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[doctormadeleine]

Scientific Fact or Fake News in the era of the COVID pandemic

Dr Madeleine Muller, East London, South Africa

The COVID19 pandemic has brought about a paradigm shift in how we think about information. For the first time in recent history you can be arrested for creating or spreading fake news.

But as your finger hovers over that forward button, how do you decide whether something is fact or that you may indeed be the bearer of fake news?

In this article I will discuss five levels of truth and give pointers on how to navigate your way through the information jungle out there.

Level one includes the established Scientific facts we all agree on. The earth rotates around the sun, apples always fall to the ground and humans can’t breathe under water. We call these facts, because the same observations have been made by different independent people, in different settings and locations across the world and the observations are always replicable. Much of what we know of the natural world is made up of scientific facts.

Information on level two, I will describe as Evidence based science and is mostly found in areas of scientific innovation. In medicine when we e.g develop new treatments or prevention strategies, we need to gather information about how well that treatment works in a real life situation, its possible adverse events and how best to use it. I won’t cover the different research methodologies, but studies must be large enough, well designed and have been done in diverse populations to give credible results, and most importantly must be able to be replicated. The medical profession has burnt its fingers in the past by accepting early information too quickly. A good example is the initial belief that hormone replacement therapy (HRT) would be protective of women in old age, until the Million Women Study in 2000 discovered that risks go up exponentially after 5-10 years on treatment.

Level three I will call Experimental Science and although in medicine we like to think that we are using evidence based medicine most of the time, in reality a lot of what we use to diagnose and manage patients are still in an phase of being experimental. Experimental science include many hypothesis - either through new discoveries, or through using an understanding of pathophysiology or through initial small studies etc. This is the science where we still find contradictory viewpoints and scientists don’t always agree. We are still exploring and learning, and some of our theories may turn out to be true, and others may be completely false.

Level four is where we it gets interesting. I am gong to call this Narrative news and you will notice I no longer use the word science or fact. Human beings have the remarkable ability to make up stories to make sense of the world around them. This is an essential survival skill if you want to make quick decisions on minimal information. But it also leads to our favourite pass time: jumping to conclusions. It is extraordinary the complicated, rich and very plausible narratives we can come up with to make information fit. The less we know, the more fascinating and juicy the story, and the more likely to get passed on.

We believe the narratives we create, and academics and scientists are not exempt from this tendency, so how do we know that we have inadvertently stumbled on fake news?

Fake news, at level five, is obvious lies, untruths and hoaxes. Either created for malicious purposes or sometimes by extreme ideologists who create narratives to suit their political agendas. These are usually easy to spot by experts and a five minute google search will reassure the average person that it is false.

We have certainly seen all five levels of information spread in the current COVID19 pandemic. Level one is the solid science we all agree on - the virus has been identified and the genome plotted - verified by scientists across the globe.

Level two includes the body of knowledge built up by experts and infectious disease consultants across the world on e.g. the incubation period and route of infection. These observations have been repeated in many populations and agreed on by different clinicians.

But most of what we know about the virus is still level three, experimental science. WE have various hypothesis and small studies that show possible initial treatments and understanding of the pathophysiology of the disease. Chloroquine as a treatment for COIVD19 is a good example. There are studies done with very small numbers, either showing a possible effect, and others showing no benefit at all. These studies and information sharing give scientists a clue on what needs to be included in our larger trials but the actual truth has not yet been established. Although sharing of level 3 information is useful by practitioners who are actively working in the field and can decide what to take forward, it can cause confusion and misunderstanding in the general public.

But level 4 and level 5 seems to have the biggest spread of all. And I think the greatest danger is narrative news: plausible, sensationalist stories that is not based on any data or established facts, and muddies the important messages around treatment and prevention we are trying to get out there.

Let’s get back to that moment when you are about to forward that article, or that link. Spend a bit of time to consider on which of the five levels this is sitting.

Is it fact?

Established, reproducible science?

A new hypothosis?

A really good story or a complete hoax.

If you are struggling to differentiating I would like to give three pointers.

First - establish the credentials of the person writing. A google search should easily establish if this is an expert or an armchair opinion.

Secondly look at what the data set is that the information is based on. Are these drawn from opinions, data, experience, research papers etc. What are the references and follow the trail.

