News & Features — 10 May 2023 at 9:30 am

Evidence Explorer: Updates and news from the academic community, Spring 2023

Dr Phoebe Dugmore / Emergency Medicine Registrar / Severn

Dr Ruth Warren / Foundation Year 1 / South Yorkshire

Dr Holly Andrews / Anaesthetics CT3 / Evidence Explorer Lead / Peninsula

Kayaking a flooded field on West coast of Scotland

The spring snow has transformed, the bluebells have bloomed and here at Adventure Medic we are packing away the ice tools and cautiously dusting off the summer wetsuit. Whilst the team have been busy across the globe supporting expedition endeavours clinically, the academic community have had an equally as productive transition into summer. We’ve once again seen some really interesting publications both in novel research and case studies and as always there’s been some hard hitting expert commentary on emerging Global Health issues.
This quarter we’ve had collaboration from two budding adventurists – Drs Warren and Dugmore who have been invaluable in the critical appraisal of what is a large body of work from our academic colleagues across the world. Here they present what we think are some of the most pertinent pieces to our practice and interest. From health care reports under a Taliban regime to solar water disinfection advice and evidence based guidance on how to avoid misdiagnosing stroke at high altitude.
We’ve got something for everyone this issue – happy reading!

Dr Phoebe Dugmore

Phoebe is passionate about pre-hospital and emergency medicine. She thrives on challenges and inspires others to push their own boundaries; be that by running ultramarathons or travelling for 3 months around Europe in a van with her partner, 4 month old and a dog! Evidence explorer is her latest challenge and has allowed her to marry her outdoor and pre-hospital interests with cutting edge research.

Dr Ruth Warren

Ruth is a Foundation Year 1 Doctor working in South Yorkshire.  She has travelled extensively whilst visiting family abroad, which exposed her to inequalities across the world from a young age. Her interest in Global Health was sparked during medical school and she decided to study this further through an intercalated Masters in International Development and Public Health. Through this, she was able to conduct research during the COVID-19 pandemic, working with small community in Tanzania, and in partnership with an NGO protecting children living in the slums of Kampala, Uganda. Her ongoing interest in Global Health has led to her involvement in this edition of Evidence Explorer.

Expedition and Wilderness Medicine

Spring ski touring in the Lyngen Alps – sun, snow and ski paradise by Dr Abbey Wrathall

Every expedition medic will be well versed in the nuances of AMS, HACE and HAPE but what about the conditions that we see more commonly in our daily practice across Emergency Departments in the UK that mimic these high altitude conditions? Common things are common is a rule that of course we adapt to our environment but it’s also essential that we don’t miss potentially life threatening diagnoses by focusing on the red herring. Read on to understand more about stroke at high altitude.
Alongside this important article we present WEM’s approach to rebalancing gender equity and their evaluation of solar water disinfection methods alongside an interesting read on the medical implications of TASER devices and a comprehensive teaching paper on non-freezing cold injury.

Stroke at Moderate and High Altitude.
Syed M, Khatri I, Alamgir W, et al. High altitude medicine and Biology. March 2023.

With an improvement in road infrastructure, we’ve seen a rise in the access to high altitude for both recreation and living purposes in recent years. There are a lot more people entering these environments who, due to co-morbidities may not have done in times gone by. This together with normal physiological changes that occur at high altitude means that the incidence of stroke in our expedition population is likely to increase. This article reviews the available literature on the topic and is helpful for those medics working at high altitude to think about stroke as well as HACE. One of the most interesting take-homes from this article is that it highlights that venous sinus thrombosis is actually more common than arterial stroke so keep it in your differentials. Furthermore they discuss that conventional risk factors that must not be forgotten.
Further studies are needed on this topic but it makes for a useful read.

Changing Times and Shifting Priorities: Promoting Gender Equity at Wilderness & Environmental Medicine, Editors note
Binder W, Kenefick R, Rodway G, et al. Wilderness and Environmental Medicine. March 2023.

Most females are aware of the ongoing gender inequities in the medical profession but this editorial gives a real stark picture of the magnitude of the problem. Despite the majority of medical students in the UK in 2022-23 being women there is still a huge gender imbalance, particularly in academic medicine. It is significantly harder for women to get publications which we all know is an important part of many specialty application tick boxes. Women were found to be first authors in less than 25% of WEM articles – this is not ok.
WEM have recognised these frankly shameful gender inequities, releasing a statement with clear steps they are going to take to improve diversity in their editorial board and reviewer pool. So let’s watch this space!

Evaluation of Escherichia coli Inactivation at High Altitudes Using Solar Water Disinfection
Van Hoesen K, Mundo W, Mierau S, et al. Wilderness and Environmental Medicine. March 2023.

