Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone.

BACKGROUND: Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. METHODS AND FINDINGS: We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. CONCLUSIONS: National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries.

BACKGROUND: Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs. METHODS: We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised. FINDINGS: In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention. INTERPRETATION: Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs. FUNDING: The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.

Lowering the Risk of Rectal Cancer among Habitual Beer Drinkers by Dietary Means.

Whole-life beer consumption and a quantitative measurement of several dietary micronutrients consumed in adult life were obtained from the dietary and alcohol data of the case-control arm of the population-based Melbourne Colorectal Cancer Study. There was a statistically significant risk, adjusted for other established risk factors, among habitual beer drinkers (AOR 1.75, 95% CI 1.28-2.41) with a significant positive dose-response effect (AOR trend 1.34, 95% CI 1.16-1.55). Among beer consumers the data were interpreted as showing an attenuation of this risk with consumption of the four micronutrients involved in methylation: folate, methionine, vitamins B6 and B12, and the four micronutrients examined with antioxidant properties: selenium, vitamins E, C, and lycopene. The strongest effects were noted with vitamins E, C, and lycopene, and the weakest with methionine and selenium. Whilst not condoning excessive beer drinking, the regular consumption of foods rich in these micronutrients may provide a simple and harmless preventative strategy among persistent habitual beer drinkers and deserves further study with larger study numbers.

The Melbourne Colorectal Cancer Study: reflections on a 30-year experience.

This article reflects on 30 years of conducting the Melbourne Colorectal Cancer Study, a comprehensive, population-based investigation of colorectal cancer (CRC). The study had an incidence arm, a case-control arm and a survival arm, and contributed considerable knowledge about CRC risk, aetiology, prevention and screening. The incidence arm: confirmed high rates of CRC in Australia and the prevalent view that rates rise in first-generation immigrants from countries with low rates of CRC; and enabled the first report of high rates of colon cancer among Australian Jewish people and the first report of high rectal cancer rates anywhere. The case-control arm elicited: the contribution of family history, antecedent colorectal polypectomy and multiple antecedent stressful life events to CRC risk; the risk of rectal cancer in habitual beer drinkers; the first dietary risk score (emphasising the importance of a diet pursued over adult life that is high in foods of plant origin and fish, and low in fat and red meat); and the highly protective effect of regular aspirin use (stimulating much research globally, with the possibility of aspirin becoming an important preventive agent). The survival arm: found an adjusted CRC-specific 5-year survival rate of 42% among patients with CRC and 85% among matched control subjects; confirmed cancer stage as the most important single determinant of survival; and found that the survival rate among people with the earliest stage of CRC was only marginally lower than that of matched community control subjects, underlining the importance of early detection.

World leaders surviving serious illness: Franklin D. Roosevelt and Pope John Paul II.

The quality of medical care and the degree of transparency communicated to the world whilst President Franklin D. Roosevelt and Pope John Paul II were seriously ill, as well as the global consequences of critical decisions they made during this time, were examined from published studies and through personal communications. Franklin D. Roosevelt, in his last years, was secretive about his health and, with one exception, was probably given indifferent medical advice, arguably hung on to office too long which, at least for Europe, contributed to some negative outcomes. Pope John Paul II, when quite ill, was open and communicative about his illness, had high-quality medical and surgical care and, together with his spirited will, greatly contributed to favourable European political outcomes, and to European and world stability.

Colorectal cancer risk, chronic illnesses, operations and medications: case control results from the Melbourne Colorectal Cancer Study. 1988.

The associations between colorectal cancer risk and several chronic illnesses, operations and various medications were examined in 715 colorectal cancer cases and 727 age- and sex-matched controls in data derived from a large, comprehensive population-based study of this cancer conducted in Melbourne, Australia. There was a statistically significant deficit among cases of hypertension, heart disease, stroke, chronic chest disease and chronic arthritis and a statistically significant excess of 'haemorrhoids' among cases, and all of these differences were consistent for both colon and rectal cancers and for both males and females. Although no statistically significant differences were found for other cancers, there were twice as many breast cancers among cases (16) than among controls (8) and also there were 9 uterine cancers among cases and only 2 among controls. There was a statistically significant deficit among cases in the use of aspirin-containing medication and vitamin supplements and this was consistent for both colon and rectal cancers and for both males and females. There was a statistically significant excess of large bowel polypectomy among cases. The modelling of these significant associations simultaneously in a logistic regression equation indicated that hypertension, heart disease, chronic arthritis and aspirin use were each independent effects and consistent for both colon and rectal cancers for both males and females and also that these effects were independent of dietary risk factors previously described in the Melbourne study. The possible relevance of these findings towards an understanding of colorectal cancer risk and aetiology is discussed.

