Category Archives: Global Health

The wikipedia pithy definition is: the health of populations in a global context. https://en.wikipedia.org/wiki/Global_health

Palliative care tradeoffs

Is life so precious that any number of painful, lonely, frightened deaths is acceptable to preserve one life?

As a child, I competed with my siblings to see who could hold their breath the longest. I remember the increasingly desperate need to draw a breath as time slowed in proportion to discomfort. The idea that units of time are constant is made absurd when you need to breathe and can’t. It is almost painful. Then there is the sweet, instant relief as you give up. The spent air is forced out, and a lungful of fresh air is gulped in. The whole thing is followed by raucous laughter and calls for another round.

Wouldn’t it be grand if people dying from COVID could just laugh it off as they draw the next sweet breath of air? Immediate salvation from death by hypoxia. Families around the world prayed for those easy breaths as they bundle loved ones into cars, tuk-tuks, and rickshaws in a desperate search for air—and care. On arrival at a hospital, staff had to make a quick decision. With limited resources, they had to choose who would be left to die.

I was told of one hospital where the “not to be treated” were seated in a circle with a single oxygen mask to share between them. They handed the mask from one to the other until, like the ten green bottles, one by one, they dropped out of the round. A colleague’s mother gasped her last breath seated in that circle. In other hospitals, the COVID patients died supine and alone on cots and floors tucked away from the urgent task of saving lives.

I have spent two nights of my adult life taking one careful breath at a time. Asthma. I very rarely have it, and when I do, it is environmentally triggered. On the last occasion, it was 11pm. We were six weeks into the pandemic, and I was alone in my flat in Dhaka. Breathing had become work. Tiring work. I remember skipping breaths because it was restful. Although I was worried, arriving with breathing difficulties at the A&E of a panic-stricken hospital seemed a bad idea. With judicious and relatively frequent use of a salbutamol inhaler, the worst of it only lasted a handful of hours before I settled into modest discomfort and sleep.

It is a poor analogy, and I cannot really imagine the feeling of dying from COVID. It did get me thinking, however. What tradeoffs should be made to provide decent palliative care for those COVID patients who are dying?

The standard triage arrangement in hospitals prioritises patients according to the severity of the condition and treats the most severe cases first. If you are waiting to treated for a broken arm and someone is rushed in with myocardial infarction (MI). The MI wins, at least in terms of the immediate allocation of resources. And this will be true, even if the MI patient is highly unlikely to survive. No one dies because of the choice to treat the worst-off first. This is in sharp contrast to battlefield triage (or triage in humanitarian emergencies), where resources are severely limited. The choice to treat the most severe cases will condemn others, who have greater chances of survival, to a needless death. Battlefield triage will put some critical patients beyond care, focusing resources on lives that can be saved.

For many doctors, the COVID pandemic was their first experience of battlefield triage. At its worst, the situation meant there was not enough oxygen, ventilators, personal protective equipment, or staff.

Given two patients who will die without treatment and only enough resources to treat one patient, who should be treated? One patient is over 80 and has multiple co-morbidities; the other patient is under 30 and has no co-morbidities. The patient under 30 would win that lottery for (potentially) live-saving care.

But what of our over-80 patient (Sarah)? Does she warrant any resources? Does she deserve any clinical management and care even though her death is inevitable? Without any healthcare resources, she will die alone, distressed and in discomfort over the next 24 hours. If the situation is particularly dire—as it was during periods of the pandemic when patient waves crashed against the hospitals’ doors—even giving staff time to Sarah will endanger other lives that could be saved.

I am setting up a tradeoff. Tradeoffs have been used extensively to identify people’s preferences for different health states. The classic tradeoff is the time tradeoff (TTO). It is used in clinical research (and patient management) to identify preferences between the length of life and quality of life. The TTO might look something like this.

Imagine you have 10 years of life left with chronic obstructive pulmonary disease (COPD). You could trade those 10 years of life with COPD for fewer years of life in perfect health. How many years of life in perfect health would be equivalent to 10 years with COPD?

If you would not give up any years of life with COPD to live in perfect health, you are saying that you have no preference for a life with COPD over a life in perfect health. They are equivalent with respect to time. The example I give here is bare-bones. Numerous variations of the TTO have been developed to estimate preferences for different health states. Another tradeoff, the person tradeoff (PTO), was created to evaluate the severity of various disease states. The flavour of the PTO is given in the following, and I will stick with COPD for consistency.

Imagine you could choose (A) to extend the lives of 1,000 healthy people by one year, or you could choose (B) to extend the lives of N people with COPD by one year. How many lives of people with COPD would you need to extend for one year to choose B over A?

Suppose you would not tradeoff any lives (that is, 1,000 healthy people living for an extra year is equivalent to 1,000 people with COPD living for an additional year). In that case, you are saying (at least within the calculus of the PTO) that you have no preference for a life with COPD over life in perfect health.

