• The politics of exclusion: fighting for patients with Kidney failure in Yemen’s War

      Heller Perarche, A; Fall, C; van Leeuwen, C; MSF London; MSF OCA; MSF USA (Oxford University Press (OUP), 2019-12-15)
      Background To contribute toward the dialogue on addressing non-communicable and chronic disease in humanitarian emergencies, this article will explore the experiences of Médecins Sans Frontières in attempting to find support for the haemodialysis network in Yemen. With the changing profile of the global disease burden and a broadening concept of emergency health needs to include chronic illness and disability, the aid sector has committed through the World Humanitarian Summit and the Sustainable Development Goals to leave no one behind and thus to meet the health needs of these previously excluded and highly vulnerable people. The civil war in Yemen compromised the medical supply chain supporting the health facilities providing dialysis for patients with end-stage renal disease. The article will critique the aid sector’s slow response to this issue and expose the gap between principles, commitments, and practice related to noncommunicable disease in emergencies. Method Following direct experiences from the authors as leaders in the aid response in Yemen, reviews of grey literature from aid and health actors in Yemen were conducted along with a review of literature and policy documents related to noncommunicable disease in emergency. Key informant interviews and press statements supported analysis and events that took place in the time span of roughly 4 years that frames this period of analysis. Results Examination of the impacted patient population, interviews, literature and documented events indicates that there is discord between policy, commitments stated by aid donors and practice. Conclusion The aid sector must use a more contextualised approach when designing programmes to manage the burden of non-communicable diseases in health contexts where crises occur, particularly for lifesaving forms of therapy. Aid agencies and the global health community must increase pressure on donors and implementing agencies to live up to their commitments to include these patient populations.
    • Potential impact and cost-effectiveness of condomless-sex-concentrated PrEP in KwaZulu-Natal accounting for drug resistance

      Revill, Paul; Phillips, A; Cambiano, V; Johnson, L; Homan, R; Nakagawa, F; Meyer-Rath, G; Tanser, F; Rehle, T; Moyo, S; et al. (Oxford University Press (OUP), 2019-12-18)
      Abstract INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) in the form of tenofovir-disoproxil-fumarate/emtricitabine is being implemented in selected sites in South Africa. Addressing outstanding questions on PrEP cost-effectiveness can inform further implementation. METHODS: We calibrated an individual-based model to KwaZulu-Natal to predict the impact and cost-effectiveness of PrEP, with use concentrated in periods of condomless sex, accounting for effects on drug resistance. We consider (i) PrEP availability for adolescent-girls-and-young-women (aged 15-24; AGYW) and female sex workers (FSW), and (ii) availability for everyone aged 15-64. Our primary analysis represents a level of PrEP use hypothesized to be attainable by future PrEP programmes. RESULTS: In the context of PrEP use in adults aged 15-64 there was a predicted 33% reduction in incidence, and 36% reduction in women aged 15-24. PrEP was cost effective, including in a range of sensitivity analyses, although with substantially reduced (cost) effectiveness under a policy of ART initiation with efavirenz- rather than dolutegravir-based regimens due to PrEP undermining ART effectiveness by increasing HIV drug resistance. CONCLUSIONS: PrEP use concentrated during time periods of condomless sex has the potential to substantively impact HIV incidence and be cost-effective.
    • A reflection on case reporting in resource-limited settings

      Wind, A (Oxford University Press (OUP), 2019-12-09)
      In 2015, I was in the Democratic Republic of the Congo (DRC), working as a pediatrician with Médecins Sans Frontières (MSF). As had been the case in my two previous assignments with MSF, I encountered many interesting and challenging cases—cases that I had never experienced prior to working in resource limited settings. Contrary to when I work in the USA and have access to extensive laboratory exams and diagnostic testing, in our hospital in the DRC, no such tools were available, and thus I needed to use a whole new level of clinical skills and deductive reasoning. To make clinical management even more challenging, I rarely saw these types of cases written about or published in the medical literature. I was discouraged that although these clinical examples were perfect fodder for medical case discussions, they did not have the ‘components’ required for a traditional case report. In frustration, I wrote the following: ‘The reason why we, those working in “resource limited settings”, do not often attempt to publish case reports is because we don’t often find an answer. We think that published articles and case reports should be neat and clean. That students or colleagues should be able to read a mystery case, try to solve the puzzle, and at the end be rewarded with an answer brought about by some obscure lab or radiology report. But that’s not what happens. The world of medicine in resource limited settings isn’t neat and clean. It’s frustrating and messy. Mystifying and sad. You can come up with a million differentials but ultimately the child, because of, or in despite of, your chosen treatment, makes it. Or doesn’t make it. And you never get an answer. You don’t learn. And you can try to look in the literature, but the research will talk about IGF1 and MRI and calcium. I can’t even get a cal.ci.um. And so, the mystery disease leads to a mystery death and you are left feeling powerless. And there is not even a take home message.’ I am excited that now with the Oxford Medical Case Reports collaboration, there is a platform to start regaining some power, to start creating a take-home message. There is a platform for collaboration amongst all of us medical professionals working in resource limited settings—a platform to share these unique cases to perhaps discover that they are not so unique at all. They are just not published.