And lastly - if you cannot distinguish which level the information is on, fact check it with an expert in that specific field. I always appreciate being asked by friends and community members to double check information before it is shared.

COVID19 is teaching us many things, including how to appropriately navigate and judge the constant stream of information out there. This is the skill for the 21st century, for us and our children, weighing the level of truth and not taking it all in blindly. We live in an era of too much information, and much of it is fake!

Stay safe, Stay aware, and all the best with your journey in discernment.

Written by Dr Madeleine Muller MBChB.MRCGP.DIPHIVMan

Family Physician, East London, South Africa

References

Chloroquine and hydroxycloroquine: current evidence for their effectiveness in treating COVID19; Frie K & Gbinigie K; Oxford COVID-19 Evidence Service Team; Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences; University of Oxford

Thinking, Fast and Slow. Daniel Kahneman, 2011 (for in depth understanding of narrative bias and “jumping to conclusions.” )

[doctormadeleine]

Setting up Cutting Edge Medical Programs in Rural facilities.

Key Elements for Success: A Case study set in rural Mnquma subdistrict, Eastern Cape

Dr Madeleine Muller, Rural Doctors Association of South Africa(RuDASA)

To watch or listen to this article: https://youtu.be/c5_R3WCQ6PM

To read continue below

South Africa boasts some of the most progressive medical programs in the field of Infectious Diseases, especially in the areas of TB and HIV. But how do we ensure that patients living in rural, resource poor areas have access to this cutting edge, first world medicine?

This is is Dr Madeleine Muller and in this article I will describe how we found that leadership and mentoring were key elements in setting up a sustainable Decentralized Drug Resistant TB site in the Mnquma sub-district in the Eastern Cape. We believe these principles could be applied to any program in a resource poor setting.

Let us set the scene. Mnquma encompasses a beautiful rural area on the Eastern Coast of South Africa. It has a population of 253000 of which only 46000 people are living in the only small town, Butterworth

Although a small town, Butterworth hospital serves not only the rural area of Mnquma but patients coming from surrounding sub-districts as the N2 linking Durban to East London runs right through it. It has to deal with everything from minor ailments and complicated chronic disease programs to major trauma due to road traffic accidents and has a high number of deliveries. As in all rural areas it finds it challenging to attract long term doctors who often prefer to settle in larger urban centers. Capacity is always tight and there are times when doctors at the hospital has to make do with too few hands on deck.

Now lets look at the requirements of running a DRTB program. Drug resistant TB is probably the most complicated Infectious disease program of all our public sector programs. Patients have to be provided with a challenging combination of numerous tablets for 9 months to two years. In South Africa we have the latest drugs available for treating MDR and XDR treatment including Bedaquiline, Clofazamine and Linezolid. This has contributed to our XDRTB treatment success rate reaching 75% in 2018, a phenomenal achievement. But these fancy drugs need to be closely monitored to minimize adverse events and prevent further resistance.

In 2014 DRTB care was decentralised to ensure prompt treatment closer to patients’ homes. Butterworth hospital was one of the first to run a service, but when the experienced doctor left it in 2016 it quickly petered out. In October of 2017 the Mnquma sub-district decided to start again. Several things had to happen!

Firstly we needed a spot from where to run the DRTB clinic. Butterworth Gateway clinic made available a parkhome in their backyard with four rooms, one of which was the storage space for the clinic. The nurses pitched in to clear the space. Some furniture was borrowed from the clinic and others donated by the Aids Healthcare Foundation (AHF).

Then we gathered all your bits you need to operate, such as BP cuff, scale, NG95 masks and disposables for taking blood. Butterworth Gateway helped out and AHF donated hemoglobin meter, scale and glucometer. We also needed a couple of high tech machines. The MDR TB directorate linked us up with an ECG sponsored by Jansen and a Kuduwave through Emoyo.

Thirdly we needed to stock up your latest and greatest medicines and for this we had a lot of support from the local regional TB hospital, which provided us with medicines such as BDQ and trained the pharmacists on procurement processes. The meds are stored in a makeshift plastic drawer set on wheels, which is kept in the gateway clinic pharmacy and is dutifully wheeled out every Thursday for the clinic.

