Volume 2 Issue 1 2010

Samoa Medical Journal

Biomedical Research and Education for the Asia-Pacific Medical Community A Collaboration of the Samoa Medical Association and Oceania University of Medicine

Samoa Medical Journal Volume 2 Issue 1 April 2010 Table of Contents SMJ Editorial Board Contact Information

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Editorial MEDICAL CHALLENGES IN 2009 AND LESSONS TO BE LEARNT Dr Ben Matalavea

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Letter 6 DOCTORS AS TEAM PLAYERS. MESSAGE FROM THE PRESIDENT OF THE SAMOA MEDICAL ASSOCIATION Toleafoa Dr Viali Lameko Special Report 7 A REPORT ON OCEANIA UNIVERSITY OF MEDICINE‟S EMERGENCY RESPONSE TEAM (OUMERT) ACTIVITIES FOLLOWING THE SAMOAN TSUNAMI ON THE 29TH SEPTEMBER 2009 Gilsenan, B A, Patu, C, Smith, I B J Review 13 IMPACT OF CARDIOVASCULAR DISEASES ON SAMOA Lameko, V Miscellaneous 18 SUMMARY OF POPULATION INDICATORS FOR SAMOA Punivalu, M, Lameko, V, Cheema, S Research 19 A MULTI-INTERVENTION PROGRAM TO REDUCE ANTIBIOTIC PRESCRIPTION FOR PATIENTS WITH UPPER RESPIRATORY TRACT INFECTION IN PRIMARY HEALTH CARE SETTINGS IN THE UNITED ARAB EMIRATES Alawadi, F, Brebner, J, Khalil, Z

Personal Perspective MY EXPERIENCES IN AFRICA Du Toit, P

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Opinion 33 TOBACCO SMOKING AND CARDIOVASCULAR DISEASES Lameko, V Literature Update HINARI COLUMN Cheema, S

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Education and Training 40 CURRENT TRENDS IN UNDERGRADUATE MEDICAL EDUCATION: Program and Curriculum design McKimm, J Conference report 49 ASIA PACIFIC MEDICAL EDUCATION CONFERENCE, SINGAPORE, 4-8 FEBRUARY 2010 Held, S, McKimm, J, Cheema, S Opinion SAMOA‟S FIRST TEACHING HOSPITAL Cheema, S

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Obituary DE FALENIU ASAUA

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Information for Authors

(Inside Back Cover)

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Samoa Medical Journal Editorial Board Editor-in-Chief Dr. Ben Matalavea MBChB Deputy Editor-in-Chief Professor Surindar S. Cheema PhD Assistant Editors-in-Chief Dr. Monalisa Punivalu MBBS Dr. Igor Bondarenko PhD Editors Dr. Limbo Fiu MBChB Dr. John Adams MD, MPH Dr. Tia Vaai MBBS Dr. Viali Lameko MBBS Dr. Aleki Fuimaono MBBS Dr. Farrah Fatupaito MBBS Dr. Francis Maru MBBS Dr. Penehuro Tapelu MBBS Dr. Ian Parkin MB BS, FRANZCP Dr. Robert Thomsen MBBS Dr. Greg Raymond PhD Hon. Professor Judith McKimm MA, MBA Adjunct Editors Dr. Roy Eldor MD Dr. Alec Ekeroma MBBS

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EDITORIAL

MEDICAL CHALLENGES IN 2009 AND LESSONS TO BE LEARNT Dr Ben Matalavea Editor-in-Chief Samoa Medical Journal 2009 will go down in history as one of the most challenging years to Samoa‟s health sector and its capacity to cope with disasters on a large scale. The global pandemic of the novel H1N1 influenza virus and the aftermath of the devastating tsunami affecting the South Pacific region, particularly Samoa, clearly challenged the readiness of our health system to respond to disasters that directly and indirectly affect the lives of the Samoan people. While the H1N1 pandemic only claimed two lives according to health authorities, the most devastating natural disaster to instantly claim many lives (149) in Samoa is, of course, the September 2009 tsunami. The challenges presented by both these events differ. The pandemic, although it swiftly spread throughout the whole world in a matter of months, was mostly a mild illness for most people, which was most fortunate. Samoa‟s experience from the 1918 influenza pandemic is still a disaster unmatched in recorded history, claiming the lives of an estimated 25% of the total population of Samoa then. The most vulnerable and high risk groups of people to be affected by the 2009 H1N1 influenza virus were identified to be pregnant women, young children, and those with co-morbidities such as respiratory conditions. In addition a vaccine against this virus will soon be available here in Samoa. The response by the World Health Organization and local health authorities evolved as more data was made available, and in the end only 2 deaths were confirmed due to the H1N1 infection.

All the severely injured victims were resuscitated and stabilised at the disaster scene and all were safely evacuated from the scene to the main hospital before nightfall, a trip that takes about 2 hours. There was only one survivor that died in hospital shortly after the tsunami, a 96 year old lady who was caught by the wave while being rescued in a pickup truck. Otherwise the rescue operation for the disaster must be remembered as a success story for the local health care providers who worked tirelessly throughout that first 24 hours before overseas help arrived. The immediate medical response by Samoa‟s closest allies, mainly New Zealand and Australia, was overwhelming to say the least. There was also medical help from other parts of the world such as Canada, the USA and the UK. The doctors, nurses and so many other allied health personnel who came to our rescue demonstrated a sense of comradeship on a large scale I have never experienced before. Their kind and selfless acts to help Samoa is an experience I felt lifted our spirits far beyond what was expected and will go a long way in healing the „post traumatic stress‟ that the local medical fraternity felt at the aftermath of the disaster. I do hope that tsunami related articles will appear in our future publications. 2010 is shaping up to be a significant year for Samoa in the area of medical training. The Oceania University of Medicine (OUM) is now implementing its 5 year Undergraduate MBBS course. With the inclusion of high school leavers in this program the number of places for local students to study medicine immediately increases from the 4 that used to be trained in Fiji to 15 now locally at OUM. In addition a new teaching hospital is being built this year by the government to further improve the teaching facilities of OUM. A first major medical conference co-hosted by OUM and the Samoa Medical Association will be held on 24 April, which is also another milestone for OUM. Finally I wish to congratulate OUM for its achievements so far and also acknowledge its tremendous support and input in making this journal a reality.

The Samoa Health Sector response to the tsunami disaster, which was spearheaded by the Samoa National Health Services, is highly commendable as it was very effective given the scale and magnitude of the disaster, the lack of medical resources, and that the experience would have been a first for all those who were involved.

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LETTER

DOCTORS AS TEAM PLAYERS Toleafoa Dr Viali Lameko Samoa Medical Association President, 2010 - 2011 In the year 2000, the World Health Organization came up with a model for a health system based on „six building blocks‟ namely: 1. good health services, 2. well performing health workforce, 3. a well functioning heath information system, 4. accessibility to medical products and tech nologies, 5. a good health financing system. and 6. a greater need for strong leadership and governance from policy makers. It encompasses all the activities whose primary purpose is to promote, restore, or maintain health. A system that should include patients and their families, health care workers and caregivers within organizations and communities, other sectors and stakeholders, and the health policy environment in which all health related activities occur. In a hospital setting, this system therefore includes a lot of players such as administrators, ambulance drivers, porters, cleaners, x-ray staff, laboratory staff, pharmacy and nurses to name a few. In the midst of all these people is a group of medical doctors who are very much part of the team and who could not work alone without the support services provided by all the people mentioned above. However not every health system is the same and each poses weaknesses and threats that could have a tremendous impact on how the medical officers perform their duties efficiently. Some of these challenges include:  

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inadequate health financing that leads to short supply of medications, run down equipment and poorly paid staff an inadequate workforce to carry out the day-to-day operations and service delivery leading to the possibility of poorly organized teams with bad communication skills and styles, power struggles and personality conflicts

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Nevertheless, these challenges could be seen not only as opportunities to trigger better planning and budget allocations to finance health but also for each medical officer to lead and be an important member of the team. The Samoa health sector response to the Novel H1N1 influenza pandemic of 2009 and the Tsunami disaster that devastated villages in the southeastern part of Upolu Island clearly illustrate the importance of the medical officers‟ role not only as a team player but very often they are called upon to be team leaders. It again reminds us that: 1. Doctors shall consider every member of the team as an important and a valuable asset to the team organization 2. Doctors shall work with the team to demarcate each team member‟s responsibilities to avoid pointing fingers if matters arise 3. Doctors shall be an example of integrity and honesty, and therefore report mistakes and errors to improve patient safety 4. Doctors shall be a force behind good change and continuously lobbying to prioritize patient safety in every clinical setting. I feel that we are seeing progress in the acute and long term care of patients in Samoa. We have a much clearer idea of what we need to do to improve teamwork within the health system. Although policies and clinical standards are now in place to guide and monitor our clinical practice, the stakes and public expectations are high. The public are often mislead to believe that the practice of medicine should be without errors and mistakes forgetting that doctors are also human beings. A doctor too has good and bad days. A doctor who may only have a two hours sleep the previous night, a doctor who may have not seen his or her own children and wife or husband for two straight days because of the demanding working hours. In conclusion, I urge my colleagues to take heart and know your limitations because no doctor will know everything and no one knows how to relate to every patient and different situation. Try to make time to reflect on the day‟s work and try to draw a balance between work and the rest of the world around you. I urge my colleagues to consider others whom you work with with utmost respect and share your knowledge by teaching others what you know. One of the greatest joys I found of being a doctor is seeing my patients get better and go home with a thankful heart. I wish the Samoa Medical Journal success and many more editions in the near future.

SPECIAL REPORT

A REPORT ON OCEANIA UNIVERSITY OF MEDICINE’S EMERGENCY RESPONSE TEAM (OUMERT) ACTIVITIES FOLLOWING THE SAMOAN TSUNAMI ON THE 29TH SEPTEMBER 2009 Gilsenan, B Ai; Patu, Cii; Smith, I B Jiii Griffith University, Australiai Oceania University of Medicine, Samoaii University of Edinburgh, UK iii Introduction This report outlines the work carried out by the Oceania University of Medicine Emergency Response Team (OUMERT) in the days following the Samoan tsunami of 29 September 2009. The work focused on providing immediate health care to the 3 villages of Lepa, Saleapaga and Satitoa, which were amongst the most devastated villages affected by the tsunami. Background At 6.48am Samoa local time on Tuesday 29 September 2009, an earthquake measuring 8.0 on the Richter scale occurred 190 km south of Apia, the capital of Samoa (refer to Fig 1). Samoa is located in the South Pacific Ocean, about 2,200 miles south of Hawaii, with a population of 180,0001. There are two main islands, the bigger island of Savaii and the smaller island of Upolu being home to three-quarters of Samoa‟s population. The earthquake triggered a tsunami that traveled north of the epicenter colliding with the south east coast of the island of Upolu within 10 minutes. The effects were also felt in American Samoa and Tonga. A total of 189 people died across the pacific region, with the greatest loss of life in Samoa with 149 deaths2. The Samoan National Health Care Service (NHCS) initially responded by dispatching emergency medical teams to the affected areas and commencing disaster response triage and treatment protocols in the emergency department of the Tupua Tamasese Meaole (TTM) National Hop spital in Apia.

Figure 1. Location of quake epicenter in relation to the Samoan islands

However, there were many people directly affected by the tsunami that did not present to hos pital, or did not attend follow up appointments of tsunami-related injuries. Moreover, many individuals were indirectly affected by the tsunami through loss of access to clean water, food, shelter, infrastructure and chronic medications. In the days following the tsunami, mobile medical teams were set up to provide care for these people. This report is a summary of the actions of one of these, the OUMERT. Mandate of the OUMERT Oceania University of Medicine (OUM), under the guidance of Vice Chancellor Prof. Surindar Cheema and Deputy Dean Dr Monalisa Punivalu, first sent a team of doctors and medical students to the areas affected on Thursday 1st October, two days after the tsunami. The team was led by Dr Viali Lameko and Dr Carmichael Patu. Over the following days, a coordinated approach was mounted by the Samoan government though the Ministry of Health, TTM National Hospital and overseas aid organizations. The OUM team was one of four mobile medical teams working under the direction of the Samoan National Health Care Service, and was allocated the task of providing medical assistance to the villages of Lepa, Saleapaga, and Satitoa. These villages were all located on the south coast of Upolu and were destroyed in the tsunami, with Saleapaga sustaining the most casualties. Local village residents who survived moved from low-lying beach villages to higher areas of remote rainforest and quickly began to build settlements. The OUM team visited these villages on weekdays (Mon-Fri) for two weeks post tsunami, with the exception of Thursday 8th October, when the team provided care for the village of Apai on Manono Island. Records of patients seen and treatments provided were kept according to Ministry of Health protocol from Monday 5th October. Accurate records were not kept for the early response by OUM on

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A

Thursday 1st and Friday 2nd October. Consequently this report includes data from the period including Monday 5th October to Friday 16th October. Tsunami-related medical problems Table 1 provides a summary of the consultations undertaken by the OUMERT. Note that individual patients may have had multiple diagnoses. OUMERT.

B

Initially the team was predominantly involved in the treatment of lacerations and infected wounds of patients, particularly to feet and legs, incurred during the tsunami. The team provided care by cleaning and dressing wounds, ensuring adequate antibiotic cover where appropriate, and in some cases providing dressing materials for patients to self-care. Pain relief for wounds and tsunami-related musculoskeletal injuries was also provided. Respiratory infections were a major initial concern given the high prevalence of aspiration pneumonia in tsunami victims reported at the TTM hospital. Antibiotics were provided for suspected cases, although the numbers of these seen were small. The team also provided antibiotics for several cases of non-aspiration lower respiratory tract infections (LRTIs). Many upper respiratory tract infections (URTIs) were seen (see Table 1). Despite the likelihood that most URTIs were viral, antibiotics were often provided, particularly in the pediatric population, due to concerns that these cases could develop into more serious conditions such as rheumatic fever.

C Figure 2. The Village of Lepa (A,B) and Saleapaga (C) posttsunami. Images (B,C) courtesy of UK Times On-line and UK Guardian respectively.

Post-tsunami chronic disease management Replacement of long-term medication was a major part of the team‟s work initially as many patients with conditions such as diabetes and hypertension lost their medication as a result of

Figure 3. Map of South-East Tsunami affected Coast of Upolu. Red arrows indicate villages assigned to OUMERT. 8

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Table 1. Total number of diagnoses for the period 5/10/09 – 16/10/09.

Diagnosis Wound +/- infection Abscess Respiratory tract infection Upper respiratory tract infection Lower respiratory tract infection

0-12 years 19 4

>12 years 45 6

32 10

21 19

Chronic disease Diabetes Mellitus Type II1 Suspected Impaired Glucose Tolerance2 Hypertension1 Possible Hypertension requiring follow-up3 Hypertension requiring intervention4 Check-up (Nil medical illness identified) Skin condition Scabies Fungal infection Impetigo Irritant dermatitis (“Nappy rash”) Dermatitis (other) Eczema Psoriasis

20 4 13 6 2 5

4 13 3 5 2

2 5

4 1 1

Gastrointestinal disease Diarrhoeal disease Vomiting Abdominal pain (Nil vomiting or diarrhoea) Musculoskeletal diagnosis Musculoskeletal pain (chronic) Musculoskeletal pain (Acute) Gout Fracture (Radiologically diagnosed) Dental disease Otologic disease Otitis Media

3

1 2 19 6

2 2

Otitis Externa Viral illness (non-specific) UTI Pregnancy Other 1

3

1

Previously diagnosed according to international criteria 2 New diagnosis made by OUM MMR. (Random BSL >12.0 mmol/L) 3 Single reading; SBP=140-160 and/or DBP=90-100 4 At least two separate readings, within the one consultation; SBP>160 and/or DBP>100 plus at least one other CHD risk factor (obesity, DM, smoking, age >65).

3 2 1 2 1 3 2 2 10

damage caused by the tsunami wave. Moreover, it became evident that chronic disease was exacerbated by acute major stressors such as displacement, acute illness, and psychological distress. It was recognized that optimal glycemic control would be an important factor in successful wound healing, and minimizing the risk of diabetic complications which would further disadvantage those patients already in a difficult situation. The team carried out check-ups on children, the elderly, and patients with chronic disease. Blood pressure and blood sugar measurements were performed as part of the check-ups and medication regimes were altered or uninitiated where appropriate. Post-tsunami public health issues In the days following the tsunami, it became evident that poor living conditions, limitations of transport and infrastructure and reduced access to clean water were developing public health issues of major concern. Living conditions were generally poor with the commonly observed overcrowding, limited shelter, and open sewage creating the potential for the spread of infection. Respiratory tract infections and scabies were common diagnoses, particularly in the pediatric population (under twelve years). Infections of wounds and insect bites were also a concern due to the unsanitary environment.

As rebuilding of villages began in the weeks post-tsunami, construction injuries provided a major source of wounds and subsequent infection. In addition to male builders, many children sustained wounds from playing in the makeshift camps and from building debris. The prevention of tetanus and wound infection was a major priority for the team. Systemic antibiotics were given as appropriate, and the team ensured that patients were covered for tetanus by giving new vaccinations where necessary.

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heightened awareness regarding the importance of drinking either bottled or boiled water. Similarly, safe food preparation, handling and storage practices which were promoted by various visiting medical teams along with awareness campaigns by the Ministry of Health helped minimize outbreaks of such illnesses.

As rebuilding of villages began in the weeks posttsunami, construction injuries provided a major source of wounds and subsequent infection. In addition to male builders, many children sustained wounds from playing in the makeshift camps and from building debris. The prevention of tetanus and wound infection was a major priority for the team. Systemic antibiotics were given as appropriate, and the team ensured that patients were covered for tetanus by giving new vaccinations where necessary. Transport to and from the new villages was a major problem from the outset. Many families lost vehicles in the tsunami, leaving them unable to independently access food, water and other basic essentials. The absence of established roads leading to the new settlements, particularly Saleapaga, was also problematic for agencies supplying aid (such as the Red Cross), and access was made even more difficult after heavy rain. The displacement of families created problems for the team in providing continuity of care. It was sometimes difficult to locate patients requiring follow up consultation as there was considerable migration of individuals on a daily basis. Other public health concerns included the potential for outbreaks of infectious disease including diarrheal diseases, measles, dengue fever, and typhoid. The prevention and treatment of diarrheal disease, particularly in the pediatric population, was a priority for all aid agencies and medical teams involved in the tsunami response. Fortunately, there were no major outbreaks of diarrheal disease or typhoid fever. A likely key determinant in this outcome was the rapid and successful delivery of potable water, as well as a

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The new settlements provided a significant potential for mosquito breeding sites, largely due to collections of stagnant water. Heavy rainfall during this period also exacerbated the situation. Combined with a lack of mosquito nets, this led to a significant number of children presenting with multiple mosquito bites, some of which were infected. However, there was no outbreak of dengue fever. Psychological impact of the tsunami No OUM team members had specialist psychological training although the OUM doctors present were all experienced in general counseling of patients and family members as part of their responsibilities as physicians practicing in Samoa. A qualified psychologist with disaster management experience would have been invaluable during this period. Difficulties in providing psychological support for patients were compounded by the language barrier experienced by those members of the team who could not speak Samoan. However, despite these difficulties it was clear that many individuals were suffering from distress. The team witnessed several funerals taking place in the days following the tsunami and these included prayers, singing and food. Normal grief reactions are to be expected, and it was heartening to see families maintaining cultural norms regarding the burial of loved ones, despite their situation. Samoan traditions of hospitality were evident and the team was often offered food and water despite the families‟ circumstances. The impact of the disaster on the affected population‟s immediate psychological health was apparent. One elderly woman spoke to the team about her experience of being caught in the tsunami and losing two grandchildren. She was lethargic, had lost her appetite, and continued to taste salty sea water in her mouth two weeks after the disaster. As head of the family, her only motivation for eating was to provide reassurance to her children and grandchildren. Several other

cases of self-neglect were seen; an elderly man suffering from severe pneumonia did not seek medical attention, insisted he was well, and was only diagnosed when offered a check-up. His primary concern was the progress of shelter construction for his family. Another patient refused hospital admission for a severe abscess as her priority was looking after her family. There is a high prevalence of religious faith in the Samoan population, and it is likely that this, combined with strong family support and traditional customs, will contribute to Samoa‟s recovery. The team often observed people displaying a remarkable resilience in the face of adversity, and for this reason it is difficult to assess or quantify the long-term psychological impact that the tsunami will have. Appropriate psychological support needs to be made a priority in the coming months as immediate issues of aid and rebuilding are resolved. OUM’s role in post-tsunami healthcare provision OUM‟s initial tsunami response consisted of daily visits to Lepa, Saleapaga and Satitoa where acute medical problems were increasingly replaced by chronic disease management and other nonurgent presentations. These changing presentations, along with increasing access to health care at Lalomanu district hospital, led to a reduced requirement for mobile medical teams. OUM responded to this reduced demand by reducing the frequency of visits to the affected areas. OUM is committed to providing long-term health care to the people of Samoa directly and indirectly affected by the tsunami. This is achieved through medical services provided by the Rotary 5000 program which is a monthly screening service targeting the areas affected by the tsunami3. Challenges and recommendations Immediate access to medical supplies and uncertainty regarding appropriate medication and equipment, limited the team‟s efficiency in the first few days post tsunami. This was in part due to limited stocks being available nationally, a situation which improved within days as overseas aid became available. The team became more effective as field experience was gained and medication and equipment requirements became apparent. The logistical coordination for the team improved over the first few days resulting in daily stocktaking and the initiation of accurate and consistent record keeping for medical supplies and drugs as well as patient records.