Mainstream medicine versus complementary and alternative medicine in the witness box: resolving the clash of ideologies.

Mainstream medical philosophy and practice differ in many respects from those of complementary and alternative medicine (CAM), differences which are explored in this article. Because of a resurgence of CAM therapies, courts and tribunals will scrutinise CAM in more and more contexts in the future. Such court cases may require the resolution of conflicts between opinions of CAM and medical experts. This article considers how courts evaluate such opinions where experts hold conflicting ideologies or philosophical approaches, and addresses the following questions: Do the opinions of CAM practitioners qualify as "expert" opinions in court? How do the courts examine the basis of such opinions? Are they systematically given less weight than the opinions of mainstream medical practitioners? Will recent procedural reforms for hearing expert evidence make it easier for courts to resolve these issues?

Colorectal cancer protective effects and the dietary micronutrients folate, methionine, vitamins B6, B12, C, E, selenium, and lycopene.

The data reported here were obtained from the case-control arm of a large, comprehensive, population-based investigation of colorectal cancer incidence, etiology, and survival, the Melbourne Colorectal Cancer Study, conducted in Melbourne, Australia. This part of the case-control study was designed to identify dietary factors associated with colorectal cancer risk in 715 incident cases compared with 727 age/sex frequency-matched randomly chosen community controls, in which a quantitative assessment of all foods eaten was made. New data are presented on the potential of two groups of micronutrients as protective agents, namely, those involved in DNA methylation, synthesis, and repair (folate, methionine, and vitamins B6 and B12) and those with antioxidant properties (selenium, vitamins E and C, and lycopene). The adjusted odds ratios showed that for folate there was significant protection for rectal cancer in second and third quintiles of consumption but not for colon cancer, and this was similar for methionine consumption. Vitamin B6 consumption was significantly protective for both colon and rectal cancer at the higher quintiles, and this was similar for vitamin B12. Dietary selenium was significantly protective at middle quintiles of consumption at both cancer sites. Dietary vitamins E and C were statistically significantly protective for both colon and rectal cancer at all levels of consumption, and for both vitamins there was a dose-response effect of increasing protection, particularly so for colon cancer. Lycopene was not associated with colorectal cancer risk. A combined model included vitamins E, C, and B12 and selenium as micronutrients protective for colorectal cancer and folate, which, however, showed an increased risk at the highest level of consumption. These data support the proposition that a diet containing the dietary micronutrients involved in DNA methylation (folate, methionine, and vitamins B6 and B12) and some of those with antioxidant properties (selenium and vitamins E and C) may have a role to play in lowering colorectal cancer risk and also that such protection can be achieved by dietary means alone.

Proof of cancer causation and expert evidence: bringing science to the law and the law to science.

This article discusses the medico-scientific and the legal views of cancer causation and how these two approaches impact on expert evidence. Cancer cause lends itself well to an exploration of the critical issues which surround its proof and the role of expert evidence in this proof. The article does not seek to identify or to resolve all the controversies or inconsistencies in the area. Rather, it sets up a basic framework for the general presentation and testing of expert medico-scientific evidence in litigation related to cancer causation. Specifically, it seeks to identify the technical questions of law and medical science regarding which medico-scientific disciplines can be relevant to proving cancer causation, and who the relevant expert witnesses to achieve this task would be. Emerging areas of cancer causation are then examined in light of this framework.

Carcinoma in a Pharyngeal Pouch: Five-Year Survival after Resection.

A 57-year-old man had a resection performed of a pharyngeal pouch, which was complicated by a squamous-cell carcinoma. There is no evidence of recurrence five years later. The clinical and radiological features of this condition are briefly discussed.