These tradeoffs are all focused on the valuation of years of life. In the TTO it is explicit because you are changing the amount of time that a single life is lived. In the PTO, it is implicit. You are not asked to vary the time of a single life. You are nonetheless trading years of life: 1,000 person-years in perfect health is equivalent to how many person-years with COPD?

The tradeoff I am proposing for palliative care (explicitly terminal care) is somewhat different. In the TTO and the PTO, you are trading things of an equivalent nature—time or person-years. In the scenario of palliative care, you are trading things of different kinds (apples and oranges)—life against a comfortable death.

How many comfortable deaths need to be achieved to forsake a single life? The reality is that a comfortable death need not take a lot of resources away from saving lives, but it will need some. If reallocating resources results in one extra person dying, how many painful, lonely, frightened deaths would need to be made comfortable deaths to make that tradeoff acceptable? I would be prepared to lose lives that could otherwise be saved if it meant that many people whose lives could not be saved were given comfortable deaths. This view is not reflected in many government policies and I suspect that until the tradeoff is made explicit and data gathered, there will be no progress in fair resources for palliative care. It would also be good if voices from the global south were reflected in such considerations

The Leadership a-Gender — 1

After competence, are certitude, charisma and chutzpah the 3-Cs of research leadership?

An image encouraging positive thinking to overcome self-doubt. Just make sure there are no large dogs about.

When Rob Moodie was the CEO of the Victorian Health Promotion Foundation (VicHealth) he started a “conversations in leadership” series for the recipients of VicHealth Public Health Research Fellowships. The idea was to begin an explicit process to develop research leadership in public health, drawing us together to think about the qualities that were necessary.

There were ten of us at the first gathering; two men and eight women. Beyond the fact that it was a meeting for “future leaders”, none of us knew what it was all about. Rob went around the table, asking each of us in turn to introduce ourselves; he also asked how we felt about being identified as a future leader in public health research.

The gender divide was immediately and starkly revealed. When Rob asked Paul (the other man in the room) and me how we felt, we gave suitably immodest responses. I can’t remember our precise answers, but they would have reflected in some way on the appropriate recognition of our talent. Then the first woman spoke. She told, hesitantly, of a gnawing fear that she would be “found out”. Someone, probably sometime very soon, would realise that she was a fraud. She had no right to the VicHealth Fellowship, and she had even less claim on being a leader. Paul and I glanced at each other. Who were we to say that she was wrong? And then there was a visible sigh from the other women in the room. Each one, in turn, expressed an almost identical fear of being found out. This is a well-recognised phenomenon in the gender and leadership literature, described as, “imposter syndrome“: the fear of being found out.

Notwithstanding my bravado or Paul’s, I suspect neither of us felt quite as sure of our place as future leaders as we expressed. I know I didn’t. Nor, however, did I fear being found out in quite the same way the women had expressed. I may have worried a little about whether my performance would be good enough (was I leadership material?), but I did not experience the depth of self-doubt expressed by my colleagues. I had been invited into the room and, therefore, I had a right to be there! They received the same invitation but doubted their right.

An article in the Harvard Business Review on overcoming the feelings of inadequacy associated with imposter syndrome described individual, cognitive behavioural techniques (CBT) to help people manage the sense. If these techniques work, that’s great! The solution, however, reveals at least as much about organisational gender bias as it does about ways to overcome it. Underlying the CBT approach is not simply a view that self-doubt is misplaced, but that there is a deficit in the way a person’s brain works if they have that self-doubt. In other words, to succeed in leadership, you need to think more like me! The obverse problem, having an over-inflated and unrealistic view of one’s own excellence, is often rewarded in organisations, and the sufferer (or more likely the insufferable) is never referred to a Psychologist for therapy “because you’re not thinking right”. Having the 3-Cs of certitude, charisma and chutzpah — typically identified as leadership qualities and never as leadership deficits — means that you are thinking right.

It is worth noting that although the women expressed the fear of being found out, they had all applied for and won highly coveted VicHealth Fellowships, and they were all in that room — even with their doubt.

The researcher, Thomas Chamorro-Premuzic, suggests that many of the 3-C style traits that are traditionally associated with great leaders may in fact be emblematic of leadership weaknesses. Being quieter (a listener), more thoughtful (open to new ideas) and having some self-doubt (seeking out a diversity of expert advice) can be valuable traits in good leadership. These are traits often associated with women who are passed over for leadership positions because they have not yet had their “deficits” corrected.