Table 2. Total number of treatments provided for the period 5/10/09-16/10/09. Treatment Wound management Wound dressing Tetanus vaccination Analgesic/Anti-inflammatory agents (systemic) Paracetomol tablets Ibuprofen capsules Diclofenac Naproxen Aspirin Antimicrobials (systemic) Pediatric Panadol suspension Flucloxacillin suspension Co-amoxiclav suspension Amoxicillin suspension Co-trimoxazole Adult Flucloxacillin capsules Amoxicillin capsules Co-amoxiclav capsules Roxithromycin capsules Erythromycin capsules Metronidazole capsules Penicillin V capsules Griseofluvin capsules Ciprofloxacillin capsules Nitrofurantoin capsules Co-Trimoxazole capsules Chloramphenicol capsules Antimicrobials (topical) Chloramphenicol eye drops Betamethasone ear drops Topical skin preparations Permethrin cream 5% Hydrocortisone cream Anti-fungal preparations Betamethasone cream Oral hypoglycaemic agents Metformin Glicazide Anti-hypertensive agents Captopril Felodipine Enalapril Quinapril Nutritional Supplements Oral Rehydration Solution Iron Sulphate Multivitamin capsules Gastrointestinal medications Prochlorperazine capsules Omeprazole capsules Loperamide Hydrochloride Other

66 3

80 10 5 1 1

23 12 12 19 2 30 19 12 3 3 3 2 2 1 1 1 1 2 1 16 7 4 1 11 8 9 1 1 2 5 1 1 1 1 1 3

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Recommendations to improve the medical response in future natural disasters should include better anticipation of the conditions most likely to be encountered. This information would be invaluable in planning appropriate health care response. It would ideally be compiled in advance and available at the time of any future national disaster. A national protocol such as this, which recommends the most important supplies for an early phase response, would allow greater efficiency and ultimately result in optimal and timely patient care. OUM should run practice mobilization drills each year so that the OUMERT protocols and logistical processes are followed to ensure a rapid and effective response in case there is another disaster. The OUMERT clearly established itself as an important and flexible rapid response team in times of national disaster and it is recommended that a clear role for the OUMERT be established in the national registry of health response teams. OUM faculty or consultants should provide training to OUM clinical students in disaster management consulting the national protocols.

Acknowledgements Thanks to Dr. Navy Collins (Australia) and Dr. Jimmy Eteuati (Australia) who provided medical support in the week following the tsunami. TTM Hospital Pharmacy Department and Pharmacist Penaia Penaia. Medical students involved were George Tuitama, Filipina Amosa, Paul Brunton and Dinesh Brand from OUM; Kamal Cortas, Katie Bristow, and Laura Gabbott from the UK; Gemma Warnock from the University of Aberdeen; Rowena Lalji from the University of Queensland and Katherine Pass from the University of Bristol. Thanks to Moananu Tyrone Laurenson and Dr. Greg Raymond for securing funding for the OUM mobile team and providing logistical support. Penny Ah Fook, Donna Raymond, and others at OUM who provided invaluable logistical support. Notes 1. Number from the 2006 national census 2. Number provided by the Samoa Disaster Management Office 3. Rotary 5000 is a screening program targeting remote areas that are carried out on the last Friday of every month. It is an initiative by the Oceania University of Medicine and Rotary of Samoa.

Figure 4. Photo taken at a Saleapaga shelter depicting substandard living conditions.

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REVIEW

IMPACT OF CARDIOVASCULAR DISEASES ON SAMOA’S HEALTH CARE SYSTEM Dr Viali Lameko Senior Clinical Lecturer General Internal Medicine Department Oceania University of Medicine and Attending General Internal Medicine Physician Tupua Tamasese Meaole National & Teaching Hospital Introduction In the year 2000, the World Health Organization1 urged its member states to strengthen their health care system‟s (HCS) performances to improve health outcomes. The WHO realizes that the available knowledge, interventions and technologies in the world today for curing diseases, prolonging life and promoting good physical and mental health are not reaching the people in greatest needs because of weak and deteriorating HCS and as a consequence the gaps in health outcomes continue to widen. Samoa, a small island state in the South Pacific, is one example of a country that is going through economic, demographic and epidemiological transitions which is now evident by the rise in cardiovascular diseases replacing communicable diseases2. This paper will describe what constitutes a health care system. An introduction to the Samoa country profile including health profile, health care system and economic base followed by a look at the epidemiology and the impact of cardiovascular diseases (CVD) on its health system. The discussion that follows will analyze the key challenges that the health system of this small island state is facing in trying to curb the burden of CVD and the impact on the system including human resources, service delivery, health financing and health policies. Some key recommendation for policy changes is provided that may be useful to improve the health system in Samoa. Health Care Systems The HCS encompasses all the activities whose primary purpose is to promote, restore, or maintain health1. It includes efforts to influence determinants of health as well as more direct health-improving activities. A system should in-

clude patients and their families, health care workers and caregivers within organizations and communities, other sectors and stakeholders, and the health policy environment in which all health related activities occur. In 2000, WHO came up with a model for a health system based on „six building blocks‟ namely: good health services, a well performing health workforce, a well functioning heath information system, accessibility to medical products and technologies, a good health financing system, a greater need for strong leadership and governance from policy makers1. Samoa Samoa comprises a small group of South Pacific islands with a total population of 180,741 (2006). Almost half of the population (49.2 %) is below 20 years with a median age of 20.5 years, and elderly people (65 +) made up 4.7 % of the total population3. The economy of Samoa is relatively small, with a GDP per capita estimated at USD1,860 (2004)4. Samoa’s Health Care System (NHCS) The public health sector dominates the Samoa‟s NHCS5 with a relatively small private health sector. The services providing more specialized care by doctors are all based in the capital whilst nurses in health care centers provide services to the rural areas with limited facilities6. A large informal circle of health care providers exists including some 900 traditional healers and 200 plus traditional birth attendants. Extensive networks of Women‟s Committees are the major partners in the rural areas. Samoa’s Health Profile Life expectancy at birth is 68 years3 for the total population (66 for males, 70 for females). The infant mortality rate is 17.8 per 1000 live births 7 and maternal mortality rate at 60/100,000. Communicable diseases (CDs) currently are under control. On the other hand, the non-communicable diseases (NCDs) are growing to an epidemic proportion replacing CDs as the main causes of death8. In 2002, strokes top the list followed by ischemic heart disease and hypertensive heart diseases9. These major NCDs are due to the rapid rate of changing lifestyle and exposure of the entire population to high prevalence of risk factors such as unhealthy diets, tobacco smoking, alcohol consumption and lack of physical activity.

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Samoans are increasingly suffering from hypertension, diabetes and obesity10. Approximately 40% of the total population is currently smoking (56.3% for males, and 21.8% for females). Prevalence of obesity is 52.7% (48.4% for males and 67.4% in females), high blood pressure is 21.4% (males 24.2%, females 18.2%), diabetes is 23.1% (male 22.9%, females 23.3 %) which has doubled since a 1991 survey, and 30% of the total population are current alcohol drinkers. Critical Analysis Health Service Delivery Issuesi Five policy strategies will be critical for reversing the current trend of mortality from CVDs: improvement of the acute treatment and subsequent secondary prevention for those who survive the events, prevention targeted at high-risk individuals and populations, improvement of rural health services through reorganized primary health care, inclusion and strengthening the link with general practitioners as another arm of primary health care, continuation of the population-wide preventive strategies currently in place. The critical point for clinical services in this country is the lack of standard treatment guidelines and operating procedures to care for the sick2. Each doctor is utilizing guidelines of preference from different hospitals around the region for example New Zealand, Australia and Fiji. These should be developed with a consensus approach and be used in hospitals and health centers to support the staff in their decision-making. These critical decisions would include the rapid identification and initiation of first line treatment for patients with suspected ischemic heart diseases, acute coronary syndrome, and strokes. These guidelines will also help define the staff roles and responsibilities at all levels. The same guidelines will also direct an efficient referral system between the private sector and the Tupua Tamasese Meaole Hospital, which is the only secondary referral hospital in the country. Another critical area that needs urgent attention is the ambulance service in the NHCS. It is poorly equipped with one proper ambulance plus one van-converted ambulance, which services the whole island. The drivers are not paramedics, which raises much concern about this service. In the USA, availability of paramedics with ambulances has been partly responsible for the 30% decline in door-to-needle time for initiation of thrombolytic therapy between 1992 and 199511 and subsequent mortality.

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Survivors of CVDs events pose health problems that could persist across time and would require some degree of health care management 12. Samoan patients would benefit tremendously from a rehabilitation program that focuses on secondary prevention strategies. An effective partnership (public-private mix) with the informal health sector, NGOs, private sector and other governmental organizations is needed to ensure a strong and sustainable rehabilitation and health promotion program that could reach all levels of the society, especially schools, villages and workplaces. One of the strengths with the NHCS response to CVDs is the free-of-charge access to all CVD medications. However, the NHCS should also revisit the existing dispensing and accessibility policy for low cost medications such as Aspirin, blood pressure lowering drugs (especially angiotensin converting enzyme inhibitors) and hypoglycemic and lipid-lowering drugs such as statins. Making these medications available at all times at the rural health centers and district hospitals should be a priority. This is because there has been consistent evidence that low cost combination therapy for secondary prevention has been shown to lower the risk of cardiovascular death by up to one half with few side effects13. Much health infrastructure and assets are aging and deteriorating14 and therefore need replacement and maintenance work. Newer equipment in the major hospitals and health centers demands some modifications of buildings and electrical supplies to support a safe environment for patient and staff. The other critical issue here is development of special policies that address standardized health service delivery to the rural and remote areas in Samoa. The development of tools to guide care provided by the rural nurses is a priority. The 2006 census shows that the Apia urban area contained close to one-quarter of the Samoan population while a little over three-quarters reside in the rural regions. The distance issues, the population characteristics and different disease patterns that are more prevalent amongst those living in the rural areas of Samoa should be addressed separately. For instance, there is a high prevalence of scabies, acute rheumatic fever, and upper respiratory tract infection, to name a few, amongst rural children as compared to those who live in the urban area. There is a lower prevalence of smoking tobacco, drinking alcohol and regular exercise amongst the rural population as compared to the urban. In addition, the difficulties in attracting and retaining health workers in the rural setting are a challenge. The HRPP manifesto 2006 clearly suggests that there should be “equivalent” access to good health and health care for people living in differ-

ent places, but there is no clear indication in health policies to reflect such a plan. Health workforce Issuesii Samoa currently has 74 medical doctors in clinical practice, with 49 at the National Health Services, 3 at the Oceania University of Medicine, one at the Diabetic Clinic, and 21 in private general practice, which corresponds to one doctor per 2,442 inhabitants. There are 242 nurses in practice, which corresponds to one nurse to approximately 746 inhabitants2. There is a desperate need for more medical doctors and nurses to properly cover the health services15. Additionally there is a lack of medical specialists and paramedical staff such as epidemiologists, nutritionists, dieticians, laboratory technicians and psychiatrists. This is reflected in the high proportion of costly overseas referrals costing the government of Samoa millions of dollars every year 16. Secondly, many patients bypass the rural health centers and go straight to the referral hospital in the capital. Decentralizing the specialized services to the rural health centers is an option but could be a challenge given the inadequate human resources. A constant drain of health workers away from rural areas to work at the main hospital results in an inequitable distribution of health professionals and services concentrated in the capital. The nurses work alone at all the rural and district hospitals (except MT II hospital on the island of Savaii) having no access to medical personnel. Consequently, the quality of care in the rural regions is affected and many patients suffer late referrals or long waiting hours at the only main hospital at the capital2. Acute strokes and heart attacks will have to bypass all these rural health centers and go straight to the only referral hospital in the capital. Another major drain on the health sector is the migration of health workers (doctors and nurses) to nearby countries like New Zealand and Australia where the remuneration is much higher and better working conditions and opportunities for their career development are offered17. Recommendations Appropriate remuneration packages for workers are the most difficult issue to deal with but very important for retention of the workforce. The Samoan Doctors‟ Association went on strike for three months in 2005 over poor salaries and working conditions15. Many left the country for overseas posts during and after the strike. Staff members require ongoing development

(training) and supportive environments for work including infrastructure and assets plus adequate and timely payment for services. This maximizes the performance and motivation of the existing workforce. A new private/public partnership medical school18 has been set up in Samoa hoping to produce some additional quality medical officers to feed the huge demand in the near future. Upgrading the nurses‟ qualification as a faculty of the National University of Samoa is a great achievement and strategies to increase its annual intake should be encouraged. Outsourcing some activities especially primary health care and preventive screening activities to the private sector, if carefully managed, is sustainable and cost effective. Recruiting overseas doctors is an option but is going to cost the nation more. Health Information System (HIS) Issuesiii One of the major obstacles in compiling reports for health in this country is the lack of available valid data. There are also in practice two confusing HIS systems in the public system; one is operated centrally and another one operated by the rural nurses. No feedback from the private sector is provided at all. In addition the available data is barely used because of lack of epidemiologists and skilled analysts. The NHCS needs to simplify the HIS to allow for both the public and private sector to be involved in the system. The 2006 situational analysis14 identified the need for the staff involved to upgrade their capabilities to manage, use and maintain the system. Decentralizing parts of the HIS for data collection using manual books is a starting point and essential to feed back the information to the staff. Second, the Ministry of Health (MoH) must recognize the importance of research (operational or qualitative research) as an essential resource to inform policy formulation, planning and evaluation of programs and start allocating funds to build the capacity of potential researchers19. Equitable access to essential medical products and technologiesiv The Government of Samoa has a National Drug Policy and associated Plan of Action20 that instruct the MoH to provide at all times efficacious, high quality, safe and cost effective pharmaceutical products to the population of Samoa.

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A recent public consultation (2005)14 identified the following flaws: shortages of common drugs, shortages of peripherals such as dressings, needles and syringes, delays of ordering and delivery of drugs to the peripheral health centers, inefficiencies in the use of medications and poor first in first out practices at the health centre level. Those who have already suffered a CVD event are at risk of recurrences and death. But this risk could be substantially lowered with a combination of low cost medicines like aspirin, blood pressure lowering and a cholesterol lowering drugs. The policy definitely needs implementation and monitoring which will contribute to overall improvement of the NHCS performance. Health Care Financing Issuesv Samoa already spends 5.6% of its GDP on health, equivalent to18 % of the national budget, which is one of the highest amongst the Pacific Island Countries21. Public expenditure for health comprised 61% of total health spending in 2002/2003. Private spending comprised for health comprised 19.7% of total health spending, and donations and foreign aid (increasing every year) made up the remaining 19%16. Health expenditure on NCDs in 2000 accounted for 43.3% of total health expenditure with the majority going to clinical care16. The overseas treatment scheme is still increasing year after year and CVD takes almost 80% of the share. The main health financing questions that may need answering in the future in terms of policies and sustainability of service to the people of Samoa are: Should the government continue financing 60% of the health budget? What is the role of individuals and the private sector in financing the Samoan health system? Is there a role in the future for private insurance companies in financing health? Should donors continue increasing their current level of disbursements to health financing?

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drugs could be used as substitute for other equivalent higher price prescription drugs and the Government could aim to initiate policies for improving the efficiency by which pharmaceuticals are imported, distributed and sold in the country. Population-based health promotion interventions have been shown to be the most cost effective methods of reducing the risk of CVDs across the entire population. Thus, the NCD policy and action plan mentioned above should be strengthened and monitored at all levels. Leadership and governancevi The MoH, as the regulator of health in Samoa, must ensure that appropriate, culturally sensitive, and evidence-based strategic policy frameworks exists to guide and monitor the health sector partners for better health status in the country. It should strive to gain national and international co-operation to maximize the effectiveness of its leadership and governance role. International organizations are willing to help and donate funds, but they need to see good governance (with the principles of transparency, accountability and cooperation) in the country of concern23. Conclusion If available health interventions are not reaching the people who need them the most then what is the use of a health system?

The Government of Samoa could look at identifying potential areas to contain costs or to increase its revenues through alternative financing mechanisms such as cost recovery (and not necessarily by creating a health insurance mechanism like social insurance or Medisave22) whilst not marginalizing vulnerable groups and the poor.

Cardiovascular diseases are on the rise and have already taken their place as the number one killer in this small island state of Samoa. More worrying, since more than half of its population are less than 20 years old who and already exposed to risk factors of CVDs, this country should prepare for hard times in the next twenty years (lag time) if action is not taken now. This country will need not only a health system that can detect and treat acute heart attacks and stroke but also be able to cater for the long-term rehabilitation for those who survive the events. The country is short of medical personnel, nurses, paramedics and so forth. The government funds 60% of the total health budget, donor and private funds provide 20% each and the government should start searching for other mechanisms to finance health such as an insurance scheme, otherwise sustainability will be a big issue in the near future.