Many of our readership who have been on expeditions are familiar with Solar Water Disinfection (SODIS) devices. SODIS is established at lower altitudes (LA) to inactivate most pathogens and is dependent on UV-A and UV-B radiation. This study, conducted in Colorado, focused on trying to determine whether SODIS is also effective at high altitudes (HA). With less atmospheric density at HA, there are greater amounts of UV radiation so they hypothesised that it should be effective. They used E-coli as the model bacterial contaminant and added it to sterile water in 3 different types of container placed at 3 different altitudes with the attempted same weather conditions. After 6 hours they then tested samples from each. Interestingly they found different results to existing literature including time most bacterial inactivation occurs being in the first 2 hours and temperature of the water playing less of a role than previously thought. Plastic bottles were also found to be the best container.
From this study its clear further research is needed but it’s a promising start in informing guidelines and recommendations for safer water drinking policies at HA.

Non-freezing cold injury: A little-known big problem
Tipton M, Eglin C. The Physiology Society. March 2023

This is a really interesting article not only for the expedition medic but also the EM and GP guys amongst us. Most medics and lay people alike have heard of Frostbite but non-freezing cold injury (NFCI) is a bit of an unknown to us all. However it is a lot more common, being a hazard for rough sleepers and the ever increasing cold-water swimmer population, and can cause significant long-term complications for patients.
The editorial aims to give a bit of background on the condition and also highlight the lack of understanding there appears to be surrounding its pathogenesis and pathology. The mechanisms remain unclear – is it primarily vascular, neural or a combination of both? Combine that with the large number of environmental and patient-specific variables to consider and it makes screening, assessment, prevention and treatment of this illness very difficult.
Experimental physiology have released 3 back to back papers examining the condition from both the neural and vascular perspectives which are worth a read to increase our understanding but the clear take-home is that there is very little reliable literature on the topic and a longitudinal study is what is needed.

Annalise Wille from Arizona also presents a succinct presentation of this condition – the ‘screaming barfies’ – in the February edition of Wilderness Medicine Magazine.

The use of TASER devices in UK policing: an update for clinicians following the recent introduction of the TASER 7.
Bleetman A,  Hepper A, Sheridan R. Emergency Medicine Journal. February 2023.

Conducted energy devices (CED) or tasers as they are more colloquially known have been utilised by the UK police force for some time. In order to help control serious and violent situations they are intended to bridge the gap between close quarter options such as batons and irritant sprays and the much more significant lethal firearms. When used correctly, the CED is designed to deliver an electric shock to the individual it’s directed at which will cause pain and ‘neuro-muscular incapacitation’ whereby they fall to the ground. TASER 7 devices are those used most commonly by UK forces now and although highly effective, they do some with some medical consequence.
Thankfully, despite the electrical nature of discharge, arrhythmias are rare but the manufacturers do advise a period of cardiovascular monitoring and an ECG with particular relevance to the pregnant individual. The discharged CED ‘barbs’ invariably cause burns around the skin contact sites and require a specialist technique in order to remove. Injuries from the fall that ensues are also very common and it is essential that all patients receive a thorough primary and secondary survey.
As an event medic or for anyone working in pre-hospital teams alongside the police force this article is a must read. The authors explain great detail about the specific extraction methods to remove the barbs and advice on the monitoring and investigations required for individuals who have been ‘hit’ by a TASER 7 device.

Global Health and Humanitarian Medicine

The ‘Pap of Glencoe’ during a round of the Glencoe horseshoe on a perfect sunny day by Dr Robbie Nielson

Health inequalities are often the driving force for global health research and initiatives. In this quarter’s selection of articles, health inequalities amongst marginalised groups are highlighted and analysed.
The first two articles focus on those faced by poorer groups and of ethnic minorities, highlighting that even in high-income countries, these groups may not even have adequate access to water and sanitation, cascading to a higher risk of non-communicable diseases and poor population health. 
Belizzi et al in our third article advocate for the recognition of another group of vulnerable people – those displaced from their homes and countries by extreme weather due to climate change.
The last three articles are predominantly focussed on conflict, but all individually highlight the detrimental effects of conflict on women’s health.  Whilst the restriction of women is evident in conflict, the empowerment of women emerges through the last two articles as a solution to women’s adverse health outcomes and as a tool for conflict resolution.
Some tough but inspirational reading from acclaimed authors in the field. Read on to find out more.

