria. New agencies have arisen, several within the UN but many with other international, national or local bases. Recently several Islamic agencies have become involved, and there is a move for private sector involvement. Coordination of all these agencies has posed problems and it is recognised that decision-making has not
always been optimal, having to be made on imperfect data in a complicated political context.

He devoted much of the lecture to expanding details on five recommendations he considered essential for the improvement of responses to such crises. First is the need to “Operationalise the concept of centrality of protection”, recognising the priority to provide a safe environment for people but appreciating the complexity of this challenge. Second is the need to “Integrate affected persons into national health systems” making use of the talent and experience of the displaced persons. Third is a need to “Remake, not simply revise leadership and coordination”. He argued that the WHO has justifiably held a central position on the global stage but that it has failed repeatedly in recent years – it must repair its structures and procedures soon, or lose its central position. Fourth is the need to “Make interventions more efficient, effective and sustainable” which has many implications, including the need to move from annual budgets and short term thinking to recognition of need for long term infrastructure and the importance of education and livelihoods for societies if they are to survive and prosper.

Finally he referred to the need for “Data and research to improve outcomes and impact”. The need for effective
evidence-based decision-making is obvious – but this requires systematic collection and critical analysis of data in order that the required evidence can accumulate. He referred in particular to the Wellcome Trust / DfID R2HC initiative (on “Research for Health in Humanitarian Crises”) which is encouraging rigorous research on this group of problems. Dr Spiegel closed by referring to what he called the “forgotten emergencies” in countries such as South Sudan and Central African Republic, which have been crowded off the global agenda because of the magnitude and urgency of the crises in and around Syria. The world has failed both in allowing these circumstances to arise, and in responding to them. Something new is required to deal with these immense
problems– a new pumphandle.

The vote of thanks was proposed by Professor Jimmy Whitworth, and Dr Spiegel was invited to remove the handle of the pump to close the proceedings. Society Members then adjourned to the John Snow Pub in Soho for the Annual General Meeting of the Society.

• 

• 

The 23rd annual Pumphandle Lecture was given on the 8th of October 2015 by Dr Atul Gawande, Professor of Surgery and of Public Health at Harvard, well known author (eg The Checklist Manifesto and Being Mortal), and Executive Director of Ariadne Labs, a joint centre for health systems innovation, as well as Chairman of
Lifebox, a UK-based nonprofit devoted to making surgery safer globally.

Dr Gawande began by referring to Snow’s work on cholera, and the subsequent evolution of the complex health care systems of today.

He highlighted the effectiveness of a simple checklist approach in three key areas – surgery, maternal and childcare, and primary healthcare – emphasising that a checklist is not a protocol, but a list of the most common things that experts miss, and which should be tailored for particular activities and institutions.

Drawing from experience in the airline industry, the checklist approach was adapted by Dr Gawande’s team and
recently introduced, first in surgical practice. The explicit checking of a list of just 19 items, in theatre, has led to
important reductions in surgical mortality in many countries. He emphasised the necessity of monitoring the system through setting targets, continued contact and data feedback.

In the case of maternal and child health, he emphasised the importance of identifying a set of ”minimum required guidelines” and the collection of data to identify what is missing in the real world. He described
studies in areas of India where one in 20 newborns die in utero or soon after birth. Critical analysis led to agreement on a series of actions before admission, during birth, after birth and when the mother was being discharged. Improved results were not from additional skills training or supplies but the use of a 30-item checklist at different stages.

In assessing primary healthcare, it is common to consider four S categories: staff; stuff; structure and systems.
However, users typically ask about four C’s: contact (is there a place to go that is open); continuity (do staff recall medical histories); coordination (is information transmitted to add to wider public health discussion) and comprehensiveness (can a primary healthcare institution take care of the majority of medical needs). To address these concerns, Dr Gawande and colleagues have recently launched the primary healthcare performance
initiative, which has been approved by the UN General Assembly, in order to identify which is the simplest system to follow to close the gap between aspiration and achievement.

All these are examples of innovative ways by which to remove crucial pumphandles confronting public health.

The vote of thanks was proposed by Professor Dilys Morgan, using a checklist, and Dr Gawande was invited to remove the handle of the pump to close the lecture. Society members then adjourned to the John Snow pub in Soho for the Annual General Meeting of the society.