Also there is a need to rationalize health service delivery and allocation of resources to minimize wastage. Pharmaceuticals for instance account for over 16% of the total health expenditure and over 24% of out-of-pocket expenses. Generic

On the bright side, the health sector reform processes currently happening in Samoa are hoping to bring innovative policies and strategies not only to strengthen public and private partnerships but also to provide a timely evaluation of

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the current NHCS that hopes to improve the health outcomes for this country and especially to curb and reverse the current burden brought by cardiovascular diseases. Notes A good service delivery health system is one that delivers effective, safe and quality interventions to everybody with minimum waste of resources A well performing workforce is one that has sufficient staffs who are fairly distributed around the country and are competent, responsible and productive given the limited resources. A well functioning HIS is one that could collect, analyze and review data and managed to disseminate and use information for planning and evaluating health care system. A well functioning health system ensures that the medical products and technologies are quality assured, safe, efficacious and cost-effective and scientifically sound for use. A good health financing system ensures that there is enough funds for operation and has the ability to protect the vulnerable groups and at the same time could provide incentives for providers. Involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design and accountability. References 1. WHO. Health systems: improving performance. World health report 2000. Geneva: World Health Organization, 2000. 2. Samoa. Ministry of Health. Health Sector Plan 2008 – 2018. Apia: Ministry of Health, 2008 3. WHO. Working together for health. World health report 2006. Geneva: World Health Organization, 2006 4. Samoa Ministry of Finance. Strategy for the Development of Samoa 2005 – 2007 (SDS). Apia: Ministry of Finance, 2005 5. WHO. Country Cooperation Strategy Report for Samoa 2003. Geneva: World Health Organization, 2003. 6. Samoa. Ministry of Health. The Samoa National Health Service Planning Framework. Apia, Ministry of Health, 2002. 7. Samoa. Department of Statistics. Demographic and vital statistics survey, analytical report. Apia: Department of Statistics, 2000 8. Samoa. Ministry of Health. Leading causes of mortality. Annual Report 2000/2001. Apia: Ministry of Health, 2002. 9. WHO. Mortality Country Fact Sheet 2006. Samoa. Geneva: World Health Organization, 2006. http://www.who.int/whosis/mort/ profiles/mort_wpro_wsm_samoa.pdf

10. WHO. WHO NCD STEPS Surveillance Survey of NCD Risk Factors, 2002. Geneva: World Health Organization, 2002 11. United States. National Registry of Myocardial Infarction (NRMI I and NRMI II) United States, 1998 12. WHO. Non-communicable Diseases and Mental health: Innovative care for Chronic diseases: Building Blocks for Action. Global Report. Geneva: World Health Organization, 2002 13. WHO. Secondary Prevention of Noncommunicable Diseases in Low and Middle Income Countries through Community-Based and Health Service Interventions. Wellcome Trust Meeting Report, August 1-3, 2001. Geneva: World Health Organization, 2001. 14. Samoa, Ministry of Health. Samoan Health Sector Situation Analysis, May 2006. Apia: Ministry of Health, 2006. 15. Samoa. Ministry of Prime Minister and Cabinet. Samoan Doctors Industrial Action, Commission of Enquiry Report 2005. Apia: Ministry of Prime Minister and Cabinet, 2005. 20 16. Samoa. Ministry of Health. Samoa National Health Accounts Financial Year 2002/2003. Apia: Ministry of Health, 2003. 17. WHO. WPRO Annual Report, 2005. Manila: Western Pacific Region of the World Health Organization, 2005. 18. Samoa. Oceania University of Medicine (Samoa) Act, 2002. http://www.paclii.org/ws/ legis/consol_act/ouoma2002331/ 19. Fuster, V. Epidemic of cardiovascular disease and stroke: the three main challenges. Circulation.1999, 99: 1132 – 1137 20. Samoa. Ministry of Health. National Drug Policy and Pharmaceuticals and Plan of Action 2005. Apia: Ministry of Health, 2005 21. World Bank. World Development Indicators 2009. Washington: International Bank for Reconstruction and Development, 2009 22. Duckett, S. J. The Australian Health Care System. 3rd ed. South Melbourne, Oxford University Press, 2007. 23. Walt, G. Globalization of international health. Lancet. 1998, 351: 434 – 437 34

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MISCELLANEOUS

SAMOA POPULATION INDICATORS Category

Total population (6th November 2006)

A: 2006 Samoa Bureau of Statistics1 180,741

Male

93,677

Female

87,064

Population 0-14 (%)

39

37.6 56.7

Population 15-64 (%) Pensioners 65+ (%)

B: 2009 CIA Fact Book online2 219,998

5

5.7

Median Age: 0-14 years

37.6

Median Age: 15-64 years

56.7

Median Age: 65 years and over

5.7

Life expectancy at birth (total population)

71.86

Urban population (%)

21

Median age

20.5

Sex ratio at birth

107

Crude birth rate/1000

27.3

28.6

Crude death rate/1000

4

5.79

Total fertility rate/1000

4.2

Teenage Fertility rate/1000

28.6

Infant mortality rate (total)/1000

20.4

Male Average life expectancy at birth/years

71.5

Female Average life expectancy at birth/years

74.2

Samoan literacy rate 15-24 (male)

89%

Samoan literacy rate 15-24 (female)

92%

English literacy rate 15-24 (male)

71%

English literacy rate 15-24 (female)

81%

Unemployment rate population 15+

1%

Labour force participation rate 15+

50%

Special needs population

1%

Percentage of households with computers

9.7

Percentage of households with cell-phones Percentage CIA world fact book online. https:// www.cia.gov/library/publications/the-world-factbook/ geos/ws.htmlof households with radio

47.5

24.2

89.1

This table was compiled by: Dr Monalisa Punivalu, Dr Viali Lameko and Professor Surindar Cheema References 1. Bureau of Statistics, Samoa. Population and Housing Census Report Nov 2006. Apia, Samoa 2. CIA world fact book online. https://www.cia.gov/library/publications/the-world-factbook/geos/ ws.html.

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RESEARCH ARTICLE

A MULTI-INTERVENTION PROGRAM TO REDUCE ANTIBIOTIC PRESCRIPTION FOR PATIENTS WITH UPPER RESPIRATORY TRACT INFECTION IN PRIMARY HEALTH CARE SETTINGS IN THE UNITED ARAB EMIRATES Fahima Alawadii, John Brebnerii and Zeinab Khalil iii, iv, v, vi*

Pharmacy and Supply Department, Ministry of Health, Dubai, UAEi School of Medicine, Department of General Practice & Primary Care, University of Aberdeenii Endocrine Center of Excellence, Austin Health iii Department of Biochemistry and Molecular Biology, University of Melbourne, Australiaiv Oceania University of Medicine, National Health Complex, Motooua, Apia, Samoav Abstract Overuse of antibiotics in treating Upper Respiratory Tract Infections (URTIs) in Primary Health Care Clinics (PHCCs) is an area of great concern due to development of antimicrobial resistant pathogens and unnecessary expenses to health care systems and patients. The present study is the first controlled study of its kind conducted in local PHCCs in Dubai and Sharjah, UAE (over a 3 month period from December 2006 to February 2007). Using two study samples (no intervention/control group and intervention/study group), this study measured the impact of a multi-intervention consisting of physician management guidelines and patient educational leaflets to reduce antibiotic prescriptions to patients with URTIs and sore throat. Differences in socio-demographic characteristics, signs and symptoms, and home self-management between the two study populations were considered. Furthermore, the impact of age and education on the effectiveness of the multi-intervention program was also investigated. A significant reduction in antibiotic prescriptions from 64% (no intervention group) to 21% (intervention group) resulted. Evidence was pro-

vided to support the argument that this significant reduction in antibiotic prescription was not influenced by important confounding factors like throat yellowish discharge and ear pain. The significant reduction in antibiotic prescriptions clearly indicates that use of physician management guidelines and patient educational information reduces patient demand for antibiotic prescription. Furthermore, since the reduction in antibiotic prescription was not influenced by age or education, we contend that the successful multi-intervention program used in this study could be successfully implemented to a wider population. Introduction The extent of overuse of antibiotics in treating Upper Respiratory Tract Infections (URTIs) in Primary Health Care Clinics (PHCCs) is an area of great concern. This concern arises from the development of antimicrobial resistant pathogens and an unnecessary increase of expenses to health care systems and to patients1. Primary health care practitioners frequently prescribe antibiotics to treat URTI symptoms, even though there is no proof of benefit of this therapy2, 3. In addition, patients with URTIs expect to receive an antibiotic prescription from the physician after diagnosis4, 5, 6. Antibiotic expectation of patients/patient demand therefore, plays an important role in over-prescribing antibiotics for respiratory infections7. It has been demonstrated that when general practitioners (GPs) prescribe less antibiotics for respiratory tract infection, their patients subsequently consult less frequently, which leads to a process of demedicalization8. In an exploratory study conducted by our group in eight PHCCs in the UAE, we recorded that 59% of patients with URTIs were prescribed antibiotics (unpublished data). Furthermore, URTIs were found to be the most common reason for patients to visit a primary health care center for treatment. This has also been shown elsewhere, such as the United States, Canada, Turkey, Taiwan and Spain where URTIs account for most antibiotic prescriptions9. The situation in primary health care centers is rather challenging. Fischer et al indicated that due to shortage of time as well as over-crowded PHCCs, physicians‟ efforts to reduce/delay antibiotic prescription through communication with patients and recommending self-medication with home remedies were rare10. Furthermore, patients and physicians have different perceptions of the nature of infection and their expectations

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are usually not communicated11. Patients have a growing role in therapeutic decision-making, therefore patient education and improving communication between physicians and patients can positively influence the appropriate antimicrobial use12, 13. Independent evidence suggests that physician management guidelines could lead to appropriate antimicrobial prescribing and use1, 14 and that educational intervention of the public is essential in altering patient demand and pressure on general practitioners for inappropriate antibiotic prescribing15, 16. This in turn can control the over-prescribing of antibiotics12, 17. It has also been reported that written information in addition to verbal instruction to patients would result in better outcomes in using antibiotics7, 18. However, educational interventions aimed at either the physician or patient could not probably bring a successful result in reducing antibiotic use. The intervention should be multidimensional. A number of controlled studies prove that antibiotic prescription rates could be reduced successfully if combinations of interventions are used. These interventions should focus on patients‟ expectations as well physicians‟ prescribing behaviours19, 20, 21, 22, 23. Initial unpublished data collected by our group from eight PHCCs in the UAE revealed that the symptom of sore throat was present in most of the URTIs cases that were referred to those clinics in Dubai and Sharjah (76%) and it was higher than other presenting signs and symptoms (fever 45%, headache 62%, yellowish throat discharge 39%, cough 72%, ear pain 31%, runny nose 54% and nasal yellowish discharge 22%). Having large numbers of URTI patients with symptoms of sore throat attending PHCCs, the aim of this study therefore was to examine the impact of implementing a multiple intervention program including physicians' management guidelines (through verbal discussion) and patients' educational leaflet plus verbal instruction, on reducing antibiotic prescription for URTIs with sore throat. Again from the eight clinics that were initially evaluated, high prescribing of antibiotics was more noticeable in two clinics (Hor Alanz Clinic, Dubai 63% and Reqah Clinic, Sharjah 71%). Therefore, these two clinics were chosen to be included in this research program to investigate the impact of a multi intervention program on reducing antibiotic prescription. In summary the present study is the first controlled study of its kind conducted in local primary health care centers in Dubai and Sharjah,

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UAE. Using two study populations (no intervention and intervention groups) this study aimed at measuring the impact of combined interventions, of introducing management guidelines to physicians as well as educational leaflets to patients, on reducing antibiotic prescriptions to patients with URTIs and sore throat. Confounding factors such as differences in sociodemographic characteristics, signs and symptoms, and home self-management between the two study samples were considered in the data analysis. Furthermore, the effect of age and education on the impact of the multiintervention program was also investigated. Methods The current controlled study comparing no intervention vs multi-dimensional intervention to reduce antibiotic prescribing at PHCCs, was approved by the Undersecretary of Curative Medicine in the Ministry of Health (MOH) and the Medical Directors of Dubai and Sharjah districts. Ethical permission to carry out the research study was obtained from the respective Research Ethics Committees. A circular from the Undersecretary requesting participation in the research study was sent to two clinics, Hor Alanz Clinic in Dubai and Reqah Clinic in Sharjah. In the initial exploratory study conducted by the investigators, these clinics were estimated to be the busiest clinics in each Emirate. We documented that URTIs accounted for about 50% of the visits made by patients to these two clinics and that antibiotic prescription rates for adult patients with URTIs were estimated to be 63% and 71% respectively. Data collection was conducted in the two clinics over the three months of December (2006), January and February (2007) (6 weeks for phase I and 6 weeks for phase II). These three months are considered to be the high season of flu and URTIs in the UAE. The protocol for the no-intervention arm of the study required the investigator to be based in the pharmacy of each clinic. Data was collected from a cross-sectional sample comprised of local UAE men and women of adult age with upper respiratory tract infection, attending the two PHCCs (Hor Alanz and Reqah clinics) and agreeing to participate in the study. Patients were recruited by approaching those who were suffering from upper respiratory tract infection. All 166 patients approached agreed to participate and were included in the no-intervention arm of the study (Group I). The inclusion criteria were male or female UAE nationals suffering from URTI and sore throat aged between 14 – 60 years while the exclusion criteria included patients less than 14 years of

age, staff working in the MOH, patients unwilling to participate and patients with asthma or allergic rhinitis. All patients were asked for their consent to participate in the study and were notified that all collected data is confidential. A patient interview questionnaire was developed for data collection. The questionnaire was constructed in English (Appendix I) and after following a process for ensuring translation validity and checking for face validity, it was produced in Arabic. The Arabic questionnaire was then given to others for translation back into English. The original English questionnaire was then compared with the new English version to check for accuracy. Necessary modifications were then undertaken in the Arabic version of questionnaire. Furthermore, to check the face validity of the questionnaire, it was given to three health care professionals (2 pharmacists and one epidemiologist). Their ideas about clarity, appropriateness and whether it measured what it was supposed to measure were recorded. Changes requested by any individual were discussed with the group and if appropriate the changes were made. The patient interviews were conducted in Arabic, faceto-face by the investigator. Patients were interviewed while their prescriptions were being prepared. The health card number of patients included was taken as reference to trace the prescription as names were not indicated on the questionnaire. The second component of this study involved the multi-intervention arm that was conducted subsequent to the no-intervention arm. The researcher was based in the nursing room with access to all patients. In this study, the multiintervention approach included physician management guidelines (Appendix II) which were extracted from SIGN (Scottish Intercollegiate Guidelines Network) for sore throat as well as an educational leaflet for patients with URTI and sore throat (Appendix III). Following the approval by the respective director of each PHCC, a set of management guidelines was given to each general practitioner and verbal explanation of the benefit of implementing the guidelines in their setting was explained. The researcher explained to physicians the reason for the intervention program and the aim, which was to reduce over prescription of antibiotics for patients with URTI and sore throat. Along with the management guidelines a set of journal articles on the necessity of antibiotic prescription reduction in URTIs, was distributed. The management guidelines were accompanied by an explanation of why and where the guidelines were produced. Physicians were then asked to read the management guidelines and those that agreed to partici-

pate in the study were asked to indicate their commitment to follow the guidelines and to write down any suggestions or remarks. The guidelines were given to 10 general practitioners in the two clinics (5 in each clinic) and all agreed to participate. It was emphasized that the guidelines were only a referral source rather than a substitute to their clinical judgment. Patients were given an educational leaflet (Appendix III) and were informed of the risk of excessive/unnecessary use of antibiotics and the fact that URTIs are caused mostly by viruses and antibiotics will have no beneficiary effect. The length of explanation depended on whether the patient could read or not. Patients who were illiterate were provided with detailed explanation of everything that was written in the leaflet. Furthermore, verbal instructions and information were given to ensure that patients received the educational intervention properly even if they did not read the leaflet. The educational leaflets plus verbal instructions were aimed at modifying patients' demand for antibiotic prescriptions. Prior to their visit to the general practitioner, patients were also asked a set of questions (the same questionnaire used for the no-intervention arm). The purpose of the questionnaire was to gather information to reflect the sociodemographic characteristics of patients with sore throat, their consumption of medication, home remedies and traditional medicine prior to their attendance of primary health care clinics and the extent of the signs and symptoms of sore throat suffered by those patients. Data collection was carried out from 215 patients from both clinics. The inclusion and exclusion criteria and patient consent were the same as for the no-intervention group. The sample for the intervention arm of this study comprised of 215 patients: National UAE men and women (110 from Hor Alanz Clinic, Dubai and 105 from Reqah Clinic, Sharjah) attending PHCCs with URTIs including sore throat (Group II) who agreed to participate in the study. Patients were recruited by approaching those who had URTIs plus sore throat. Upon agreement to participate, patients were given educational leaflets and verbal explanation on the etiology of URTI and why receiving antibiotics would not benefit them if their symptoms were diagnosed as viral infection. Finally, statistical analyses were performed using the SPSS statistical package. The data is expressed as % together with 95% CI and analysed using a one way ANOVA with priori contrast between no intervention and intervention groups.

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Results The socio-demographic characteristics of Group I (no intervention) and Group II (intervention) were compared (Table 1). The data shows no significant differences among the two study populations in any of the socio-demographic characteristics listed. The Primary Outcome Measure for this study (antibiotic prescription) was compared between the two study groups. The data in Table 2 shows that antibiotic prescription for patients in Group II (intervention) was 21% and was significantly less (p=0.000) when compared to 64% for patients in Group I (no intervention). Possible confounding factors on antibiotic prescription such as use of medication, home remedies and traditional medicine prior to their visit to PHCCs were taken into account. Table 3 displays a comparison of the use of medication, home remedies and traditional medicine by the two samples prior to their visit to primary health clinics. Group I consumed significantly more medication prior to visiting the PHCC (67%) than Group II (55%), (P=0.003). However, the results show no significant difference between the two groups in using home remedies (P=0.221) and traditional medications (P=0.212). The possibility that signs and symptoms associated with URTIs could have been different between the two samples and that this difference might have impacted on the primary outcome measure was also investigated. Table 4 displays specific signs associated with URTIs in the two samples. There is no significant difference among the two samples in signs such as fever (P=0.141), cough (P=0.297), productive cough (P=0.169), runny nose (P=0.245) and nasal yellowish discharge (P=0.325). However the results show that the Group I population has a significantly greater number of patients with yellowish throat discharge (P=0.000). In addition, Table 5 displays specific symptoms associated with URTI in the two samples. There is no significant difference among the two groups in symptoms such as headache (P=0.067). However the results show that there is a significant difference among the two groups in having ear pain (P=0.044), with Group I, the no intervention group, having greater numbers of patients with ear pain. Based on the data shown in Tables 4 and 5, further analysis was undertaken to specifically examine the impact of significant confounding factors between the two groups on the primary outcome measure (antibiotic prescription). Table 6 presents the impact of the intervention program