The effects of racism, social exclusion, and discrimination on achieving universal safe water and sanitation in high-income countries
Brown J, Acey CS, Anthonj C, et al. The Lancet Global Health. April 2023

This article brings to the fore the ongoing inequalities and insecurity surrounding water, sanitation and hygiene (WASH) in high-income countries (HICs). It uses 5 contexts within USA, Europe and Australia where ethnic minority groups have significantly reduced access to water and sanitation. In these regions where lack of resources is not a contributing factor, the article argues that the driving factors for this inequality are racism, social exclusion and discrimination.  The proposed mechanisms of this include segregation; inadequate housing; property ownership rates; and lack of funding in areas heavily populated by marginalised groups compared to other regions. This has also been worsened by privatisation which brings the expectation that access to WASH is based upon individual effort and income rather than a responsibility of society to provide it as a human right for all.
This article stands out from other literature surrounding WASH where the focus is usually on low-income countries. One could argue that it is often assumed that HICs have met international WASH standards on a whole population level. This article highlights that although national statistics can achieve these standards, the disaggregated data for marginalised communities may not. These communities are often a small group and more likely to be excluded from data. Further disaggregation of national data could allow for recognition of these inequalities and therefore improve allocation of resources. The article also calls for a collective responsibility to change the wider social issues of racism and discrimination in order to tackle the WASH inequalities in HICs.
It seems that WASH inequalities may be closer to home than we realise and there is certainly a need to investigate this issue within the UK.

Risk, lifestyle and non-communicable diseases of poverty
Manderson L, Jewett S. Globalization and Health. 02 March 2023

The theme of inequalities being masked by national data continues with this commentary, which discusses how non-communicable diseases (NCDs) are most prevalent in the poorest communities. Although national data suggests that NCDs are less prevalent in the lowest-income countries compared to middle and higher income countries, it is consistently the poorest communities within these countries that have the highest rates of NCDs. In countries with high rates of wealth inequality e.g. South Africa national statistics often do not reflect the NCD prevalence in these poorer groups.  The commentary also highlights the discrepancy between genders in NCD prevalence which varies across cultural contexts and suggests an element of cultural influence rather than purely biological causes.
Similar to the previous article, there is a call for the discourse focus to shift from individual efforts to wider societal efforts in reducing NCD prevalence. As poverty is so closely linked to NCD prevalence, it suggests that wider determinants of health play a crucial role in this. However, NCD prevention campaigns and policies tend to focus on individual “lifestyle choices” rather than recognising the external factors which contribute to obesogenic environments that impact poorest groups most. It argues that those in poverty lack choice and agency in their health behaviours due to financial constraints and lack of local security. Furthermore, those in poverty are more likely to suffer from infectious disease, injury/trauma and worse maternal/child health outcomes. With the addition of higher NCD prevalence and morbidity, poorer communities face the “quadruple burden of disease”.
This article suggests the use of the term “non-communicable diseases of poverty” (NCDP) when addressing NCDs to highlight the importance that societal factors play and to shift attention away from individual efforts. It also calls for a wider systems approach with disaggregated data to recognise and tackle NCD prevalence effectively.

Global health, climate change and migration: The need for recognition of “climate refugees”
Bellizzi S, Popescu C, Napodano CMP, et al. Journal of Global Health. March 2023

This is a quick and interesting viewpoint. It addresses the rising issue of displacement of people from their countries due to extreme weather attributed to climate change. The majority of affected people are from regions within lower-income countries who must migrate elsewhere for safety. However, the main contributors to climate change are within high-income countries, further widening inequalities between different economically developed countries. These displaced groups do not always fall under definitions of “refugee” or “asylum seeker” which require a person to be fleeing from persecution. They are therefore not always entitled to the same benefits and legal protection as other refugees, despite facing mental and physical health needs directly linked to their environmental exposure and migration.
The United Nations Environment Programme (UNEP) has been using the term “climate refugees” since 1985 and the United Nations Human Rights Council (UNHRC) has broadened its protection to account for these groups as well. The article gives encouraging examples of various countries such as Argentina, Finland and Australia who have taken proactive approaches to protect climate refugees.
However, the article stresses that further recognition of climate refugees as a group of vulnerable people is required, especially as increasing numbers of people will be displaced due to weather-related disasters over time. Inclusion of this group within policies should be done to give adequate legal protection. Furthermore, projects working to mitigate the risks of extreme weather and displacement are becoming increasingly important in helping these vulnerable populations and reducing their health burden.
This article reminds us of the importance of environmentally sustainable practice and its knock-on effects on global health inequalities. It also emphasises the responsibility upon the Global North to protect these victims of weather-related disasters given its large contribution to climate change.  