The way we staffed the site is where it became more creative. The local sub-district TB directorate fully embraced this program and it was decided that the clinicians from all the facilities in the Mnquma area would rotate, rather than it just being the responsibility of one hospital. Two nurses from the local clinics rotate each week to help with booking patients, taking blood, doing ECGs and counseling. Doctors and clinical associates from Tafalofefe hospital, Butterworth hospital and the regional TB hospital take turns to provide clinical care. Pharmacists from the local hospitals, as well as CHCs provide pharmaceutical services. The regional TB hospital social worker visits once a month and the local NGO, TB HIV care, has linkage officers that can be used to trace patients.

You cannot run a program without keeping an eye on it. The regional TB hospital eDR nurse experts provided the site with its first patient clinic books, registers and booking book and we were ready to go.

But simply having a building, equipment and staff does not mean you have a sustainable DRTB service. This time we wanted to ensure that the service would keep going and we have discovered two key elements that made all the difference.

Firstly you need one person in the driver seat of your program. With so many different people helping only one day a week you need good coordination. But who should be in charge? A lead nurse? A doctor? The local hospital manager?

We found that our local enthusiastic TB coordinator was willing to take the helm. Well established in the area she ensures that the service happens every week and draws up the roster for the nurses. To support her she has a lead doctor, who draws up a schedule for clinicians and a lead pharmacist, that ensures there is pharmacy support. Without any of these three roles we have run into challenges.

The second key factor is mentoring.

A huge risk to sustainability is the very large turnover of staff and of guidelines. In the past two years we have seen four different transitions of clinicians that have provided services at the Mnquma DRTB. Most new doctors when they start, some of them foreign, have never seen a DRTB patient, or even heard of the new DRTB drugs. Add to that the dramatic changes the DRTB program has undergone as new drugs come out and policies change.

Your quality of your clinical care of the patient depends on a capable physician, so how do you run a program with inexperienced clinicians?

We have found that In the fast paced world of modern medicine it is not necessarily your expert doctor that provides the best care, but rather the clinician willing to ask when they are unsure.

Having access to an available, knowledgeable mentor makes it possible for even the greenest of doctors to give high quality care.

Mentoring can take many shapes and forms. At Butterworth Gateway we have had a monthly mentoring visit from the regional TB hospital including a doctor, social worker and early on pharmacists and nurses. Less frequently there are visits from a DOH quality mentor, a family Phycician DCST and even an Infectious disease Paediatrician. Mentoring includes training each wave of new staff, being available to discuss patients on the review day, usually via whatsapp, and to provide sets of tools and newest guidelines as they come out. When possible we have even arranged for the new doctor to come and spend a day at regional TB hospital for a quick intensive DRTB inservice when they first get started.

Over the past two years Butterworth Gateway DRTB site has provided care for 85 patients, which included 9 children. 49 of those had been transferred in and 36 have been initiated on site! Most patients receive treatment for MDRTB but we have had fifteen stable patients with XDRTB that has collected their treatment. Seven patients had to be referred to the regional TB hospital with complicated disease. And out of the 49 that have an outcome, 42, that is 85.7%, have been successfully treated for their TB! Unfortunately there are patients that are lost to follow up with seven that we have not been able to trace.

The success of this Mnquma DRTB site has certainly been a team effort with over ten different clinicians, over five different pharmacists and close to twenty different nurses providing services. This has all been held together by excellent leadership and dedicated mentoring, creating a sustainable service to our rural patients.

We are often told that DRTB programs fail because “clinicians are not interested” but we have found with good support and access to a dedicated mentor there have always been clinicians in Mnquma that have been willing to be part of the program and have enjoyed providing services to our drug resistant patients!

We believe that building links and networks with local expert and experienced clinicians can help sustain cutting edge medicine in rural areas.

RuDASA is always keen to hear your stories! Do share with us any exciting health care projects you have been involved with your in your area.

Acknowledgements

There are many people to thank for assisting in compiling this overview of the Mnquma DRTB success story. I would like to highlight the following:

Mr Madlavu, ECDOH DRTB Directorate

Mrs Matafeni, Mnquma TB coordinator

Dr Nash, Amathole DCST Family Physician

The doctors, nurses, pharmacists and support staff

that show up every week and do the job!

http://www.rudasa.org.za

[doctormadeleine]

Helping Rural Doctors Thrive in Rural Health care

At the recent Rural Health Conference in Port Edward, RuDASA (Rural Doctors Association of South Africa) has placed Mentoring and Support for clinicians in Rural health care at the core of its strategic plan. Over the next three years we hope to use a combination of online resources and face to face mentoring projects, to help doctors not only survive but THRIVE in rural health settings.