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on the primary outcome measure (antibiotic prescription) for significant confounding factors such as throat yellowish discharge and ear pain among the two study groups. The results show a significant difference between antibiotic prescriptions for patients with symptoms of throat yellow discharge (P=0.000) and ear pain (P=0.000). Antibiotic prescriptions were significantly reduced following the implementation of interventions. Lastly, the impact of age and education on the effectiveness of the intervention on reducing antibiotic prescription in the two groups was also examined. In Table 7, each study population was divided into two subgroups according to age (younger group: age 14-24 years and mature/ older group: age 25-60 years). Group II (intervention) showed a significant reduction in antibiotic prescription regardless of age. Similarly, in Table 8, each group was divided into two subgroups according to education (no/ low education (illiterate and primary) and higher education (secondary, high school and university/post grad). Again Group II (intervention) showed a significant reduction in antibiotic prescription regardless of level of education. Discussion Although medication can treat diseases they also have the potential to cause harm. Antibiotics are a good example of this situation. Overprescribing of antibiotics in health care settings has brought along the worldwide problem of resistant pathogens14, 17, 24, 25, 26 that the pharmaceutical industry is struggling to overcome by producing newer antibiotics. The existent recommendation that antibiotics are only indicated in bacterial infection is frequently not complied with. Physicians diagnose URTIs upon clinical findings but often disregard the fact that URTIs could be of viral origin and antibiotic treatment is not indicated27. It has been previously documented that clinicians prescribe antibiotics not only to relieve symptoms, but also to prevent disease transmission, prevent secondary infections and to satisfy patients‟ demand for antibiotics28, 29. URTIs are one of the most common reasons for patients‟ visits to PHCCs in the UAE as shown by our initial exploratory data collected from eight primary health care clinics in the UAE. We documented that more than 76% of patients with URTI attending primary health care in the UAE had sore throats. Antibiotics were prescribed for more than 57% of these patients. Our initial exploratory study also showed that patients‟ demand had a great influence over physicians‟ behaviour in prescribing antibiotics. Physicians had little or no communication with patients, and providing patients with

what they demand shortens the visitation time and pleases patients. Indeed, it is well documented that prescribing decisions are greatly influenced by patients' demands for antibiotics 30, 31, 32 and patients' demand has a greater influence over physicians' decision in prescribing antibiotics when physicians are uncertain for the need for antibiotics for that particular patient. Many studies suggest that effective interventions should influence the behaviour of clinicians and patients toward antibiotic prescribing via developing protocols that focus on appropriate diagnosis of respiratory tract infections and effective education programs for patients. Indeed, using a multidisciplinary intervention can result in behavioural changes of patients and physicians and significantly reduce antibiotic prescription for sore throat without affecting the outcome33. The current two-stage controlled study was conducted in two clinics Hor Al anz Clinic, Dubai and Reqah Clinic, Sharjah where high prescribing of antibiotics had been previously recorded (63% & 71% respectively). The first stage involved collecting data from a control (no intervention group) and the second stage involved the implementation of a multi-intervention program aimed at reducing antibiotic prescription for patients with URTIs with sore throat. It was previously reported that over-prescription of antibiotics often results from a deficiency of knowledge of physicians1, 14. Therefore providing physicians with diagnostic and management guidelines can help them in their decision-making. In this study, the major impetus of the guideline provided to physicians was to encourage appropriate diagnosis and treatment of sore throat so that the overuse of antibiotics is avoided. It was emphasized that the guidelines were to guide decisionmaking rather than as a substitute to clinical judgment. All the clinicians in this study were aware of the evidence for the limited effect of antibiotic treatment in URTI (sore throat) and agreed that antibiotic over-prescribing for URTI did exist in most of primary health care settings in UAE. All general practitioners in the selected clinics welcomed implementation of management guidelines and educational intervention. It is also documented that patient educational interventions, such as a patients‟ educational leaflet given at the time of consultation, are essential in altering patient demand and pressure on general practitioners for prescribing antibiotics inappropriately15, 34. Based on the above and after the introduction of management guidelines for physicians, educational leaflets were given to patients who at-

tended the clinic with URTI and sore throat. Verbal explanations were given to each patient prior to his or her visit to the physician. It was explained to patients why antibiotics are not needed in most of the URTIs and that over-use of antibiotics can result in developing resistant pathogens. They were encouraged not to pressurize physicians to prescribe antibiotics if the physicians did not think antibiotics were necessary. . The primary outcome measure was the % of antibiotic prescription to patients visiting PHCCs with URTIs and sore throat. The data in Table 2 clearly shows that the multi-intervention approach implemented was successful in significantly reducing antibiotic prescription. Antibiotic prescription was reduced from 64% for patients in Group I (no intervention) to 21% for patients in Group II (intervention). It appears that the educational intervention resulted in reducing patient demand for antibiotic prescription and similarly the management guidelines resulted in improving the physician diagnostic approach in distinguishing between viral and bacterial infections and better decision-making regarding antibiotic prescription. Confounding factors that could have impacted on the primary outcome measure were also investigated. One confounding factor examined was the use of self-medication, home remedies or traditional medicine prior to visiting the PHCCs. The two study groups were compared and the data presented in Table 3. That the no intervention group have used significantly more medications prior to visiting the clinic could be a possible confounding factor that might have partially impacted on the difference in the primary outcome measure between the two groups. It would be logical to assume that those patients who had tried other medications without relief would be requesting antibiotics and/or would be more in need of antibiotics and this could have contributed to increased antibiotic prescription for Group I. Since Group II had less previous medication, one might also argue that the effectiveness of the intervention in reducing antibiotic prescriptions cannot be attributed to prior intake of medication which could have reduced the severity of symptoms. The two study groups (no intervention and intervention) were also compared based on the signs and symptoms they had to identify and whether differences in signs and symptoms between the two groups could be a reason for reduced antibiotic prescription in Group II. Analysis of signs, presented by the two samples (Table 4), showed a significant difference for throat yellowish discharge (P=0.000) between the two groups. Percentage of patients with throat yellowish discharge was higher (71%) in Group I (no intervention) compared to Group II (intervention) (48%). Furthermore, analysis of the symptoms presented

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by the two samples (Table 5), showed a significant difference among patients in the two groups with regard to ear pain (P=0.044). The percentage of patients with ear pain was higher (37%) in Group I (no intervention) compared to Group II (intervention) (26%). The significant difference observed in signs and symptoms between the two groups with Group I demonstrating a significantly higher % of patients with throat yellowish discharge and ear pain raised the question as to whether or not these differences could have impacted on the primary outcome measure, i.e. antibiotic prescription. It is logical to assume that those patients with throat yellowish discharge and ear pain required antibiotics and hence antibiotic prescription was higher for Group I. This possibility prompted us to undertake further analysis to determine the difference in antibiotic prescription for those patients with those particular signs and symptoms in the two study groups. In this analysis, we separated the patients with throat yellowish discharge and those with ear pain to determine the impact of these confounding factors on the primary outcome measure. The data in Table 6 shows that 71% of Group I patients who had throat yellowish discharge received antibiotics compared to 35% of Group II patients who had the same sign. In addition, the data in Table 6 shows that 72% of Group I patients who had ear pain received antibiotics compared to 25% of Group II patients who had the same symptom. There was a greater than 50% reduction in antibiotic prescription with the interventions implemented and this indicates successful influences antibiotic prescription for patients with throat yellowish discharge and ear pain. Furthermore, the results nullify the suggestion/perception that the lower total number of patients suffering from throat yellowish discharge and ear pain among Group II could have resulted in the reduced antibiotic prescription rather than the interventions per se. The authors acknowledge that the current study has some design limitations due to the multiintervention approach implemented. For example, it is difficult to deduce whether the management guidelines intervention for physicians or the patient educational leaflets intervention had a greater influence on the reduction of antibiotic prescription. In an attempt to deduce this information and based on the assumption that older patients are more likely to request antibiotics from physicians than the younger patients, Group I (no interven-

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tion) and Group II (intervention) were divided into 2 subgroups by age (young group = 14-24 years and mature/old group = 25-60 years) (Table 7). For the young group, it would be assumed that the physicians‟ decision prevailed (less pressure from patients), hence the reduction in antibiotic prescription could reflect the effectiveness of the management guidelines in modifying physician prescribing behaviour. For the mature/older group it would be assumed that the physician‟s decision is influenced by patients' demand for antibiotic prescription. However one might argue also that this old group actually needed more antibiotic prescriptions, since this group of patients are less tolerant of symptoms of URTIs. Indeed, studies have shown that older patients require more medication and are therefore more likely to receive more medication35. The other question that we raised was whether the level of education of patients could have influenced the effectiveness of the interventions. The patients were divided into two subgroups by education (low level education = illiterate and primary education, higher level education = secondary/high school and university/post graduate) (Table 8). The data shown in Tables 7 and 8 clearly indicate that the interventions successfully and significantly reduced antibiotic prescription regardless of age or education. In conclusion, the multi-intervention program for reducing antibiotic prescription in UAE PHCCs resulted in a significant reduction in antibiotic prescriptions from 64% (no intervention group) to 21% (intervention group). This significant reduction in antibiotic prescriptions clearly indicates the effectiveness of physicians in following management guidelines and the effectiveness of the educational information given to patients. Evidence was provided to support the argument that this significant reduction in antibiotic prescription was not influenced by important confounding factors like throat yellowish discharge and ear pain. Furthermore, since the reduction in antibiotic prescription was not influenced by age or education, we contend that the successful multi-intervention program used in this study could be successfully implemented to a wider population with great anticipation of successful implementation.

Acknowledgement The authors wish to thank Dr Abdul Ghaffar, Under-Secretary for Curative Medicine, for his support; the doctors, pharmacists and nurses of the Ministry of Health Primary Health Care Centers in Dubai and Sharjah and the patients for making it possible to undertake this study. The authors extend their gratitude to Prof. Al-Bishri, the former Chancellor, University of Sharjah, for faciliating the supervision of this work by Prof Khalil. References 1. Zwar N, Wolk J, Gordon J. Influencing antibotic prescribing in general practice: a trial of prescriber feedback and management guidelines. Fam Pract. 1999; 16( 5):495500. 2. Mainous III AG, Hueston WJ. The cost of antibiotics in treating upper respiratory tract infections in a Medicaid population. Arch Fam Med. 1998; 7:45-49. 3. Ware J. Rational use of antibiotics for upper respiratory infections: an evidence-based approach. Clin Excellence Nurse Prac. 2000; 4 (3):151-7. 4. Virji A, Britten N. A study of the relationship between patients‟ attitudes and doctors‟ prescribing. J Fam Pract. 1991; 8:314-9. 5. Vinson DC, Lutz LJ. The effect of parental expectations on treatment of children with a cough: a report from ASPN. J Family Pract. 1993; 37(1):23-27. 6. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations a questionnaire study. BMJ. 1997; 315 (7107):520-523. 7. Holmes JH, Metlay J, Holmes WC. Developing a patient intervention to reduce antibiotic overuse. AMIA Ann Symp Proc. 2003;864. 8. Ashworth M. Do general practices which prescribe antibiotics less frequently for acute respiratory infections, have lower consultation rates for these conditions? The process of demedicalisation. The 34th Ann Sci Meeting Soc Ac Prim Care. 2005; 22(1):25. 9. Fendrick AM, Saint S, Brook I. Diagnosis and treatment of upper respiratory tract infections in the primary care setting. Clin Therapeutics. 2001; 23(10):1683-1706. 10.Fischer T, Fischer S, Kochen MM. Influence of patient symptoms and physical findings on general practitioners‟ treatment of respiratory tract infections: a direct observation study. BMC Fam Pract. 2005; 6:6. 11.Snell LM, Wilson RP, Oeffinger KC. Patient and physician explanatory models for acute bronchitis. J Fam Pract. 2002; 51:1035-40.

12.Varonen H, Rautakorpi UM, Huikko S. Management of acute maxillary sinusitis in Finnish primary care. Scand J Prim Health Care. 2004; 22:122-7. 13.McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002; 287(23):30963102. 14.Madle G, Kostkova P, Mani-Saada J. Changing public attitudes to antibiotic prescribing: can the internet help? Inf Primary Care. 2004; 12 (1):19-26. 15.Gonzales R, Corbett KK, Leeman-Castillo BA. The “minimizing antibiotic resistance in Colorado” project: impact of patient education in improving antibiotic use in private office practices. Health Serv Res. 2005; 40(1):101-16 16.Macfarlane J, Holmes W, Macfarlane R. Influence of patients‟ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ. 1997; 315:1211-14. 17.Segador J, Gil-Guillen VF, Orozco D. The effect of written information on adherence to antibiotic treatment in acute sore throat. Int J Antimicrob Agents. 2005; 26(1):56-61. 18.Gonzales R, Steiner JF, Lum A.. Decreasing antibiotic use in ambulatory practice: impact of a multidimensional intervention on the treatment of uncomplicated acute bronchitis in adults. JAMA. 1999; 281:1512-9. 19.Belongia EA, Sullivan BJ, Chyou PH. A Community intervention trial to promote judicious antibiotic use and reduce penicillin-resistant streptococcus pneumonia carriage in children. Pediatrics. 2001; 108:575-83. 20.Finkelstein JA, Davis RL, Dowell JP. Reducing antibiotic use in children: a randomized trial in 12 practices. Pediatrics. 2001; 108:1-7. 21.Perz JF, Craig AS, Coffey CS. Changes in antibiotic prescribing for children after a community-wide campaign. JAMA. 2002; 287:3103-9. 22.Welschen I, Kuyvenhoven MM, Hoes AW. Effectiveness of multiple intervention to reduce antibiotic prescribing for repertory tract symptoms in primary care: randomised controlled trial. BMJ. 2004; 329:431-3. 23.McCaig LF, Hughes JM. Trend in antimicrobial drug prescribing among office-based physicians in the United States. JAMA. 1995; 273 (3):214-219. 24.Hoel D, Williams DN. Antibiotics: Past, present, and future. Postgrad Med. 1997;101(1). 25.Tenover FC, and Hughes JM. The challenges of emerging infectious diseases. Development and spread of multiply resistant bacterial pathogens. JAMA. 1996; 275(4):300. 26.Rosenstein N, Philips WR, Gerber MA. The common cold-principles of judicious use of antimicrobial agents. Pediatrics. 1998; 101 (1):181-184.

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27.Avorn J, Solomon DH. Cultural and economic factors that (mis)shape antibiotic use: the nonpharmacologic basis of therapeutics. Ann Int Med. 2000; 133(2):128-135. 28.Arroll B, Kenealy T. Antibiotics for the common cold. Cochrane Database Sys Rev. 2002. (3): CD000247. 29.Butler CC, Rollnick S, Pill R. Understanding the culture of prescribing: qualitative study of general practitioners‟ and patients' Perceptions of antibiotics for sore throats. BMJ. 1998; 317(7159):637-642. 30.Guillemot D, Carbon C, Vauzelle-Kervroedan F. Inappropriateness and variability of antibiotic prescription among French office-based physicians. J Clin Epidemiol.1998; 51:61-8. 31.Barden LS, Dowell SF, Schwartz B, Lackey C. Current attitudes regarding use of antimicrobial agents: results from physicians‟ and parents‟ focus group discussion. Clin Pediatr. 1998; 37:665-71. 32.Cox CM, Jones M. Is it possible to decrease antibiotic prescribing in Primary care? An analysis of outcomes in the management of patients with sore throats. Fam Pract. 2001; 18(1):9-13.

33.McNulty CA. Optimising antibiotic prescribing in primary care. Int J Antimicrob Agents. 2001; 18(4):329-33. 34.Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients‟ expectation and doctors‟ actions. Br J Gen Pract. 1994; 44:165-9. Address to request additional documents (patient survey, clinical guidelines, patient education materials) and other correspondence: Prof Zeinab Khalil MBBS (Hons), MSc, PhD Professor of Medicine Oceania University of Medicine, Motootua, Apia, Samoa Email: [email protected]

Table (1): The Socio-Demographic Characteristics of patients with sore throat in Group I (No Group I (No intervention) (N=166)

Group II (Intervention) (N=215) GENDER

Male

61

36.7

(29.4-44.0)

Male

93

43.3

(36.749.9)

Female

10 5

63.3

(56.0-70.6)

Female

122

56.7

(50.163.3)

Total

16 6

100.0

Total

215

100.0

P=0.119 Age Group: Mean= 29.45, Median= 27 (SD+ 12.74)

Age Group: Mean= 29.04, Median= 27 (SD+ 11.43)

11-18 Years

38

22.9

(16.5-29.3)

11-18 Years

53

24.7

(18.930.5)

19-24 Years

29

17.5

(11.7-23.3)

19-24 Years

39

18.1

(13.023.2)

25-34 Years

50

30.1

(23.1-37.1)

25-34 Years

54

25.1

(19.330.9)

35-44 Years

27

16.3

(10.4-21.9)

35-44 Years

38

17.7

(12.622.8)

45-60 Years

22

13.3

(8.1-18.5)

45-60 Years

31

14.4

(9.7-19.1)

Total

16 6

100.0

Total

215

100.0

P=0.877

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Table (1) Continued House Wife

48

28.9

(22.0-35.8)

House Wife

52

24.2

(18.5-29.9)

Working

58

34.9

(27.6-42.2)

Working

80

37.2

(30.7-43.7)

Retired

11

6.6

(2.8-10.4)

Retired

11

5.1

(2.2-8.7)

72

33.5

(27.2-39.8)

215

100.0

Total

166

100.0

Total P=0.622

Table (2): Antibiotic Prescription for Group I (No Intervention) and Group II (Intervention) Group

Antibiotic Prescription

%

(95% C.I)

No intervention

106

63.9

(56.6-71.2)

Intervention

46

21.4

(15.9-26.9)

P=0.000

Table (3): Consumption of medication, home remedies and traditional medicine by patients prior to their attendance of primary health care clinics.

Group I (no intervention) (N=166)

Medication

Group II (intervention) (N=215)

N

%

(95% CI)

114

68.7%

(61.6-75.8)

N

%

(95% CI)

Medication

11 7

54.4%

(47.761.1)

P=0.003 Home Remedies

62

37.3%

(29.9-44.7)

Home Remedies

71

Traditional Medicine

35

21.1%

P=0.221 (14.9-27.3) Traditional Medicine

54

(26.739.3) 25.1%

(19.330.9)

P=0.212

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Table (4): Comparison of Signs between Group I (no intervention) and Group II (intervention) Group I (N=166)

Group II (N=215)

Signs

N

%

(95% C.I)

Signs

N

%

(95% C.I)

Fever

81

48.8

(41.2-56.4)

Fever

118

54.9

(48.2-61.6)

Throat Yellowish Discharge

71

33.0

(26.7-39.3)

Cough

163

75.8

(70.1-81.5)

Productive Cough

118

54.8

(48.1-61.5)

Runny Nose

133

61.9

(55.4-68.4)

Nasal Yellowish Discharge (n=137)

30

21.9

(16.4-27.4)

P=0.141 Throat Yellowish Discharge

85

51.2

(43.6-58.8) P=0.000

Cough

121

72.9

(66.1-79.7) P=0.297

Productive Cough

92

55.4

(47.8-63.0) P=0.169

Runny Nose

96

57.8

(50.3-65.3) P=0.245

Nasal Yellowish Discharge (n=103)

26

25.2

(18.6-31.8) P=0.325

Table (5): Comparison of Symptoms between the sample populations Group I (N=166)

Group II (N=215)

Symptoms

N

%

(95% C.I)

Sympt oms

N

%

(95% C.I)

Headache

118

71.1

(64.278.0)

Headache

136

63.3

(56.9-69.7)

26.0

(20.1-31.9)

P=0.067 Ear pain

62

37.3

(29.944.7)

Ear pain

56 P=0.044

Sore throat

28

166

100.0

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Sore throat

215

100.0

Table (6): Impact of Significant Confounding Factors on Primary Outcome Measure Confounding Factors Throat yellowish discharge Group I

Prescribed antibiotics

Group II

N

%

N

%

60

70.6

25

35.2* P=0.000

Not Prescribed antibiotics

25

29.4

46

64.8

Total suffering

85

100%

71

100%

Group I

Ear pain

Prescribed antibiotic

Group II

N

%

N

%

41

66.1

14

25.0* P=0.000

Not Prescribed antibiotics

21

33.9

42

75.0

Total suffering

62

100%

56

100%

Table (7): Impact of Age on the Effectiveness of the Intervention on Reducing Antibiotic Prescription in the Two-Study Population Age

Younger group

% Antibiotic prescription Group 1

Group 2

(No intervention)

(Intervention)

62.7%

17.4% P=0.000

(age 14-24 years) Mature/older Group (age 25-60 years)

64.6%

24.4% P=0.000

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Table (8): Impact of Education on the Effectiveness of the Intervention on Reducing Antibiotic Prescription in the Two-Study Population Education