Afghanistan’s healthcare under Taliban: what are the challenges?
Arif S, Rezaie KF, Madadi S, et al. Medicine, Conflict and Survival. February 2023

Afghanistan was at the forefront of news media in Summer 2021 due to the takeover by the Taliban.  This article discusses the key impacts on health that the rise of the Taliban has had and the need for international aid and funding to combat these severe issues.
Afghanistan has had high poverty and child mortality rates noted since 2002, and these have worsened in some areas since then.  It had become dependent upon international funding for various projects to strengthen the health system such as the Sehatmandi Project.  However, since 2021, much of Afghanistan’s international funding has been withdrawn. Alongside this, a lack of equipment, staffing and resources due to border controls and insecurity has compounded the failure of health services. This has led to the near collapse of the healthcare system with more than 90% of health facilities closing down and many having to travel more than 10km to access healthcare.
Women and children are depicted as particularly vulnerable during this conflict. Under the new authorities, women’s movement is more restricted and they require male chaperones which can inhibit their access to healthcare. Furthermore, more women are being forced into early marriages due to financial desperation within their families, leading to poorer maternal and child health outcomes as a result of early pregnancy.  Malnutrition is highly prevalent, affecting children the worst and making them more vulnerable to other diseases. COVID-19 has been an additional burden with inadequate resources to test and treat this disease.
This article makes the case for increased international aid to Afghanistan given the drastic health consequences of the current conflict and the withdrawal of major international donor funding of the healthcare system. It also links with the following articles regarding women in conflict and demonstrates how conflict can disproportionately affect women and act as a barrier to their engagement with health services and leadership.

FAWM accredited EM physician, Dr Terri Davis describes her role in Camp Buehring in Kuwait where she oversaw the treatment and care for Afghan refugees fleeing their country after the fall of Kabul.
Wilderness Medicine Magazine Sept 2022.

Strengthening health systems and peace building through women’s leadership: a qualitative study
Meagher K, Khaity M, Hafez S, et al. Globalization and Health. March 2023

This is interesting research that discusses the links between women’s empowerment, health systems and resolving conflict. Healthcare has been a powerful tool for peace-building, as it is valued and a common goal regardless of political stance.  Furthermore, there is a need for humanitarian projects within conflict to have a longer-term focus so that they align better with developmental goals.  This is increasingly important as conflicts become more protracted and complex, with Afghanistan as an example. A systems approach has therefore been suggested to improve long-term outcomes within conflict settings with leadership being a core element of this.  In addition, women are often worse affected by conflict due to gender-based violence and political agendas that restrict women’s freedom.
This study involved key informant interviews and 2 focus group discussions involving participants from a range of contexts affected by conflict. From the themes and codes generated, it became evident that women can be influential in peace-building initiatives with longer-lasting effects and higher rates of implementation.  As women are often viewed as non-threatening, they can be used to move more freely amongst different groups and are more likely to be trusted. As health system improvement can be a useful peace-building tool, this article suggests that the involvement of women in leadership within healthcare systems may combine the powerful effects of both approaches to resolve conflict. However, it also emerged that conflict can be a significant barrier to women’s empowerment and engagement in leadership, making this difficult to implement.  It suggests a feminist approach may be required to tackle the double burden of conflict and patriarchal oppression many women face in conflict.
Although it is not clear how to overcome the barriers that conflict brings in empowering women, this article does provide some practical points for peace-building projects.  Lederach’s framework of leadership (proposed by a professor of international peacekeeping) was used and adjusted to include specific areas at each level where women could be encouraged to participate within health systems.  This framework may be a useful reference point for peace-building frameworks and participation of women in leadership going forward.

Women’s sexual and reproductive health in war and conflict: are we seeing the full picture?
Hedström J, Herder T. Global Health Action. March 2023

This final article again highlights the vulnerability of women within conflict. Women’s sexual and reproductive health (SHRH) is significantly worse during conflict. However, much of the literature surrounding this issue focuses on structural factors such as poverty, malnutrition, lack of infrastructure, and poor water and sanitation facilities as the drivers of this issue.  This article suggests that insufficient attention has been paid to the cultural factors which harm women’s SHRH. Examples of this include forced marriage, forced retirement, control over contraception and gender-based violence.  In some conflicts, these factors are intentionally used as part of military tactics.
These factors also vary significantly across different contexts and over time.  Therefore, this article argues that approaches to women’s SHRH must be flexible and dynamic over time instead of using blanket approaches. A feminist approach is proposed to fully understand the root causes and extent of poor SHRH for women. To implement this approach, it suggests enhanced engagement of women from conflict and post-conflict zones in interviews and discussions on the impact of conflict on their SHRH.  However, it also mentions that poor reproductive health can impede women’s participation in decision-making and peace-building.
Despite this, the need for engagement of women in projects working to improve SHRH and peace-building in conflict zones has again been emphasised and future projects should consider the importance of engaging women throughout the process wherever possible..  Through this, there may be a solution to overcoming the cycle of poor health outcomes and disempowerment of women often seen in conflict.


As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.