There are some clearly terrible traits for research leaders to have. Being a bully, mean, harassing staff and being incompetent would be high on that list. In research leadership, raw incompetence would be unusual. The others, sadly, are not. Research organisations need methods for identifying good research leaders that do not fall back on tired tropes, and provide women fair paths of advancements. These are organisational systems issues, not individual deficits to correct. Almost two decades ago, Rob Moodie’s conversations in leadership was a gentle step in that direction: making us all ask the question, what is it to be a great leader? He never said, by I suspect that he hoped we would carry forward some insight into the leadership a-gender.

Conflicts of interest in research leadership (Part II)

(The fond farewell. When enough is enough)

When I started my research career, a research leader’s retirement was a moment to celebrate. Their lives and their contributions were recalled through their research, their papers, their PhD graduates and Postdocs. The Festschrift was often published, literally celebrating their intellectual contribution to a field. Some of those researchers truly retired. Many took honorary appointments that gave them a desk or space in their old laboratory, and access to the library and email. They might mentor junior staff or be a part of a PhD student’s supervisory team. Many continued to do fabulous, original research. Others became the departmental raconteur, recalling embarrassing stories of now senior departmental researchers who were once their postdocs. The retired research leaders were appreciated but no longer had a formal role in the organisational structure.

My experience today with research leaders approaching an age that would, before, have been the time to retire — the time that I am beginning to see on my horizon — is somewhat different. The game now is one of holding back the younger researchers, and hanging on, limpet-like, to substantive position for as long as possible. It is cast as an age discrimination issue. If I am capable, and I am performing at a high level, then my age should not be a barrier to my continued leadership role. Indeed, I have vastly more experience than junior colleagues, and it would be perverse to choose them over me.

While it is true, age need not be a barrier to the capable performance of one’s duties, it is also true that senior positions are rare, and if they are held by an increasingly ageing leadership, how will we train and develop younger cadres of leaders? Turning over leadership refreshes ideas and organisations.

I recall a radio interviewer with a well known Australian clinical researcher. He recounted how, as a junior researcher, his supervisor put him down as the first author on a significant scientific paper — a career launcher. He had not earned the spot, but the supervisor saw his potential and also recognised his capacity to influence the trajectory of a promising career. Without debating the ethics of that particular decision — it was a different time — there is little doubt that the paper launched one of Australia’s great scientific careers. Forty-plus years after those events, I have seen very capable, senior research leaders forsake their leadership role in favour of hanging on to power. They do not surround themselves with bright, eager, up-and-comers. They do not mentor and position their staff to take over. Instead, they retain non-threatening doers, many of whom will not even appear in the acknowledgements of their scientific papers.

In a post I wrote a little over a year ago I observed that in the interests of gender fairness, men had to be prepared to relinquish power. I have a similar view of intergenerational fairness. Those research leaders among us who were born in a twenty-year, golden age between about 1945 and 1965 have been extraordinarily lucky with the opportunities that we have had. In the interests of fairness and, frankly, in the interests of science, we need to know when to step away. We can still be a part of an exciting research agenda; maybe we do not need to be seen to lead it.

Perhaps the last act of truly great research leaders is to step back.

Staff who want to leave

Learning from a member of staff that she wants to leave can feel surprisingly hurtful. It can be particularly upsetting when he wants to stay within the organisation, just not in your unit.

As bosses, we very often spend far more time with our staff than we do with our own family or friends. We invest time and resources in their development. They become a part of our lives and our plans. When they announce their intention to leave, it can feel like rejection.

I thought you liked it here. You can’t leave now, I’ve invested too much in you. Your the only person who can… And finally, “How ungrateful!!!!”

I have been that person who my boss cursed for leaving, and I have been that boss who cursed (silently) the person who wanted to leave. I have also seen colleagues abuse, belittle and try to destroy the careers of staff who want to leave. No surprise really, with a boss like that, that a person wouldn’t want to stay. Pathological behaviour by a boss in one quarter portends pathology in other quarters.

The most relevant advice I ever received about leaving was from Steve Schwartz, former vice-chancellor or Murdoch, Brunel, and Macquarie Universities. “You have to remember, Daniel”, he said, “the person most interested in advancing your career is you.”

And that is the heart of it. As bosses, we do not act solely with the best interests of our staff in mind. Sure, we are not indifferent to their welfare but that is not the raison d’être of the workplace. When we engage them, challenge them, mentor them, and develop them, it is at least in part because we hope to have smarter more engaged and more productive staff in return.

Inevitably, of your good staff, some will stay and some will leave. If your sensible, you were already a part of the discussions about long term career planning and you had plenty of warning– maybe not in detail, but at least in direction. When the time comes and they want to leave, do not curse them (outwardly). Congratulate them on their new opportunity and wish them well. If there is some outstanding work that desperately needs their skills to complete, you may be able to negotiate a better departure date. Do not try and bully them into staying. When staff cannot leave, it is not employment, it is servitude.