% Antibiotic prescription Group 1

Group 2 (Intervention)

(No intervention) Low level education

63.2% P=0.000

(Illiterate and primary) High level education (Secondary, high school and university/post grad)

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25.6%

64.1%

20.5% P=0.000

PERSONAL PERSPECTIVE

MY EXPERIENCES IN AFRICA . . . Paul du Toit Final year medical student, Oceania University of Medicine I have recently returned from two months in South Africa where I did some of my clinical rotations as part of my OUM medical degree. My first stop was a surgical rotation at a teaching hospital in the Cape Province. On my first morning the student coordinator took me for a walk around the hospital to orientate me and to introduce me to the doctors and sisters who would be looking after me. While walking through the maternity wing, I noticed a woman sitting on a bench in the corridor who was groaning loudly and appeared to be in the second stage of labor. All the birthing suites were occupied and there were no available beds in the maternity ward. While I was being introduced to the sister-in charge, the groaning woman let out an agonizing scream as her membranes ruptured and she slipped onto the floor. “Paul, have you delivered a baby before?” enquired my supervisor while handing me a pair of sterile gloves. While the sister and my supervisor continued to lament about bed shortages, I brought a healthy Xhosa baby girl into the world. I had been there less than an hour! Each day started with a quick ward round and then the rest of the morning was spent in theater. It was good to be taught the correct sterile techniques of scrubbing up, gowning and gloving and over the weeks these simple tasks became second nature. For the first week I spent most of my time watching surgery and being the “trolleyboy”, wheeling the patients in and out of theater but by the second week I was being invited to assist in some of the cases. As the doctors realized how keen I was, they spent more time teaching me techniques and towards the end I was doing simple procedures like lymph node biopsies, breast lumpectomies, skin grafts, diabetic ulcer debridements etc always under strict supervision. I assisted in a wide variety of operations, including some interesting orthopedic cases, cesarean sections, appendectomies, tonsillectomies, colonectomies, and of course, there were always the trauma cases that filled any spare theater time. I was fascinated by the delicate surgery performed by the ophthalmologist

and was always amazed at how dexterous the general surgeon was with his gastroscope. The anesthetics registrar taught me how to perform a spinal anesthetic and I was given a chance to perform two „spinals‟ on my own. On Tuesday afternoons I attended surgical clinics and on Thursday afternoons I attended the orthopedics clinics, where I was given the opportunity to pop and backslab many fractures and tendon injuries. On Monday, Wednesday and Friday afternoons I worked in Accident & Emergency. One of the first procedures I learnt was how to insert a chest drain. In South Africa violence is a way of life and in some sectors of society the most common way to settle an argument is with a knife. One Saturday night I was at the hospital until 3am with a stream of stab and gunshot wounds one after the next. At one stage I had 5 patients sitting on a bench, all with pneumothoraces from stab wounds. In the end I could insert a chest drain in less than 10 minutes! I will always remember the comment one patient made to me that night, “Doctor, can you fix me quick because I have to go and get revenge”! One aspect that I found rather amusing was how these criminals, who would be sitting there with a bullet or knife-wound in their chest, would be so terrified when I came towards them with a dental syringe filled with local anesthetic! As all the local medical students were writing their exams, I was the only student at the hospital and the young doctors would often seek me out to teach me procedures. I had the opportunity to do a few lumbar punctures, pleural taps, breast biopsies and skin cancer excisions. One man I examined in Accident & Emergency said to me, “Doctor, there is something wrong with my gearbox” and when he saw the confused expression on my face he pulled down his trousers to reveal a syphilitic chancre on his penis! My next rotation was in pediatrics at a teaching hospital in the province of Kwa-zulu Natal. When I arrived on the 4th January, the intern‟s orientation program was just starting and I was invited to join them each morning for a pediatric lecture. The topics included the major pathologies

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the interns would encounter in South Africa, such as HIV, Tuberculosis, Acute Gastro-enteritis and dehydration, pneumonia and chest infections etc. My rotation was split to include a week in the neonatal nurseries, a week with a pediatric HIV specialist, a week in the pediatric Outpatient Department and a week in the pediatric wards. Unless you have worked in a sub-Saharan hospital you will not understand the devastation HIV is having in that region. 80% of the patients at both hospitals I worked at were HIV positive. In fact there is such a stigma attached to being HIV positive that the doctors now use the term „RVD‟ instead of HIV which stands for Retroviral Disease, when discussing patients within earshot of others e.g. on ward rounds. I found it emotionally difficult to deal with the children who were mostly RVD positive and whose parents had died of AIDS. They were often being looked after by a grandmother or by an aunty. In theory, if the child is born by cesarean section, and the mother takes anti-retro-virals for her last trimester, and the child is given AZT for its first week of life, and the child is not breastfed, it has about a 2% chance of vertical transmission. However, in Africa it is not plausible to give almost every mother a c-section and formula feeding is discouraged because of the mortality caused from contaminated water, so most children born to RVD positive mothers end up being RVD positive themselves. One day I joined the Red Cross team that goes out to do a clinic at an AIDS orphanage in a rural area . Although all the children were RVD positive they were all amazingly healthy and living almost normal lives, going to school etc. They were all on ARVs and all had negligible viral loads and very high CD4 counts. In theory these children could live normal lives to old age, however, no one knows what effect the ARVs will have on them, as the side-effects include, amongst others, pancreatitis and lactic acidosis. One of the benefits of working with so many HIV positive patients is that I have learnt some very good techniques for taking bloods to minimize the chance of a needle stick injury. For example, whenever one has a contaminated syringe in one hand, the other hand should go behind your back. When taking blood from children, two nurses are required to hold the child still so that they don‟t move suddenly or try to pull away. Tuberculosis (TB) is rife in Africa and the prevalence is rising as more patients become immunocompromised due to HIV. I

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had read all about pulmonary TB but was astounded by the effects of extra-pulmonary TB. When you take a history in Africa you always need to enquire about TB exposure as TB can affect any part of the body eg TB meningitis, TB abdomen, Spinal TB etc and this can make diagnosing difficult. The TB-DOTS (Tuberculosis Directly Observed Short-course) program does not work well in Africa as there are not the resources to keep the patients at the hospital nor to pay staff to observe them taking their meds. However, the drug companies have made it easier for the patients by combining the drugs into one tablet e.g. you can prescribe: RHZE (150, 75, 400, 275) which contains Rifampicin, Isoniazid, Pyrazinamide and Ethambutol. Taking one tablet per day is more attractive to the rural patients. However, there is still a major problem with drug resistance and even the second line drug, Streptomycin, is often not effective. One day I was offered a seat on the Air Mercy Service which is a Red Cross initiative to fly specialist doctors out to district hospitals to help with difficult cases. As the 10-seater plane was just about to touch down at the first hospital, the pilots put the engine into full throttle and aborted the landing. They then circled around before landing on the grass runway. The pilot later informed me that there had been springbok grazing on the runway and they had to be chased off! My supervisor and I were the last two to be dropped off and as the plane was taking off to collect the others, the engine failed and it crashed. Luckily there were no doctors on board and the pilots walked away from the wreckage! In Africa, I was given opportunities that I would never have had elsewhere and I would certainly recommend it to my fellow students.

OPINION

TOBACCO SMOKING AND CARDIOVASCULAR DISEASES Dr Viali Lameko Senior Clinical Lecturer General Internal Medicine Department Oceania University of Medicine and Attending General Internal Medicine Physician Tupua Tamasese Meaole National & Teaching Hospital I met one of my best friends last week after a game of golf and because he is a smoker, I naturally introduced the topic of “quitting smoking” into our conversation. In summary this is what he had to say; “Doc, I know smoking tobacco kills, but it is very hard to quit. Every time I try to quit, I feel terrible, depressed, and irritable.” “I know it is addictive but I am scared of the withdrawal symptoms.” “I know it causes lung cancer and heart diseases.” “I know it costs me approximately 95 tala per week for two packets a day, 380 tala per month, or more than 4,000 tala per year, and since both my wife and I smoke, this amount doubles, but it is very hard to quit.” I felt uncomfortable listening to his carefree views on the seriousness of the matter. “Doc, why do you bother? I know tobacco kills but aren‟t we all going to die some day? Evidence and Why We Seek to Prevent Tobacco Related Diseases During the early 1950s scientists began to publish scientific studies suggesting that cigarette smoking causes lung cancer and other diseases. Two of the most influential of the early studies, published by Drs. Richard Doll and Austin B Hill (UK)1 and Drs Ernst L. Wynder and Evarts A. Graham (USA)2 showed that smokers had a greater risk of lung cancer than non-smokers did.

Today, tobacco smoking causes 4.9 million deaths worldwide every year – more than the total deaths from HIV, tuberculosis, motor vehicle accidents, suicide and homicide combined3. It is an important and reversible risk factor for coronary heart diseases. The incidence of a myocardial infarction (MI) is increased sixfold in women and threefold in men who smoke at least 20 cigarettes per day compared to subjects who never smoke4. On the other hand, the risk of recurrent MI in a study of smokers who had an MI fell by 50% within one year of smoking cessation and normalized to that of non-smokers within two years5. In other words, the amount of cigarettes currently smoked increases morbidity and mortality from CVD, and benefits begin to appear a few months after cessation, reaching the nonsmoker level in several years. Tobacco cigarettes are the only products available in shops today with consistent evidence that it kills half of all continuing consumers. Passive smoking by children adversely affects their lung growth and function. A non-smoker married to a smoker has a 30 % higher risk of lung cancer. Pregnant women who smoke during pregnancy are 3 times more likely to cause foetal intrauterine growth retardation and low birth weight babies. When you smoke you inhale more than 4000 chemicals6 including:     

tar (road sealing) acetone (paint stripper) ammonia (toilet cleaner) cyanide (rat killer) carbon monoxide (car exhaust fumes)

The Role of the Tobacco Industry But the Tobacco Industry did not brush these evidences under the carpet. They worked towards protecting the political and legal position of the industry and its profits instead 7. It bothers me to know that despite the strong scientific evidence on the danger of smoking, production and consumption trend increases8. 1 Many public health workers and tobacco control professionals have long suspected that the tobacco industry has known that smoking is dangerous and addictive. But there was no proof to substantiate this suspicion until in mid-1994, when an unsolicited box containing several thousand pages of documents from the Brown and Williamson Tobacco Corporation (B&W) arrived at Professor Stanton Glantz‟s office at the University of California, San Francisco9. These documents combined with some private papers from a former research director at B&W‟s parent, British American Tobacco (BAT), pro-

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vided a candid-private-camera view of the tobacco industry‟s thoughts and actions over the past thirty years and were published in the 1995 and 1996 issues of the Journal of the American Medical Association (JAMA). For instance this is what Dr. S. J. Green, Head of BAT research and development and a member of the board, wrote in the documents, 1976: “B&W and BAT frankly recognized that nicotine is an addictive drug and that people smoke to maintain a target level of nicotine in their bodies. The companies also recognized that smoking causes a variety of diseases, and they actively worked to identify and remove the specific toxins in tobacco smoke that cause these diseases”.10 Instead of removing toxins from cigarettes, their response to this growing body of scientific evidence was to promote new types of cigarettes, such as cigarettes with filters and "low-tar" cigarettes which at the end they conceded that the filters did not actually make the cigarettes healthier, but only gave smokers the illusion of smoking a healthier product. Mr Ernest Pepples, B&W vice president and general counsel, wrote in 197611: “The industry has moved strongly toward filter cigarettes, which have increased from .6% in 1950 to 87% in 1975. KENT cigarettes were introduced in 1952 with an unusually heavy promotion campaign discussing the micronite filter. Other companies moved strongly into the rapidly growing filter market. In 1951, nine out of twenty brands on the market accounted for as much as 1% of market share. By 1964, 17 of 41 brands had more than 1% share of market. Some claimed to possess the least tars. In most cases, however, the smoker of a filter cigarette was getting as much or more nicotine and tar as he would have gotten from a regular cigarette. He had abandoned the regular cigarette, however, on the ground of reduced risk to health.” Asia-Pacific‟s population smokes more than half of the tobacco sticks that are produced and distributed by the tobacco companies around the world and because of the weak tobacco control laws in these countries, it is predicted that they

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will exceed the 75% mark by the year 2020 if nothing is done about it. Why? This is what Mr M A Morris (the Managing Director of Phillip Morris, the largest manufacturer of tobacco in the world) wrote in the Company‟s Mission Strategic Consistency, 21 December 199212: “Asia is the place to be. Let‟s be sure we are focusing enough there as each of these markets become unleashed” In 1994 at the Phillip Morris Corporate Affairs Conference, Manilla, Mr Morris went on to say this12; “Governments here (AsiaPacific) are focused on growing their economies and improving living conditions. The press and politicians are generally not on a crusade of political correctness and legal systems do not promote whimsical litigation.” Needless to say women and teenagers in the Asia -Pacific are the target for sales and marketing by the tobacco companies. Samoa is not an exception, and now and then you would notice around the corner either a teenager or a young woman puffing away. The B&W and BAT withheld this important information for years that revealed how the tobacco industry effectively manipulated the terms of debate in the scientific and legal communities in a way that led to an obsessive concern about “causality,” to the exclusion of common sense. Tobacco smoking and prevention The humanitarian argument will be, it is better to be healthy than ill or dead13. On the other hand, the case for preventive medicine is often argued on economical grounds where medical economists measure the burden of diseases with indicators like Disability Adjusted Life Years (DALYs) lost due to premature death and healthy life years lost due to disability from diseases. And since smoking tobacco is one of the risk factors for cardiovascular diseases and cancers, this puts this habit as a strong predictor of premature disability and death. Suffice to say here that premature death or ill health impairs earning capacity on an individual basis for the household, and the costs of medical care are high and continually escalating. Prevention is therefore said to be a money saver.

quit and enjoy more productive years with your families and friends. Future Directions for Samoa The Samoa Health Sector under the leadership of the Minister of Health with all the stakeholders have developed and pushed the Tobacco Control Bill in 2008 that is now the Tobacco Control Ct 2008. It is an important milestone as far as health promotion, preventative medicine and health protection is concern. All we need now are the regulations to implement the Act. Multiple studies have consistently shown that implementing smoking bans in public spaces including bars and restaurants significantly reduces the risk of acute coronary events. This is because there is a causal effect between second-hand smoke and cardiovascular disease and that the benefits of a smoking ban can be observed very quickly14. The limitation of space means I do not have to go into the millions our government gains from BAT profits by selling cigarettes to our people in Samoa, and how free markets give more power to the tobacco companies to take advantage of the poor and the powerless. However, the fundamental nature of the Samoa Tobacco Control Bill is to protect the present and future generations of Samoa from the devastating health, social, environmental and economic consequences of tobacco and exposure to tobacco smoke. Studies have shown that the earlier someone starts smoking, the higher his or her chances are of becoming a regular smoker and the less likely he or she is to quit. The Brown and Williamson and British American Tobacco documents revealed that the tobacco industry has been amazingly successful in protecting its ability to market an addictive product that kills its customers in epidemic numbers. I care about my friend, he is like a brother to me, but I despise the tobacco that he, his wife and his young children (through second-hand smoking) inhale daily. He is right that everyone will die someday but smoking tobacco will speed up this process. I have given him the description of a smoker who is admitted to hospital for a heart attack, stroke, lung cancer or chronic obstructive lung disease. Those who survive get a second chance to be with their loved ones but disability will drag them down slowly over the remaining years of their lives. Friends, you have the right to know the right information so that you can each make informed decisions. You do not have to die prematurely or suffer the disability caused by these „preventable tobacco related diseases‟. You have a choice to

Nobody should tell you that it is too late to quit now. Studies have shown a rapid decline in cardiovascular death risk in the first five years after quitting (61 % reduction in regard to heart attacks and 42% in regard to strokes deaths)15. See a doctor or give us a call at the Oceania University of Medicine and ask for help from anyone of the staff. The health promotion division at the Samoa Ministry of Health are also there to help you with your first crucial steps towards quitting the bad habit. I will end this with a quote by C. Everett Koop, MD., SC.D., Surgeon General USPHS 1981-198916: “During my years as surgeon general and since, I have often wondered how many people died as a result of the fact that the medical and public health professions were misled by the tobacco industry. Now we can see in retrospect, as the documents revealed that the tobacco industry was demoralized and in disarray in the mid1960s, but the public voluntary health agencies and others did not take the kind of decisive action against the industry that some inside the industry expected and feared.” Do not start smoking tobacco. Tobacco is addictive and every cigarette stick you smoke increases your risk of developing lung cancer, heart attack, a stroke and many other deadly diseases. References 1. Doll R, Hill A B. Smoking and carcinoma of the lung. BMJ. 1950; 2: 739-748 2. Doll, R, Hill, B. The mortality of doctors in relation to their smoking habits: a preliminary report. BMJ (Clinical research ed.) 1954; 328 (7455): 1529–1533 3. World Health Organization. Smoking Statistics, 220. Geneva: World Health Organization, 2002. 4. Prescott E, Hippe M, Schnohr P et al. Smoking and the risk of myocardial infarction in women and men: Longitudinal population study. BMJ 1998; 316:1043 5. Wilhelmsson C, Vedin JA, Elmfeldt D et al. Smoking and Myocardial infarction. Lancet 1975;1:415 6. Wingand, J S. (July 2006). Additives, cigarette design and tobacco product regulation. A report to World Health Organization Tobacco Free Initiative Tobacco Product Regulation Group. Kobe:Jeffrey Wigand, 2006. Online: http://www.jeffreywigand.com/WHOFinal.pdf accessed 16April2010

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7. Glantz S A, Fox P J, Lightwood J M. Tobacco Litigation. JAMA 1997; 277(9): 751 – 753 8. Guindon, G E, Boisclair, D. Past, current and future trends in tobacco use. Washington DC: The International Bank for Reconstruction and Development / The World Bank, 2003 9. Glantz S A, Slade J, Bero L A, et al. The Cigarette Papers. JAMA . 1996: 276(12): 997 – 998 10.Bero L, Narnes D, Glantz S A et al. The Tobacco Industry and the Brown and Williamsons Documents – Reply. JAMA. 1996; 275(4): 280 11.Glantz, S A, Barnes, D E, Bero, L et al. Looking through a keyhole at the Tobacco Industry: the Brown and Williamson Documents. JAMA. 1995; 274(3): 219-22 12.Alechnowicz K, Chapman S. The Philippine tobacco industry: the strongest tobacco lobby in Asia. Tobacco Control. 2004; 13(suppl II): ii71 – ii78 13.Geoffrey R. The Strategy of Preventive Medicine. New York: Oxford University Press, 1993. 14.Committee on Secondhand Smoke Exposure and Acute Coronary Events, Institute of Medicine. Secondhand Smoke Exposure and cardiovascular Effects: making sense of the Evidence. Washington, DC: National Academies Press, 2009. 15.Wilhelmsson C, Dedin J A, Elmfeldt, et al. Smoking and myocardial infarction. Lancet. 1975; 1:415 16.Glantz S A, Slade J, Bero A L et al, eds. The Cigarette Papers. Berkley: University of California Press, 1996

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LITERATURE REVIEW

THE HINARI CORNER Cheema, S Vice Chancellor, Oceania Univesity of Medicine

In this regular column, recent papers in PubMed‟s databases relevant to medical health in Samoa and the South Pacific will be listed. PubMed comprises citations to over 19 million articles from Medline and life sciences journals. PubMed may provide links to the full text of the articles from the citations via PubMed Central or the publishers‟ web sites It is hoped that our busy doctors and healthcare workers at the TTM hospital, Ministry of Health and the private sector in Samoa will find some of these articles interesting and become motivated to read the full papers. For those in Samoa the full text of these articles will likely be available at the OUM Medical Library through its subscription to HINARI. For those of you who not familiar with HINARI, here is an extract from their website : The HINARI Programme, set up by WHO together with major publishers, enables developing countries to gain access to one of the world's largest collections of biomedical and health literature. Over 6400 journal titles are now available to health institutions in 108 countries, areas and territories benefiting many thousands of health workers and researchers, and in turn, contributing to improved world health. The following are articles on Medicine and Medical Sciences, relevant to Samoa and the South Pacific: 1: Barnes SS, Small C, Bennett J, Barnes J, Keogh R. Prevalence of smoking in rural Samoa. N Z Med J. 2010 Feb 19;123(1309):134-6. PubMed PMID: 20186235. 2: Vanderlaan DP, Vasey PL. Male Sexual Orientation in Independent Samoa: Evidence for Fraternal Birth Order and Maternal Fecundity Effects. Arch Sex Behav. 2009 Dec 29. [Epub ahead of print] PubMed PMID: 20039114.