And we are inviting partners and colleagues who are passionate about mentoring and teaching to link up with us.

Let us imagine for a moment, the newly qualified community service doctor at a district hospital in one of our beautiful, but remote rural areas. A hard year lies ahead with long hours, high pressure emergency care scenarios, complicated patients and very basic resources.

How do we help this doctor experience his or her com-serve year as a calling, and not just a post out in the bundus that have to be survived?

How do we retain these young doctors in rural health facilities after their community service year is completed?

Dave Isay, Ted Talk award winner, describes three key aspects that are always present when inspired people talk about their calling.

Firstly, you need to be doing something you are good at. Secondly you need to you believe the work you are doing is making a difference and finally you need to feel appreciated and supported.

Let’s take these three aspects and look at the challenges of a com-serve doctor finding his or her calling in rural health. Imagine our com-serve officer, arriving at a small rural district hospital. Up till now he or she was used to being part of a huge team of consultants, registrars and maybe even some interns, and suddenly he is solely responsible for his own ward and has his own patient load. He may very well feel out of his depth and sometimes downright terrified.

There is enormous potential to make a difference. but the clinician has to feel empowerd to make that difference

And lastly, in a small rural facility doctors often feel themselves to be isolated and lonely. Most district hospitals only have a handful of doctors and everyone is busy and overstretched. There simply is not the capacity to provide the support always needed.

We want to use mentoring to help doctors gain in competence, to empower them to change things for the better and to increase resilience and reduce burnout by offering support and appreciation.

To achieve this our vision consists of two distinct aspects.

Firstly, to grow better doctors they need access to resources and support at the coal face of seeing patients. We have excellent guidelines, textbooks, algorithms, hotlines and WhatsApp groups in South Africa as well as many passionate and supportive mentors, but the young doctor may not know where to find it during a busy OPD session.

We are in the process of gathering together all of the key information a rural doctor may need into one online portal to makes it easy to find the most appropriate information for managing his or her patient.

For key work place scenarios in rural care the doctor can log into the RuDASA membership portal (membership free) and find links to the following:

Relevant and appropriate guidelines for that topic.

Relevant teaching video presentations.

Posters, algorithms and tools.

And most importantly, the contact details of a national or local expert that can provide assistance, be it via phone, WhatsApp, Vula etc. Right there on the spot.

The second part of our vision is creating opportunities for face to face contact with local experts, consultants, mentors or peers. Once a relationship is established between a rural doctor and an expert or mentor, they are much more likely to contact them.

In BCM and the Amathole district in EC, Dr Dave Stead and co from CMH are piloting a Discovery funded project called BAMSI, where a rural doctor will have the opportunity to do a one week structured in-reach at the Cecilia Makiwane Regional hospital. Learning is further augmented with onsite visits from district specialists and local consultants.

For new doctors arriving at the beginning of the year we are proposing an annual Community Service officer meet and greet. This workshop-based program would include practical sessions and also opportunities to meet socially. Local experts and mentors will be invited to pop in to meet the new doctors. Depending on local capacity this could take different shapes.

The gold version would be a five-day com-serve in-service week in January (perhaps funded by an NGO or RTC), but even just a one- or two-day in-service hosted at a local DOH facility is already very valuable.

In the Amathole District we are piloting a Rural Doc Weekend Retreat with a morning CPD session on Resilience in Rural and fun activities. This will be open to rural local doctors, including com serves, to build a support network and create personal linkages.

RuDASA is all about networking and the purpose of this plan is to link our doctors to each other, to experts and to resources.

We are inviting individuals, organizations and businesses who are passionate about supporting rural clinicians to partner with us and to help develop and support some of these initiatives. Rather than reinventing the wheel we want to learn from great stories already happening in rural South Africa.

Contact Dr Madeleine Muller, RuDASA ex-co (Mentoring portfolio) on drmullerbz@gmail.com if mentoring is a passion for you or your organization and you want to link up, or if you would like more information.