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The San Community, Namibia

Jessica Doyle - Health Poverty Action - 19 Jul, 2018

Our partner charity Health Poverty Action sees health as not merely a medical challenge, but a fundamental issue of justice and human rights. They believe that where you are born should not determine your right to health. They prioritise the health of marginalised communities, who have been forgotten by the rest of the world. 

Health Poverty Action has been working with the indigenous San community in Tsumkwe, Namibia since 1997. The San, known for their unique clicking languages, have long been treated as second class citizens, and this has meant the San people are significantly poorer than the majority of the Namibian population and have much worse health. HIV is on the rise amongst the San people, malaria is endemic and multi resistant tuberculosis is widespread. The closest hospital is some 300 kilometres away and there is a severe lack of nurses and doctors. 

The San people face many barriers to good health; local health staff do not speak their language or understand their culture and so San communities are often ill-treated and thus less confident when attempting to access health care services. These cultural barriers, when combined with a lack of nutritious foods, the nomadic lifestyle of the San, living in remote areas and frequently going on long hunting expeditions far from health centres contribute to poor health. 

Health Poverty Action believes it is important to work closely in partnership with the San to understand the barriers to healthcare. They support communities with the practical knowledge they need to take charge of their own health, whilst working with local government to strengthen existing health systems to ensure they receive good quality, culturally appropriate care. We do this in a number of ways:

Strengthening local organisations and community groups to carry out health awareness-raising on HIV, TB and malaria.

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Meet ≠ioma N!ania. When he began having chest pains and sweating in the night, he didn’t know what his symptoms meant. It wasn’t until a community representative from his local area attended some health training from Health Poverty Action that he learnt he had TB.

“When he returned from his training, he started to teach us in the village that chest pain and night sweats can be signs of TB. He encouraged me to go for a test.”

Training treatment supervisors.  

Many San people live a nomadic lifestyle which makes moving to a big town for months of treatment very difficult- both socially and financially. Health Poverty Action is training treatment supervisors to visit families in their communities, take samples for diagnosis to ensure treatment starts early to prevent hospitalisation, and visit them again to deliver their medicine to ensure they complete their treatment. To prevent the further spread of multi drug resistant TB it is essential patients complete their course of medicine. 

Di//ao Cwi a young woman who lives in a village 36km from the nearest clinic in Tsumkwe said:

“My treatment supervisor made sure I took the prescribed medicine every day. I really thank him for being with me right through my treatment

Strengthening the capacity of local health services to provide quality, cultural health care.

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Sarah Zungu is a senior counsellor in Tsumkwe working to ensure that the San people have representation in government. She understands the importance of health services that are culturally appropriate as she has seen the rates of HIV and TB drop since health professionals began speaking San languages. She is pleased to see more San people training as nurses.

Working with the San people to establish small-scale agriculture projects to provide nutritious food to people living with TB and HIV.

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Shonongeni Auaseb is trained in health education and teaches other San people about HIV, malaria and tuberculosis. He also works in the gardens in Tsumkwe growing fruit and vegetables for TB patients receiving treatment.

Providing training for the San people in health rights, which enables them to demand their right to health.

Health Poverty Action has set up Clinic Health Committees in the San community to provide a space where San community representatives can speak to local health officials. Local services can then be adapted and feedback collected and passed onto government officials at regional and even national level. Although the process has often been challenging and slow, the voices of the San are finally being heard. Health Poverty Action has found that when, communities are able to participate in decisions about their health services and culturally appropriate options are available, health improves.

To support health professionals working in challenging circumstances abroad, we are asking NB Medical members to join our ‘As One’ campaign and either donate their time or money to support their colleagues around the world. 

Updated NICE Guidance NG98 Hearing Loss in Adults: Assessment and Management June 2018

Lucy Hamilton - Nurse Practitioner & Nurse Education Lead - 5 Jul, 2018

Joe, a student, came to see me recently to have wax removed from his ears. He reported that he was finding it difficult to hear in lectures. He thought his ears might be blocked with wax and had already been using olive oil drops for 7 days. Sure enough, when I examined his ears both canals were impacted with wax. I am always conscious of the risk of doing damage to the ear through irrigation. The most common complication is otitis externa but the risk of serious complication such as perforation is estimated at 1 per 1000. The procedure went well with the satisfying removal of two plugs of wax and the smile that appears on the face of the patient when their hearing is restored.