3: Deka R, Xu L, Pal P, Toelupe PT, Laumoli TS, Xi H, Zhang G, Weeks DE, McGarvey ST. A tagging SNP in INSIG2 is associated with obesity-related phenotypes among Samoans. BMC Med Genet. 2009 Dec 22;10:143. PubMed PMID: 20028541; PubMed Central PMCID: PMC2804583. 4: Lambdin BH, Schmaedick MA, McClintock S, Roberts J, Gurr NE, Marcos K, Waller L, Burkot TR. Dry season production of filariasis and dengue vectors in American Samoa and comparison with wet season production. Am J Trop Med Hyg. 2009 Dec;81(6):1013-9. PubMed PMID: 19996430. 5: Gauvain M, Munroe RL. Contributions of societal modernity to cognitive development: a comparison of four cultures. Child Dev. 2009 NovDec;80(6):1628-42. PubMed PMID: 19930342. 6: Aberg K, Dai F, Viali S, Tuitele J, Sun G, Indugula SR, Deka R, Weeks DE, McGarvey ST. Suggestive linkage detected for blood pressure related traits on 2q and 22q in the population on the Samoan islands. BMC Med Genet. 2009 Oct 23;10:107. PubMed PMID: 19852796; PubMed Central PMCID: PMC2770055. 7: Norris P, Fa'alau F, Va'ai C, Churchward M, Arroll B. Navigating between illness paradigms: treatment seeking by Samoan people in Samoa and New Zealand. Qual Health Res. 2009 Oct;19 (10):1466-75. PubMed PMID: 19805808. 8: Mishra SI, Luce PH, Baquet CR. Increasing pap smear utilization among Samoan women: results from a community based participatory randomized trial. J Health Care Poor Underserved. 2009 May;20(2 Suppl):85-101. PubMed PMID: 19711495. 9: DiBello JR, McGarvey ST, Kraft P, Goldberg R, Campos H, Quested C, Laumoli TS, Baylin A. Dietary patterns are associated with metabolic syndrome in adult Samoans. J Nutr. 2009 Oct;139 (10):1933-43. Epub 2009 Aug 26. PubMed PMID: 19710163; PubMed Central PMCID: PMC2744614. 10: Erdem G, Sinclair S, Marrone JR, I'atala TF, Tuua A, Tuua B, Tuumua F, Dodd A, Mizumoto C, Medina L. Higher rates of streptococcal colonization among children in the Pacific Rim Region correlates with higher rates of group A streptococcal disease and sequelae. Clin Microbiol Infect. 2009 Jul 20. [Epub ahead of print] PubMed PMID: 19681949. 11: Alefaio S. Reflections of a practitioner: purely a journey of the heart. Pac Health Dialog. 2009 Feb;15(1):171-6. PubMed PMID: 19585748.

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12: Boyce DE, Tice AD, Ona FV, Akinaka KT, Lusk H. Viral hepatitis in a homeless shelter in Hawai'i. Hawaii Med J. 2009 Jun;68(5):113-5. PubMed PMID: 19583106. 13: Willoughby K. A sad farewell to Sulu Fesili. Nurs N Z. 2009 May;15(4):5. PubMed PMID: 19552120. 14: Adalja AA. Southern hemisphere influenza vaccine in American Samoa? J Travel Med. 2009 May-Jun;16(3):226; author reply 226. PubMed PMID: 19538588. 15: Huppatz C, Capuano C, Palmer K, Kelly PM, Durrheim DN. Lessons from the Pacific programme to eliminate lymphatic filariasis: a case study of 5 countries. BMC Infect Dis. 2009 Jun 12;9:92. PubMed PMID: 19523192; PubMed Central PMCID: PMC2702370. 16: Fischer GE, Thompson N, Chaves SS, Bower W, Goldstein S, Armstrong G, Williams I, Bialek S. The epidemiology of hepatitis A virus infections in fourPacific Island nations, 1995-2008. Trans R Soc Trop Med Hyg. 2009 Sep;103(9):906-10. Epub 2009 Jun 10. PubMed PMID: 19520409. 17: Duda TF Jr, Lee T. Ecological release and venom evolution of a predatory marine snail at Easter Island. PLoS One. 2009 May 20;4(5):e5558. PubMed PMID:19462001; PubMed Central PMCID: PMC2680045. 18: Little V. Palliative care needs in American Samoa. J Palliat Med. 2009 May;12(5):411-3. PubMed PMID: 19416035. 19: Chambers EW, McClintock SK, Avery MF, King JD, Bradley MH, Schmaedick MA, Lammie PJ, Burkot TR. Xenomonitoring of Wuchereria bancrofti and Dirofilariaimmitis infections in mosquitoes from American Samoa: trapping considerations and a comparison of polymerase chain reaction assays with dissection. Am J Trop Med Hyg. 2009 May;80(5):774-81. PubMed PMID: 19407123. 20: Mladonicky JM, King JD, Liang JL, Chambers E, Pa'au M, Schmaedick MA, Burkot TR, Bradley M, Lammie PJ. Assessing transmission of lymphatic filariasis using parasitologic, serologic, and entomologic tools after mass drug administration in American Samoa. Am J Trop Med Hyg. 2009 May;80(5):769-73. PubMed PMID: 19407122. 21: McGrath BB, Edwards KL. When family means more (or less) than genetics: the intersection of culture, family and genomics. J Transcult Nurs. 2009 Jul;20(3):270-7. PubMed PMID: 19398610; PubMed Central PMCID: PMC2773542.

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22: Oneha MF, Magnussen L, Shoultz J. When does abuse become abuse? Issues Ment Health Nurs. 2009 Apr;30(4):279-80. PubMed PMID: 19363733. 23: Middleton S, Vermeulen W, Byth K, Sullivan CE, Middleton PG. Treatment of obstructive sleep apnoea in Samoa progressively reduces daytime blood pressure over 6 months. Respirology. 2009 Apr;14(3):404-10. PubMed PMID: 19353775. 24: Brown IJ, Tzoulaki I, Candeias V, Elliott P. Salt intakes around the world: implications for public health. Int J Epidemiol. 2009 Jun;38(3):791 -813. Epub 2009 Apr 7. PubMed PMID: 19351697. 25: Aberg K, Dai F, Sun G, Keighley ED, Indugula SR, Roberts ST, Zhang Q, Smelser D, Viali S, Tuitele J, Jin L, Deka R, Weeks DE, McGarvey ST. Susceptibility loci for adiposity phenotypes on 8p, 9p, and 16q in American Samoa and Samoa. Obesity (Silver Spring). 2009 Mar;17(3):518-24. Epub 2008 Dec 18. PubMed PMID: 19238140. 26: Rosenbloom JI, Kaluski DN, Berry EM. A global nutritional index. Food Nutr Bull. 2008 Dec;29 (4):266-77. PubMed PMID: 19227051. 27: Capstick S, Norris P, Sopoaga F, Tobata W. Relationships between health and culture in Polynesia - a review. Soc Sci Med. 2009 Apr;68(7):1341 -8. Epub 2009 Feb 3. Review. PubMed PMID: 19195751. 28: Christl SU, Seifert A, Seeler D. Toxic hepatitis after consumption of traditional kava preparation. J Travel Med. 2009 Jan-Feb;16(1):55-6. PubMed PMID: 19192130. 29: Rosen RK, DePue J, McGarvey ST. Overweight and diabetes in American Samoa: the cultural translation of research into health care practice. Med Health R I. 2008 Dec;91(12):372-3, 376-7. PubMed PMID: 19170313. 30: Pala C. Conservation. Scientists laud Bush's blue legacy but want more. Science. 2009 Jan 9;323(5911):192-3. PubMed PMID: 19131597. 31: Dibello JR, Baylin A, Viali S, Tuitele J, Bausserman L, McGarvey ST. Adiponectin and type 2 diabetes in Samoan adults. Am J Hum Biol. 2009 May-Jun;21(3):389-91. PubMed PMID: 19107905. May-Jun;21(3):389-91. PubMed PMID: 19107905.

FEATURED ABSTRACT 1. BMC Med Genet. 2009 Dec 22;10:143.

A tagging SNP in INSIG2 is associated with obesity-related phenotypes among Samoans Deka R, Xu L, Pal P, Toelupe PT, Laumoli TS, Xi H, Zhang G, Weeks DE, McGarvey ST. Center for Genome Information Department of Environmental Health University of Cincinnati College of Medicine 3223 Eden Avenue Cincinnati, OH 45267 USA [email protected] BACKGROUND: A genome wide association study found significant association of a sequence variant, rs7566605, in the insulin-induced gene 2 (INSIG2) with obesity. However, the association remained inconclusive in follow-up studies. We tested for association of four tagging SNPs (tagSNPs) including this variant with body mass index (BMI) and abdominal circumference (ABDCIR) in the Samoans of the Western Pacific, a population with high levels of obesity.

PMCID: PMC2804583 PMID: 20028541 [PubMed - in process] Note: Professer Steve McGarvey is a frequent visitor to Samoa and engages in high quality research. The OUM library will monitor the publication of recent articles relevant to Samoa and the South Pacific. If you wish to join the OUM “PubMed Alert List” please send your email address to the OUM librarian at matila.faapopo or surindar.cheema at oceaniamed.org. Those on this list will receive regular updates via email and can thus come by the OUM library to read the full articles through HINARI. It is important that the medical community in Samoa takes an active role to keep its medical and clinical knowledge current in order to develop good lifelong and independent learning habits which will ensure that their patients benefit from the latest discoveries and thinking about disease mechanisms, treatments and most of all prevention.

METHODS: We studied 907 adult Samoan participants from a longitudinal study of adiposity and cardiovascular disease risk in two polities, American Samoa and Samoa. Four tagSNPs were identified from the Chinese HapMap database based on pairwise r2 of >or=0.8 and minor allele frequency of >or=0.05. Genotyping was performed using the TaqMan assay. Tests of association with BMI and ABDCIR were performed under the additive model. RESULTS: We did not find association of rs7566605 with either BMI or ABDCIR in any group of the Samoans. However, the most distally located tag SNPs in Intron 3 of the gene, rs9308762, showed significant association with both BMI (p-value 0.024) and ABDCIR (p-value 0.009) in the combined sample and with BMI (p-value 0.038) in the sample from Samoa. CONCLUSION: Although rs7566605 was not significantly associated with obesity in our study population, we can not rule out the involvement of INSIG2 in obesity related traits as we found significant association of another tagSNP in INSIG2 with both BMI and ABDCIR. This study suggests the importance of comprehensive assessment of sequence variants within a gene in association studies.

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EDUCATION AND TRAINING

CURRENT TRENDS IN UNDERGRADUATE MEDICAL EDUCATION: Program and Curriculum Design Judy McKimm Professor in Medical Education Oceania University of Medicine Note: This is the first of two articles for the Samoa Medicine Journal on undergraduate medical education. This article looks at program and curriculum design, the second focuses on teaching, learning and assessment methods. Abstract Medical education has changed in focus and methodologies since its early beginnings and more recently has become more professionalized and community oriented. This article considers some of the current international trends in undergraduate medical education in program design, curriculum structure and student selection, exploring their relevance to the South Pacific context. Introduction Medical education has a long history, from early beginnings where unregulated apprentice-based learning and barbershop surgeons were the norm, through the establishment of free-standing autonomous medical schools from the 12th century onwards, to the current situation where most medical schools are embedded in large multi-faculty universities and subject to regulations from funding bodies and professional and statutory bodies responsible for regulating doctors. However, this western model is not always appropriate for developing countries, for countries with indigenous populations upholding traditional health practices and for rural and remote areas of the world. Undergraduate medical education does not exist in a vacuum. Programs and the medical schools or universities that develop, manage and deliver education are constantly responding to external and internal change drivers. There are inherent

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tensions in trying to deliver an elite, highly skilled segment of the health and social care workforce amidst calls for more dispersed clinical leadership, flatter health structures, more community based and preventive healthcare and moves to collaborative practice, interprofessional working and learning and more integrated public services. Medicine, as a profession, has also been subject to increased scrutiny and regulation not only as a result of greater accountability for public services and public spending but also due to a number of high profile cases involving „failing doctors‟. Many of the concerns expressed by medical educators reflect the need for medical curricula to prepare doctors not only who are safe to practice, knowledgeable and competent, but who also have the appropriate professional attitudes and are willing to work towards improving health systems. This article takes an international perspective (looking primarily at Australia, New Zealand, the UK and Canada) in considering some of the current trends in undergraduate medical education in program design, curriculum structure and student selection, exploring their relevance to the South Pacific context. Workforce needs and medical education In many countries around the world, including the South Pacific, there is a pressing need for more doctors in the right place, at the right time, with the right skills, providing the right care. Many countries have increased the number of medical graduates over the last two decades, primarily in response to increasing populations, changing demographics and shifting workforce trends. A particular issue is addressing shortages in rural, regional and remote areas and to encourage recruitment and retention amongst certain sectors of the population, such as indigenous or under-represented groups. Increasing medical student numbers has resulted in four main responses by universities and governments:

  



Establishing new medical schools in areas of previously underserved populations Allocating additional numbers to existing schools for existing programs Allocating additional numbers to existing schools to develop and introduce new programs, quotas or establish clinical or urban schools in rural, remote or regional areas of deprivation or health need Supporting affirmative action schemes and programs for groups under-represented in medicine

In the South Pacific, in addition to Islanders being awarded scholarships to study medicine in Fiji, New Zealand and Australia, the establishment of Oceania University of Medicine (OUM) in Samoa has provided another means of increasing medical student numbers of local residents. Some writers have suggested that taking narrow, health service based approaches to workforce planning stifles both innovation and capacity for change, and a reliance on a primarily medical workforce to deliver care that can be delivered by other health or social care workers is short sighted1. It has been suggested that more attention should be paid to formalizing roles of community health workers, mid–level health workers or „physicians assistants‟, particularly in areas where primary care, public health and preventive services need to be strengthened 2,3. Other ways of looking at the health workforce are also important, extending the scope of practice for health professionals, physician‟s assistants, nurse consultants and dually qualified practitioners must be taken into consideration when planning the future of the medical workforce and the underpinning education and training requirements. Entry requirements and selection criteria Increasing attention is being paid to how and from where medical students are selected4. In common with the South Pacific scholarship program, Australian medical schools have specific streams (supported by scholarships and tied into bonding arrangements) for students from rural and remote areas. In Australia and New Zealand affirmative action programs are well established for indigenous groups (Aborigine, Torres Strait Islanders, Māori and Pacific groups) and for students from rural regions. Evaluation of medical programs in Australia indicates high long term retention of doctors5. However the long term success of programs aimed at addressing workforce need through expanding and reshaping undergraduate medicine is still to be determined and issues remain around attracting doctors to work in such areas. As Prideaux6 and others note, the other side of the solution is around policies and strategies for workforce planning, noted by many to be a hugely difficult problem particularly with a global and increasingly mobile health workforce. Students entering a five or six year program are usually school leavers, graduates with a degree that is not deemed relevant for graduate entry or graduates with a relevant degree (e.g. in Biosciences) but where a Graduate Entry Program (GEP) is not on offer (e.g. in New Zealand). Entry requirements are usually high as there is great competition for places, typically between 12 and 20 applicants per place.

Selection for medical school in most countries is through a combination of measuring academic achievement at secondary school or university (e.g. through NCEA results, secondary school certificate, baccalaureate or A-levels); the „open space‟ in the application; referees‟ report and interview. In New Zealand and Australia, applicants also take the UMAT (Undergraduate Medical and Health Sciences Admissions Test) which is a test administered by the Australian Council for Educational Research (ACER) to assist in the selection of students into certain health science courses including most medical (MBBS or MBChB) and Dentistry (BDSc or BDS) courses, physiotherapy and pharmacy. Interviewing is often used as part of the selection process for medicine, although as McManus and Powis4 observed „selection sometimes seems more to ensure the correct number of entrants on day one, than to identify those best suited to the course and profession … the University of Adelaide recently reduced its emphasis on selection interviews, the University of Queensland may be ending interviews and a meta-analysis in Medical Teacher7 suggested that selection interviews have only a „modest‟ predictive validity and „little‟ or „limited‟ practical value‟ (p1). Multiple mini interviews (MMIs) are increasingly common in medical interviewing. Here, applicants move round „stations‟ or tables and answer questions or discuss issues relating to various topics, including ethical issues, career choices, motivation for studying medicine and previous work experience. The responses are scored against criteria, often by two interviewers. MMIs replicate the OSCE (Objective Structured Clinical Examination) in that after all applicants have completed the stations, the scores and comments are fed back and collated. The interview scores are then aggregated with other application data so that decisions can be made on who should be offered a place. Special arrangements exist in New Zealand and Australia for students from indigenous and rural backgrounds. At Auckland University for example, the MAPAS (Maori and Pacific Islanders Admissions Scheme) and ROMPE (Rural Origin Medical Program Entrants) are positive or affirmative action programs which provide quotas for students from these backgrounds, plus additional entry and support mechanisms. Most medical programs also include a quota (typically 10%) for international students, some of whom will be on study scholarships; others will be full fee paying students.