Does anybody remember the big stainless- steel ear syringes that were used in the past? They looked like something that might be used for cake decoration on the Great British Bake Off. I don’t think I’ve seen one for more than 30 years. I googled ‘ear syringe’ and was surprised they are still available to purchase, good thing then that newly published NICE guideline NG98 Hearing loss in adults: assessment and management advises us not to use them! Electronic irrigators or micro suction are recommended. Wax removal is a common procedure for primary care nurses but one which promotes a lot of discussion amongst nurses about its benefit verses the risk. NG98 recommends that removal of earwax is offered in primary care or community ear care services. The guideline also helpfully recommends that patients should be referred for specialist intervention after two attempts at wax removal.

Removal of ear wax, the indications, contraindications and complications is one of the topics covered in our new Primary Care Nurse course reference book. Come along to one of our Primary Care Nurse courses to hear more about a broad range of topics from asthma and diabetes, to women’s health and minor illness, all supported by the latest evidence, presented by myself and Dr Shiv Becker

Blog - Is it time to put a CAP on the number of PSA screening tests we are doing?

Rob Walker - 12 Jul, 2018

'All screening programmes do harm; some do good as well, and, of these, some do more good than harm at reasonable cost’. This was the opening salvo in a review article written in the BMJ 10 years ago in 2008, entitled ‘Maximising the benefit and minimising the harm of screening’. It was prompted by the pledge of the Labour Government to increase screening services in the UK, and used the lessons of the breast cancer screening programme to offer advice on how to make screening programmes as effective as possible.

Whilst the review was specifically on screening programmes, I think that initial comment should remain in the back of our mind when considering individual screening tests, with PSA screening one good example. Screening is a seductive concept for patients, clinicians and politicians alike - catch it early, treat it early, get a better outcome. It all sounds so simple. But as we know, it is not as straightforward as that, and discussing the nuances of the pros and cons of screening with individuals is difficult, especially when they are encouraged to ‘get checked’ by well-meaning friends, family and celebrities. 

The latest piece of evidence to help inform the PSA screening debate came in the form of the CAP RCT, published in JAMA in March 2018. (https://jamanetwork.com/journals/jama/article-abstract/2673968). It enrolled a massive >400,000 men, aged 50-69, over 573 primary care practices across the UK (by way of comparison the European ERSPC trial had ~160,000 men). The men were randomised to a single PSA test or no test and the median follow up was 10 years. Of those that had a valid PSA test 11% had a PSA level between 3 and 19.9 ng/mL, of whom 85% had prostate biopsy. Significantly more low grade prostate cancers (Gleason score ≤6) were detected in the PSA screened group compared to the unscreened group (1.7% vs. 1.1%). Overall there was no significant difference in prostate cancer mortality between the 2 groups. This contrasts with the ERSPC trial which did show some improvement in prostate cancer mortality in the screened group, but both these trials confirmed significant over diagnosis in the screened populations. Yes, there were a few criticisms of the CAP trial, in that only ~1/3 of men invited for screening had a PSA test which could have diluted any possible treatment effects, and the median was ’only’ 10 years and may be too short to see positive effects; but this is a huge study which significantly adds to the evidence base on this tricky subject.

The fabulous Richard Lehman in his BMJ blog (https://blogs.bmj.com/bmj/2018/03/12/richard-lehmans-journal-reviews-12-march-2018/) said this was ‘one of the most important studies ever done in British primary care’, yet it was notable by it’s absence in terms of national press coverage, with some arguing that this was another example of publication bias against trials with ‘negative’ results (despite their importance in adding to the overall evidence base). 

So where are we with our advice to men who ask about ‘getting checked’ for prostate cancer. Well, in May 2018 the US Preventative Services Task Force reviewed and updated it’s recommendations on PSA screening, incorporating the CAP results, and I shall leave you with their conclusions which I think sums up the current state of play well: ‘For men aged 55 to 69 years, the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; over-diagnosis and over-treatment; and treatment complications, such as incontinence and erectile dysfunction.'