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Key trends in medical education Medical education, like other subject disciplines, is subject to trends and shifts in philosophy, which represent responses to workforce and service demands, opportunities and advances in learning and scientific technology and the development and maturation of „medical education‟ as a discipline. Medical education now reflects the input and influence of a range of approaches to research, teaching and learning drawn from a wide range of disciplines outside the traditional sciences, including education, psychology, sociology, linguistics and other humanities. It is an exciting time to be involved in medical education and there are many examples of new medical programs and medical schools that are not modeled on traditional lines. Two key shifts that are reflected in the South Pacific medical programs are those towards graduate entry medicine programs (GEPs or GEMs) and community-based medical education. Many countries (including Australia, Canada, UK and Ireland, but also in the US, South Africa, South America and across Europe) now include GEPs alongside traditional five or six year programs for school leavers. GEPs provide a route for qualified health professionals or graduates from science or related disciplines to take a shorter (typically four year) medical program. Studies looking at the „outputs‟ of graduate entry programs compared with traditional programs indicate (although GEP programs are no panacea) a higher academic performance of GEP students (especially those with science degrees or health professions degrees) and that GEP students report a valuable learning experience8. Community based education, where most of the clinical teaching is located in the community (general practice, community clinics, small health centers and hospitals) is seen as a particularly relevant way of encouraging and supporting medical students to become GPs or practitioners in medical specialties in rural, regional and remote areas. Wollongong (a new Australian school) has planned a community based medical school based on a UK model. Here 80% of the teaching will take place in community settings; this has required establishing and developing strong links with local health service providers. This new program caters for a relatively small number, between 25 and 50 entrants per year, of graduate entrants. It reflects workforce and service needs and aims to produce graduates who have the commitment and expertise to work alongside other professionals in areas of need for some or all of their subsequent careers4. There is widespread illustration in practice that

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new medical schools do not need the full range of resources available that an established medical school would have. Lawson et al9 describe how the new Australian schools had „the luxury of first choosing the curriculum and then devising the best way to deliver it, unlike older schools which had to impose new courses onto pre-existing structures‟. In common with OUM, the new Australian and UK schools have a focus on integration of disciplines, they tend not to set up traditional departments and expect to draw from resources both within and outside the university, where necessary forming collaborations with other institutions locally, nationally and internationally. There are real opportunities in the South Pacific, because of the small size of the islands, for enabling medical students to learn and work alongside other health and social care students from the beginning of their program, so as to produce graduates who are truly able to work in interprofessional teams. Existing expertise in health professions‟ education, strong relationships with academic and health providers and a range of collaborative activities provide an invaluable resource and vision for what could be achieved regionally. Curriculum design Worldwide, there are now two main curriculum models for undergraduate medical education, although within these overarching models there are a range of educational options. The two models are:  

a five, six or seven year „traditional‟ program, primarily for school leavers a four year „graduate entry‟ (GEP) program (sometimes slightly longer) for graduates or qualified health professionals

Successful completion of either of these medical programs leads graduates to professional registration, although the immediate postgraduate period of training differs between countries. Many „traditional‟ programs, particularly in the UK, also include opportunities for an intercalated degree, typically a BSc, although some universities offer a Masters or PhD program for selected students. An intercalated bachelors‟ or masters‟ degree usually requires an additional full time year of study. Graduate entry programs Graduate entry programs are relatively new and began in Canada and Australia. The first was a pioneering problem based learning (PBL) course that began at Newcastle University, Australia in

the 1980s. The terms are generally used outside the USA to differentiate from the traditional programs for school leavers, referring to medical programs (usually of 4 years duration) where applicants are university graduates or registered health professionals. Although the courses are typically four years in length, it should be noted that most have extended terms/semesters and years throughout (e.g. 38 – 42 learning weeks) to meet initial registration requirements. Some specific GEPs have been established to allow „conversion‟ or dual registration, specifically in areas where highly specialized skills are required or where there are other workforce needs. One example is the MBBS „Medicine Max Fax‟ course at Kings College London which is designed to enable a small number of dentists registered with the UK‟s General Dental Council to „fast track‟ to a medical degree. Some GEP programs also enable health professionals to „convert‟ to medicine, even if they do not have a degree, as long as they satisfy admission requirements. In Canada, all programs are GEPs, with the majority being four-year programs. Exceptions include McMaster University and the University of Calgary where programs run for 3 years, without interruption for the summer. In the Canadian GEPs, the first half of the medical curriculum is dedicated mostly to teaching the basic sciences relevant to medicine, such as anatomy, physiology, pharmacology, genetics, microbiology, ethics and epidemiology, which may be organized by discipline or by organ system. The remainder of medical school is spent in clerkship. Typical rotations include internal medicine, family medicine, psychiatry, surgery, emergency medicine, obstetrics and gynecology and pediatrics. Elective rotations provide opportunities for students to explore specialties of interest for residency training. Some medical schools offer joint degree programs in which a limited number of interested medical students may simultaneously enroll in MSc or PhD programs in related fields. Often this research training is undertaken during elective time and between the basic science and clinical clerkship halves of the curriculum. In schools which already had established five/six year curricula, the majority have woven the GEP curricula and students into the established course. So, for example, at Kings College London, the first year is unique to the course but for the last three years of this course, students join those of the other MBBS streams for a common course. The core curriculum is covered in the first three years and the fourth year is vocationally oriented and includes the opportunity to study abroad for an elective period. Curriculum

design, balance of clinical and „academic‟ learning, teaching and learning methods and assessment all very much reflect both the dominant trends of the time, the national policy and funding arrangements, the local healthcare context and the internal management and organizational structures. In many western countries it is clear that there has been significant shift towards acknowledging the responsibilities of medical schools in addressing workforce shortages. Prideaux10 suggests however that there has been „less attention in the literature about the influence of national and local contexts despite the influence of governments all over the world in addressing workforce shortages through the outcomes of medical education programs‟ (p300). This is an area of potential further research in the South Pacific. New models of higher education Many universities offer a common first year (or Foundation year) to students wishing to enter health and science programs. Some select students for each of the programs prior to entry to the first year and offer an inter-professional learning program (such as the New Generation project at Southampton University, UK) and others (such as at Auckland and Otago universities in New Zealand) offer a common first year, after which, students are selected for entry to the various programs. Recently, most notably in Australia, North America and Europe, new models of tertiary (higher) education are being introduced for professional degrees based on broad based undergraduate degrees leading to employment, a professional graduate degree or a research degree such as a PhD. The most widely known in Australasia is the „Melbourne model‟, introduced at Melbourne University in 2008. Nursing moved to the graduate level in 2008, medicine moves in 2011, with a radical shift in structure. As the University moves to the Melbourne model, the six year MBBS/BMedSci degree and four and a half year GEP degree (MBBS) will be phased out and replaced with a new four year postgraduate degree, the Doctor of Medicine (MD) which will begin in 2011. Curriculum design and preparedness for practice The design and delivery of undergraduate medical curricula and teaching, learning and assessment methods have much in common with those of other health professions. However, partly reflecting the way in which the profession was established and also the „scientific‟ nature of medicine, the culture of medical education in-

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volves recognizing some specific trends and unique „ways of working‟. Over the last decade, accrediting and registration bodies have placed increasing focus on and scrutinized undergraduate medical curricula in response to high profile cases involving doctors. The UK GMC, for example, (which often sets the scene for other accrediting bodies worldwide) in its recent iteration of Tomorrow‟s Doctors 2009 11 , places huge emphasis on „the doctor as a professional‟ which includes learning outcomes relating to professional behaviors, ethics and law. Tomorrow‟s Doctors is the document that comprises the GMCs recommendations on undergraduate training which all UK medical schools are appraised against in the quality assurance process (see below). It is of equivalent status to the AMC‟s Standards and procedures for the assessment and accreditation of medical schools 12. The GMC13 commissioned research in 2007-2008 to investigate „preparedness‟ for practice of graduates from three medical schools with different curricula: Newcastle (systems based, integrated, five-year program, school entry); Warwick (graduate entry, four year program) and Glasgow (Problem-Based Learning (PBL) curricula, five year, school entry). The research found little difference between the preparedness of graduates between the schools, „there was a suggestion that Glasgow graduates were more confident about seeking information, possibly related to the PBL course, and that graduate entry graduates were more confident in complex communication, due to their age and relative maturity. However these may be attributions based on expectation, and there is no strong evidence that graduates do differ in their behaviour‟14 (piii). What the research did reveal, however, were some areas where it was deemed all graduates were less well prepared, specifically arriving with not enough „on the job‟ experience (although they got up to speed very quickly) and prescribing. „Weaknesses were identified both in the pharmacological knowledge underpinning prescribing, and the practical elements of calculating dosage, writing up scripts, drug sheets, etc‟14(piii). The report recommended to the GMC that medical schools should aim to ensure clinical placements with more structure and consistency, with more experiential learning across specialties, that graduates „shadow‟ the junior doctor job they are moving into and that more attention is given to supporting the development of ward-based teaching of prescribing as a skilled procedure.

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Vertical and horizontal integration Historically, medical programs comprised a twoyear „pre-clinical‟ course which focused on the biological and natural sciences (taught in a university setting), followed by a three year „clinical‟ apprenticeship style course, largely located in hospitals. This model is still found in many countries today and remnants of the model exist in many „traditional‟ programs where students are taught the (mainly) science building blocks prior to applying this knowledge in clinical practice. A pre-clinical course typically includes anatomy; physiology; biochemistry; pathology and pharmacology, plus some medical sociology, psychology and ethics/law. A typical „clinical‟ course would include students being allocated to a series of clinical attachments to gain experience of the major medical specialties. Students would take general medicine and surgery (probably in the third year and possibly again later), then move onto sub-specialties such as Neurology; Endocrinology; Gastro-intestinal medicine/surgery; Obstetrics and Gynecology; Pediatrics; Genito-Urinary Medicine, and Psychiatry. They would also work in General Practice and Accident and Emergency Medicine. Most medical programs also include an „elective‟ or „selective‟ (depending on country) where students choose to work in a different context, often another country, for a period of five to ten weeks. In the last twenty years, there have been increasing pressures on medical educators for curriculum reform, and as a consequence we have seen the decline of the traditional pre-clinical/ clinical model. As medical science developed and the extent of knowledge increased (particularly around molecular biology), growing concerns were expressed about the volume of knowledge in medical curricula and the „increase in factual overload‟15. The temporal and geographical separation of course „content‟ from clinical practice was also highly criticized in the light of developing understanding of student learning, and, as situational models of learning became more influential16, there was a shift in medical curricula towards more integrated, descriptive curriculum models17. In many countries, the traditional approach has largely been modified towards a more integrated approach to curriculum planning and design. An integrated approach is still subject centered but transcends the traditional subject boundaries. Teaching units from subject disciplines are fused together around meaningful organizing themes/ concepts such as body systems or community medicine. In medical education the term „vertical integration‟ describes the blurring of

FROM FLEXNER TO HARDEN19 Flexner (1911)

Harden (1984): the SPICES model

Teacher-centered

Student-centered

Knowledge giving

Problem-based

Discipline led

Integrated

Hospital oriented

Community oriented

Standard program

Systematic

Electives (+ core) Opportunistic (apprenticeship) boundaries between pre-clinical and clinical courses whereas horizontal integration describes how knowledge and skills from many disciplines are clustered around themes such as body systems (e.g. a cardiovascular systems course might include anatomy, physiology, biochemistry, pathology, clinical medicine, sociology, epidemiology, etc. relating to the cardiovascular system). The consequences of these shifts led to curricula being reviewed and reformed so that students gained early clinical experience and „scientific‟ learning extended into the clinical years. Medical educators described the shift from the traditional model described by Flexner in 1911 to curricula that were based round the SPICES model18, see below. The spiral curriculum model was often used as the basic curriculum model, rather than the preclinical/clinical model, with many programs being based around body systems (a systems-based approach) and clinical placements, with more emphasis on a structured curriculum, based on learning, reinforcement and application of learning. „The medical curriculum should be designed so as to provide adequate opportunities to acquire independent learning skills, while developing clinical competence to a level appropriate to a new pre-registration house officer. Experiential learning arising from extensive periods of direct patient contact is an essential component of the course, which may be supported by contributions made by skills laboratories and learning activities using simulated patients. Adequate numbers of patients in primary, secondary and tertiary care settings need to be available for face-to-face student contact‟20(p9). Measures were also put in place to try to reduce the emphasis on learning facts. Outcome-based education, OBE21, was suggested as a way of defining and structuring medical curricula, and,

although debate in medical education over objectives, outcomes and competencies still exists, there is now general consensus (also influenced by wider higher (tertiary) education quality assurance mechanisms) that curricula should be defined in terms of what students and graduates should be able to achieve at various stages of the program22, 23. The UK Quality Assurance Agency (QAA) for example, sets Subject benchmarks in all subject disciplines offered by UK universities, including medicine. The Medicine benchmark statement20 includes broad learning outcomes that graduates should achieve by the end of the medical program, including outcomes defined by the GMC in terms of professional attributes.

Although the traditional approach has often been criticized for separating the underpinning „science‟ from clinical medicine and which many people feel is best learned in a clinical context, it is often easier to develop and deliver a traditional course within the structure and organization of established medical schools. Many medical schools are divided into clinical and nonclinical departments and on a practical level, integration can often be a difficult to achieve. Barriers such as physical separation, funding mechanisms and inter-departmental rivalries are often difficult to overcome. Many new schools have been able to take advantage of a lack of „history‟ and establish curriculum management and internal funding arrangements more consistent with the needs of delivering a modern, integrated medical curriculum. The ‘Symbiotic’ Curriculum and Community Engagement One feature which has changed significantly over time is where students acquire their clinical skills and professional behaviors. In the „traditional‟ pre-clinical/clinical programs, students were primarily based in hospital (typically large teaching hospitals) settings, where they undertook fairly unstructured, apprenticeship style placements where they were allocated to a consultant and his/her team (a „firm‟) for a specified length of time. These placements were variable in quality and students were not necessarily learning the same things or the right things for their future medical practice. The implementation of more robust and standardized quality assurance and enhancement mechanisms requires that increased attention is paid to ensuring that the clinical learning experiences are a more standardized experience, that they are structured, have specific learning outcomes, are assessed and are of appropriate quality.

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Key features of the PRISMS model Product focused – i.e. practice based linked with professional development. Students learn about basic science by applying it in the clinical context Relevant to students and communities, reflecting the needs of local health communities as well as student learning needs Inter-professional – programs will espouse, encourage and reflect a culture of multi-professional learning, collaboration and teamwork Shorter courses taught with smaller numbers of students on each „unit‟ (placement, learning set, group). This also reflects the worldwide shift towards graduate entry programs and need to better integrate undergraduate education with postgraduate training Multisite locations – shift from large teaching hospitals with restricted patient mix to primary care and smaller hospitals and units. This incorporates the shift to a more immersed learning experience, especially in community settings so that students can establish closer relationships with patients and health colleagues essential for contemporary medical practice Symbiotic (organic whole) – this is the link with the prism where clinical education is the driving force, partnerships between communities, medical schools, learners and teachers are important and medical education becomes part of an increasingly diffuse and dynamic health system where health care is only one part of the wider public service agenda. Another way in which medical curricula have responded to the challenge of extending learning into the community is through a „symbiotic‟ cur24 riculum design as part of the PRISMS model (see above). The PRISMS model reflects some of the worldwide trends in medical education; however the idea of the „symbiotic‟ curriculum (with partnership with communities and a shift of location of clinical teaching) has been a slightly separate and highly influential model in many medical schools, predominantly in Australia, Canada and the UK. In response to increased awareness of the impact of the medical curriculum on both student learning and community based healthcare10, the Australian government provided a special grant as part of a comprehensive rural medical workforce strategy25. This grant led to the establishment of dedicated Rural Clinical Schools throughout Australia, aimed at serving dispersed local communities through enhanced engagement with medical schools, medical students and the university. The workforce strategy also included the Rural Incentives Program which aimed to improve the recruitment and retention of general practitioners for rural communities26. It is clear that when workforce strategy targeted funding and tailored programs are aligned, there is huge benefit, not only to the students but also to the communities and ultimately improved health outcomes. An example of community engagement and the symbiotic curriculum that has been well evaluated and researched is the Parallel Rural Community Curriculum (PRCC) which was established at

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Flinders University (Adelaide) in 1997 as a stream for 3rd year students within the 4 year graduate entry program. The program was established with the aim of addressing „the twin issues of workforce maldistribution and the inappropriate urban tertiary teaching hospital caseload‟25 (p559). The Rural Clinical School (FURCS) manages the rural programs which now include programs for nurses and paramedics, a clinical simulation centre (in Renmark) and Community point of care services. Medical students spend the whole year (immersion program) located in one of four rural centers, learning from general practitioners, other health professionals and patients. Videoconference links provide communication and teaching media and there is a well established program of research, teaching and professional development activities, including a Masters in Clinical Education. Recent research10, 26 has established that rural community based clinical education is built on four fundamental relationships: 1. A personal – professional relationship 2. A clinician – patient relationship 3. A university – health service relationship 4. A government – community relationship The student is located at the centre of these relationships, see Figure 1 below26. Evaluations of the PRCC program have been very positive. Students are not academically disadvantaged in terms of passing common examinations and assessment. Advantages to the PRCC program include an increasing independent style of learning, enhanced clinical skills as students learn to deal with „what comes through the door‟

Figure 1

Relationships in clinical education

turation of students into rural community living and to learn what rural medicine entails. The principles of a symbiotic curriculum have been strongly embedded in the experience, and the design and implementation of Pūkawakawa meets the essential features of theoretical models of community engagement28. Early evaluation of the program drawn from focus group interviews and the year 5 assessment results showed that students on the Pūkawakawa pathway have a similar academic performance to the standard Year 5 pathway. There were also encouraging outcomes for students who were Māori. Follow up studies planned will look into “Student Preparedness for Year 6” and their ultimate career destination29. Conclusion

and increased confidence with patients. Concerns over the ability of General Practitioners to teach were soon dispelled27 and the high volume and case mix meant that students are able to manage and treat a much wider variety of patient problems than in the tertiary setting. Student groups are small, this is one of the main benefits to the learning process however the program is expensive to run in terms of having to establish facilities, train and support teachers and maintain communications. In common with many other countries (e.g. the US, at the Universities of New Mexico and Minnesota; UK, at the universities of Cambridge, Durham and Newcastle) the Australian government recognizes the benefits of rural based programs which embrace community-based education6. The Flinders curriculum has been utilized by a number of schools across the world as the basis for new medical program development. In New Zealand, clinical schools have been established in various regions attached to both medical schools. These schools aim to provide a hub for teaching and learning for clinicians, academics and students. At the University of Auckland, a new program, the Pūkawakawa program began in 2008 for 5th year medical students, designed to maximize the strengths of Northland healthcare opportunities to enhance student learning in communities‟ environments and multidisciplinary teams, while ensuring students meet equivalent learning outcomes and common end-of-year assessments with the standard program. The program was designed on the „hub and spoke‟ model that has been successfully introduced elsewhere and has many similarities with the Flinders program described above. The „spokes‟ allow accul-

This article has considered some of the current trends in program and curriculum design, locating these within requirements for medical schools to consider the needs of and engage with local communities. Undergraduate medical education plays a key role in equipping the health workforce with the doctors that it requires and the way in which the curriculum is designed and structured is immensely influential. Medical curricula need to be dynamic and responsive to external influences and changes if they are to ensure that the doctors of the future have the knowledge, skills and attitudes required by the communities which they serve. Medical curricula also need to emphasize current concerns about doctors‟ performance including professionalism, concerns for patient safety and a drive towards continuous quality improvement in health care. References

1. Wilson, N W, et al. A critical review of inter-

ventions to redress the inequitable distribution of healthcare professionals to rural and remote areas, Rural and Remote Health. 2009: 9:1060, 1-21 (online) http://www.rrh.org.au (accessed 3 March 2010) 2. World Health Organisation. WHR 2003 (the World Health Report 2003) – shaping the future. http://www.who.int/whr (accessed 13 March 2010) 3. Pick, WM, Khanyisa, N, Cornwall, J T and Masuku, M. Human resources for health: a national strategy, Pretoria: Department of Health, 2001 4. McManus, C and Powis, D. Testing medical school selection tests. The Medical Journal of Australia. 2007: 186 (3) 118-119 5. Joyce, C and McNeil, J. Participation in the workforce by Australian medical graduates, Medical Education, 2006: 40, 333-339

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6. Prideaux, D. Workforce: the new core curricu-

lum for medical schools. Medical Education. 2006 40, 286-287 7. Goho, J and Blackman, A. The effectiveness of academic admission interviews: an exploratory meta-analysis. Medical Teacher. 2006: 28, 335340 8. Carter, Y and Peile, E. Graduate entry medicine: high aspirations at birth, Clinical Medicine. 2007: 7(2), 143-147 9. Lawson, K A, Chew, M and Van der Weydon, M B. The new Australian medical schools: daring to be different. The Medical Journal of Australia, 2004: 181 (11/12) 662 - 666 10.Prideaux, D. Curriculum development in medical education: from acronyms to dynamism, Teaching and Higher Education. 2007: 23, 294-302 11.General Medical Council (UK). Tomorrow‟s Doctors: outcomes and standards for undergraduate medical education. London: General Medical Council, 2009. http://www.gmc-uk.org/publications/ medical_education_publications.asp#1 (accessed 10 March 2010) 12.Australian Medical Council. Assessment and accreditation of medical schools: Standards and procedures, 2009. http:// www.amc.org.au/images/Medschool/ standards.pdf (accessed 10 March 2010) 13.General Medical Council (UK). Undergraduate medical education: reports from schools and publications. London: General Medical Council, 2009. http://www.gmc-uk.org/education/ undergraduate (accessed 3 March 2010) 14.Illing, J et al. How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools, final summary and conclusions for the GMC Education Committee. 2008. http://www.gmc-uk.org/ about/research/REPORT%20-preparedness% 20of%20medical%20grads.pdf (accessed 10 March 2010) 15.General Medical Council (UK). Tomorrow‟s Doctors: recommendations on undergraduate medical education. London: General Medical Council, 2003 16.Reynolds, J and Skilbeck, M. Culture and the classroom. London: Open Books, 1976 17.Prideaux, D. Curriculum design. Cantillon, P, Hutchinson, L and Wood, D (eds). ABC of learning and teaching in medicine, London: BMJ Publishing Group, 2003 18.McKimm, J. Curriculum design and development, e-learning for clinical teachers, London Deanery, 2003. http:// www.faculty.londondeanery.ac.uk/e-learning/ explore-further/e-learning/setting-learning-

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objectives/ Curriculum_design_and_development.pdf (accessed 10 March 2010) 19.Harden, R M, Sowden, S. and Dunn, W R. Educational strategies in curriculum development: the SPICES model. Medical Education. 1984: 18, 284-297 20.Quality Assurance Agency, UK (QAA) Medicine subject benchmark statement. London, QAA, 2002. http://www.qaa.ac.uk/ academicinfrastructure/benchmark/honours/ medicine.pdf (accessed 12 March 2010) 21.Harden, R M., Crosby, J R. and Davis, M H. AMEE Guide 14: Outcomes-based education, Part 1: An introduction to outcome-based education, Medical Teacher.1999:1466-187X, 21 (1) 7 – 14 22.Prideaux, D.The emperor‟s new clothes: from objectives to outcomes, Medical Education, 2000; 34: 168 – 169 23.Hamilton, J D. Outcomes in medical education must be wide, long and deep. Medical Teacher. 1999: 21(2) 24.Bligh, J, Prideaux, D and Parsell, G. PRISMS: new educational strategies for medical education, Medical Education. 2001: 35, 520-521 25.Australia. Commonwealth Department of Human Services and Health. Rural doctors: reforming undergraduate medical education for rural practice. Canberra: Department of Human Services and Health, 1994 26.Worley, P, et al. Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-based programs. Medical Education. 2006: 40, 109-116 27.Worley, P, et al. The Parallel Rural Community Curriculum: an integrated clinical curriculum based in rural general practice. Medical Education. 2000: 34, 558-565 28.O‟Connor, B J et al. Great Expectations: Engaging with new medical communities, poster presentation accepted for the ASME conference, July 2009, Edinburgh 29.Poole, P. Pūkawakawa - innovative but academically equivalent, paper presentation accepted for the ASME conference, Edinburgh July 2009. Address for Correspondence: Prof. Judy McKimm Oceania University of Medicine, National Health Complex, Motootua, Apia, Samoa Email: [email protected]

CONFERENCE REPORT

ASIA PACIFIC MEDICAL EDUCATION CONFERENCE, SINGAPORE, 4-8 FEBRUARY 2010 http://medicine.nus.edu.sg/meu/apmec7/ Held, Si, McKimm, Jii, Cheema, Siii. Medical Education Unit, Oceania University of Medicine, Samoai Medical Education Unit, Oceania University of Medicine, Samoaii Vice Chancellor, Oceania University of Medicine, Samoaiii Mr Sam Held, Professor Judy McKimm and Professor Surindar Cheema attended the 7th Asia Pacific Medical Education Conference (APMEC) in Singapore from 4th to 8th February 2010. The conference was attended by over 700 delegates from around the world. The main conference theme was 'excellence in medical education, quality in healthcare' with a range of keynote lectures, workshops and symposia exploring how medical and health educators can work more effectively with healthcare providers to improve patient safety and the quality of healthcare. Professor McKimm delivered one of the keynote lectures entitled Inter-professional education and improving collaborative practice: evaluating the evidence and also chaired a symposium on Interprofessional Education. In addition Professor McKimm and Mr Held ran a well attended and evaluated pre-conference workshop entitled Quality assurance and enhancement: approaches, models and perspectives. Other keynote presenters spoke about the importance of simulation in improving healthcare, strategies for increasing the quality and capacity of care through medical education, medical school and curriculum structure and leadership, medical education research and communication skills. Many interesting topics were raised during the conference with clear emphasis on how the role of medical schools is changing from being traditional elite establishments to actively engaging with communities, promoting social responsibility and accountability amongst medical students as future health professionals. OUM's mission and activities clearly reflect this changing perception of what a modern medical school should be about.

A number of recurrent themes were prominent throughout the conference, both in the formal groupings of the symposia and also occurring in the poster presentations. Two of these themes: „Quality in Healthcare, and „Inter-professional Education and Collaborative Practice‟ were directly addressed by Professor McKimm‟s contributions to the conference, and the others: patient safety, professionalism and ethics are very much on the emerging curriculum at OUM. The level of attendance at the workshop delivered by Professor McKimm and Mr Held on quality assurance and enhancement, both in terms of numbers and participants‟ level of influence within the institutions and nations they represented, suggested that quality is very much on the international agenda. There was great deal of interest in the practical methodology underpinning quality assurance and enhancement, and in the structural, cultural and system changes involved in implementing comprehensive quality assurance in medical education. With so many diverse countries represented at the conference, the importance of adapting approaches to particular contexts was not lost on the workshop participants, and the workshop environment offered an opportunity for an exchange of previous knowledge and experience in addition to new learning. As one of the major themes of the conference, the inter-professional agenda was evident in the variety of lectures, symposia and poster presentations, and equally evident in the range of professional backgrounds of the people attending the conference. There were, of course, many doctors attending, but there were also many nurses, allied health professionals, scientists and (encouragingly) some people who described their main profession as educationalists. Professor McKimm‟s well-received keynote lecture on inter-professional education and collaborative practice urged her audience to question if the amount of time and resources that are spent evaluating the effectiveness of inter-professional education to date is sufficient. A clear message emerging was that the weight of the World Health Organisation (WHO) is behind interprofessional education and practice and the medical education community should perhaps be directing its energy and resources towards the development of inter-professional education preparing graduates for inter-professional practice. The symposium on inter-professional education also highlighted some of the advantages to students and medical schools of engaging in interprofessional education as well as the challenges in logistics, different professional cultures and ensuring faculty are equipped with the skills to

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facilitate inter-professional learning.

conference.

Professor McKimm‟s keynote lecture highlights one of the perennial issues for medical education, that of providing the evidence to support practice. Education does not lend itself easily to purely quantitative methodology as the parameters of success are subtle and complex. This was addressed by another keynote speaker, Professor Kevin Eva from McMaster University in Canada, in his lecture entitled Quality healthcare through excellence in medical education research: defining the parameters. Professor Eva warns of the danger of becoming constrained by a narrow and ultimately confining definition of evidence which suggests that (in the case of medical education) proof is simply the ability to demonstrate that a given intervention works. In medical education, however, evidence should be regarded as the extent to which that same intervention adds to the overall body of knowledge, skills, competencies and behaviours that comprise the global output.

The themes of communication skills and professional standards and ethical practice once again show the Conference to be spotlighting areas of medical education that, like inter-professional practice, are not particularly easy to quantify or evidence empirically but are increasingly being seen as part of the responsibility of medical schools to model and disseminate. While few would contradict the importance of excellent communication skills in today‟s healthcare environment, Dr Jan van Dalen from the University of Maastricht in the Netherlands, in his keynote lecture Communication skills training admitted that they don‟t really know what really works in training communication skills to students. Similarly a symposium on Professionalism and ethics brought together a number of excellent speakers who gave some fascinating presentations. Professor Alistair Campbell from the National University of Singapore‟s presentation title, Can professionalism be taught? summarized the theme of the symposium, and the answer seemed to be a resounding „maybe‟.

The theme of the somewhat intangible elements of medical education was also picked up by another keynote speaker, Professor Ron Harden from Dundee University in Scotland, in his intriguingly titled lecture: If Harry Potter ran a medical school, would it matter? Professor Harden considered what is at the heart of the process that takes place as a student progresses through medical school and gradually becomes a doctor. Despite huge advances in technology, constantly evolving and increasingly sophisticated curricula, the real „magic‟, suggests Professor Harden, lies in the high levels of enthusiasm, creativity and flexibility, combined with depth of knowledge about teaching and learning processes within the staff teams of the medical schools. There were a number of interesting and thoughtprovoking presentations on the use of simulation in medical education, which reflected the trend away from high-tech gadgetry to a wider definition of simulation which puts it within the grasp of many more medical schools across the world. The presentations also supported the view that simulation will never represent a teaching „solution‟ in isolation, nor should it been seen as such. A number of the presentations on simulation concentrated on the importance of creating opportunities for students to gain experiences with simulated patients (but real people!). Apart from the invaluable clinical learning opportunities that can be offered in a controlled environment, this type of simulation also presents an ideal situation for developing skills in communication and professional standards of practice both of which also featured as themes at the

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The APMEC organisers are to be congratulated for encouraging debate and discussion on many topical and relevant themes at the leading edge of medical education worldwide. The number and range of activities covered virtually every aspect of current medical education. The diversity of activity represented in the poster displays was of particular note. Of particular relevance to OUM and the Samoan context were issues such as the importance of ensuring partnership with clinical organisations. An interesting case study was presented from a Singapore speaker of how a new teaching hospital is currently being built in collaboration with the medical school to ensure an effective clinical teaching environment alongside state-of-theart clinical facilities. Other interesting presentations were given which came under the general title of the „community facing‟ medical school, which again something we are endeavouring to achieve at OUM. Among the poster presentations were several on the theme of approaches to end of life and palliative care, including one from Mr Held whose work in New Zealand is with a range of Palliative Care Services. Colleagues from the Asia-Pacific region are keen to collaborate and share practice. Next year's 8th APMEC conference is to be held in late January in Singapore and we hope that OUM will have much to report and share with colleagues from around the world.

VIEWPOINT

supervised by experienced doctors. Without doubt, hospitals where medical students and young doctors receive basic and specialist training are generally thought of as the most advanced type of hospital. Is a teaching hospital a part of the national health network? The answer is a definite „Yes‟. In many countries, Acts of Parliament are enacted to establish teaching hospitals. For example, the University Medical School, Teaching Hospitals, Act 1955 covers the provision of teaching Cheema, S hospitals for the University of Western Australia Vice Chancellor (1). Teaching Hospitals are usually part of a Oceania University of Medicine complete health care system or network and receive grants to ensure delivery of medical services whilst undertaking education and research activities. Some teaching hospitals are in addiThe government of Samoa has the vision to realtion able to recover costs and balance their ise the enormous benefits of a new teaching hosbudgets by treating private patients (for example pital for the citizens of Samoa and for visitors to tourists who carry travel health insurance). In this beautiful nation. The new teaching hospital the USA, there will be built are about at the Motoo1,100 teaching tua National hospitals, both Health Compublic and priplex so that vate (2). If a it is located hospital has a strategically commitment to within the teaching and current natraining, it is tional hospigenerally retal environs. ferred to as a It will feature teaching hospimodern tal. Good medical teaching hospiequipment, tals also make diagnostic major contribuservices and tions to reskilled persearch and are Fig 1. State of the Art: Artist impression, planned first phase, sonnel that new National Hospital of Motootua centres for exwill augment perimental, the services innovative and technically sophisticated service. provided by the over-burdened Tupua Tamasese In the USA, teaching hospitals also serve as a Meaole (TTM) Hospital. safety net providing treatment to uninsured and underinsured patients (3). When completed (first phase planned for 2010), the teaching hospital will be a source of pride for Teaching hospitals are often the referral site for the people of Samoa. However, there may be complicated or „untreatable‟ medical conditions. questions about the merit of establishing a As the American Association of Medical College teaching hospital in Samoa instead of a regular website states, “Hope Happens at America‟s hospital. In this article, I will put forward my Teaching Hospitals‟ (4). Many of the Nobel lauviewpoints in support of a teaching hospital and reates in medicine are professors who work in or perhaps readers of the Samoa Medical Journal are attached to major teaching hospitals. For may want to express alternate views. example the Royal Perth Hospital (RPH) is Western Australia's premier teaching hospital, providWhat is a teaching hospital? A teaching hospital ing a full range of emergency services for adults (sometimes called a university hospital) is affili(except obstetrics) and serving as the State reated with a medical school and it provides speferral centre for many super-specialities. Areas cialised medical care to patients as well as cliniof excellence include interventional neurocal education and training for future and current radiology, cardiac and lung transplant, burns doctors, nurses and other health professionals. management, bone marrow transplantation, reStudents training in teaching hospitals are closely

SAMOA’S FIRST TEACHING HOSPITAL

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habilitation medicine and trauma services. RPH has hosted many significant breakthroughs in medical research - significantly, the bacterium Helicobactor pylori, which was found to cause stomach ulcers, and won the 2005 Nobel Prize for former staff members Dr Robin Warren and Professor Barry Marshall (5).

moa if they know that, should a medical emergency arise, they can access a top medical facility and qualified doctors locally. Through its partnership with Oceania University of Medicine, the new teaching hospital will attract and retain some of the best doctors in Samoa. It is not unrealistic to expect that some of the best Samoan doctors will choose to stay in the country and some of those who have left will return to Samoa. Oceania University of Medicine, owned by Samoa and the Samoan people, is prepared to play its role by ensuring that the new teaching hospital becomes a resource to serve the people of Samoa and the South Pacific by offering world-standard health care services right here in Apia.

Teaching hospitals offer and encourage the practice of evidence based medicine, specialised surgeries, modern drugs, and other intensive treatments that general and regional hospitals cannot provide. They are where medical knowledge continuously evolves and new cures and treatments are found as a result of breakthroughs in Fig 2. Planned new Ministry of Health headquarters at Motootua medical research. REFERENCES Teaching hospitals provide a learning environment where teams of doctors and allied health 1. Western Australia. University Medical School, professionals work to ensure patients have the Teaching Hospitals, Act 1955. Online: best and latest treatments available for their http://calendar.publishing.uwa.edu.au/ illness. It is also true that teaching hospitals atlatest/partb/unimedschoolact. Accessed tract and retain the best medical professionals April 2010. because they provide clinicians an opportunity to 2. American Association of Medical Colleges. teach, engage in research and establish an acaMedicare Indirect Medical Education (IME) demic career path where they can become proPayments. Online: http://www.aamc.org/ fessors within the medical school. As per the advocacy/library/gme/gme0002.htm. AcHippocratic Oath, doctors are required to teach cessed April 2010. the next generation of doctors. In the modern 3. Teaching Hospital. Wikipedia. Online: version of the Hippocratic Oath, doctors swear http://en.wikipedia.org/wiki/ by the covenant that they will respect the hardTeaching_hospital. Accessed April 2010. won scientific gains of those physicians in whose 4. American Association of Medical Colleges. steps they walk, and gladly share such knowledge America‟s Teaching Hospitals. Online: with those who are to follow (6). In many westhttp://www.aamc.org/ ern countries, large private hospitals seek the teachinghospitals.htm. Accessed April 2010. imprimatur of teaching hospital status but the 5. Royal Perth Hospital. Welcome to Royal best teaching hospitals are the large public hosPerth Hospital. Online: http:// pitals. www.rph.wa.gov.au/. Accessed April 2010. 6. Hippocratic Oath. Wikipedia. Online: http:// The new teaching hospital in Samoa will, when en.wikipedia.org/wiki/Hippocratic_Oath. fully operational, have not only the best doctors Accessed April 2010. but the best medical and surgical facilities in the South Pacific. Many of the complicated procedures that currently have to be performed overseas at great cost could, in the future, be performed locally. Patients from neighbouring countries will seek advanced medical treatments in Samoa. The planned teaching hospital will also be of major economic benefit by promoting the tourism industry. More tourists will visit Sa-

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OBITUARY

Dr. Faleniu ASAUA September 9, 1938 – February 4, 2006 With no-one to turn to, except GOD Brought up on a one square kilometer land mass (Apolima Island), the odds were against a young boy full of hopes and dreams, whose father‟s sudden death rendered his family penniless. In order to feed his family and put his siblings through school, Faleniu became a plantation labourer. Later on, as an Agricultural Department clerk, his “palagi” boss, Mr. Gunliff, recommended him for a scholarship to study medicine at the Fiji School of Medicine (FSM). However, upon discovery of the fact that Faleniu did not sit the secondary school examinations required for university entrance, FSM readied him for expulsion. His former boss intervened, and by the hand of God, Faleniu continued on to graduate as the Best All Round Graduate, also receiving a gold medal in Preventive Medicine. Despite his interest in Internal Medicine, he accepted a scholarship to specialize in Pathology, during which he completed the fiveyear course in only four, at Otago University (NZ). Working with professors at the Auckland Medical School (New Zealand) while working as a Pathology Registrar provided him with invaluable experience. He became the first Samoan born and bred consultant pathologist, heading the Samoa National Health, Central Laboratory and Pathological Department for more than two decades altogether. During his lifetime, he worked as Director of Community Services for the University of the South Pacific (Suva, Laucala Campus) and ironically as an external examiner and lecturer for FSM. He also published works on cancer and en dometrial hyperplasia.

Outside the medical field, the Congregational Christian Church of Samoa of Aai o Niue was where he served as a A‟oa‟o fesoasoani (lay preacher) and Chairman until his passing away. Surviving him are 6 grandchildren and 5 children: two medical doctors, an electrical engineer, an accountant and an entrepreneur – eleven lives moulded and shaped by their father‟s determination and faith in God.

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Information for Authors The Samoa Medical Journal (SMJ) is produced by Oceania University of Medicine, in partnership with the Samoan Ministry of Health and the Samoan Medical Association. This journal is published three times per year, beginning in September 2009. The journal is published utilizing the editorial standards of the Council of Science Editors (www.CouncilScienceEditors.org). The SMJ is intended to support and encourage medical research in Samoa and the Pacific, as well as providing a source of current information to practising physicians. Its goal is to be one element targeting improvements in the quality of health care available to residents in this underserved region. The journal focuses on the Pacific situation - epidemiology, public health, research, interesting case studies, reviews of endemic diseases, local medical news and reviews of relevant articles and books published elsewhere. It is a great pleasure to invite you to contribute to the Samoa Medical Journal. If you wish to submit your work to the journal, please email us the title and an abstract (up to 250 words) of your article. Alternatively, you may submit the full article. Please note that submission of a manuscript is not a guarantee for acceptance for publication, as all manuscripts will be subjected to peer review. Please could you also refer the journal to your colleagues and other contacts in the field, including your librarian, for promotional purposes, submissions and subscriptions. I look forward to hearing from you soon. Yours sincerely,

Professor Surindar S. Cheema, PhD Assistant Editor-in-Chief, SMJ Vice Chancellor, Oceania University of Medicine Email: surindar cheema at oceaniamed.org