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cover of episode "Incredibly distressing and incredibly dangerous"- David Miliband on healthcare attacks, and staff turnover effect on patient outcomes

"Incredibly distressing and incredibly dangerous"- David Miliband on healthcare attacks, and staff turnover effect on patient outcomes

2024/12/4
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Medicine and Science from The BMJ

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Giuseppe Moscelli
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David Miliband: 我认为国际救援委员会(IRC)的使命是应对全球日益严峻的健康挑战。我们组织由爱因斯坦创立,旨在帮助人们逃离纳粹统治,现在我们的工作范围涵盖了冲突和灾难等各种危机。健康是我们工作的重要组成部分,约占国际工作的40%。我们独特之处在于我们非常重视研究和创新,通过实地工作和智囊团,我们努力寻找最具成本效益的解决方案。我认为仅仅宣传苦难是无济于事的,寻找解决方案才是充满希望的。我们不仅帮助人们生存,还努力帮助他们发展,在营养不良、免疫、孕产妇健康、暴力侵害妇女、教育和生计等领域都开展了工作。我特别关注针对医疗保健和医务人员的袭击,这在冲突地区已成为一种日益普遍的现象。我认为我们不需要发明一套新的规则,而是需要遵守现有的规则,尽管联合国安理会需要改革。我也意识到,西方国家未能履行承诺时,也会造成损害和影响力丧失,因此我们也要整顿好自己的内部事务。对于即将到来的特朗普政府,我预计可能会对性健康和生殖健康方面的资金和行动采取限制措施,并大幅减少难民安置计划中允许进入该国的难民人数。我们将认真对待并从字面上理解所说的话,并呼吁更广泛的捐助者群体来支持我们的工作。

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David Miliband, president and CEO of the International Rescue Committee (IRC), discusses the organization's work in conflict zones, focusing on healthcare. He highlights the IRC's unique research and innovation, its response to attacks on healthcare workers, and the challenges posed by geopolitical factors, including the Trump administration's policies.
  • IRC's history and focus on health in emergency situations
  • The IRC's unique approach to research and innovation
  • Challenges posed by attacks on healthcare workers and geopolitical factors
  • Impact of Trump administration's policies on IRC's work

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Welcome to Medicine and Science from the BMJ. I'm Cameron Abassi.

In today's episode we'll hear about some new research which has looked at the impact staff turnover is having on patient outcomes. So like in this respect there is much more scope for nurses to play a bigger role and have being quantitatively more impactful to the patient health than perhaps doctors themselves.

But first, every year the BMJ has a Christmas appeal and this year we've chosen the International Rescue Committee as our partner. In our last couple of podcasts, we've been focusing on the impact conflict is having on healthcare and that's where the Rescue Committee has its focus.

To talk more about what they do and to give us some insight into how geopolitics is affecting health, I spoke to David Miliband, President and Chief Executive Officer of the International Rescue Committee and former UK Foreign Secretary. Probably like most people, I first heard of the International Rescue Committee when you became its president. So could you tell us a little bit about the organisation and what it does?

Yeah, one of my jobs was to raise the profile, so at least I can claim to have had some success in that. Look, the organization, and this is one reason I thought it was attractive when I joined 11 years ago, it's got this extraordinary history. It was founded by Albert Einstein, who was a refugee in New York in the 1930s. And so Einstein, along with 50 of his friends, created the Emergency Rescue Committee. It became the International Rescue Committee.

to help get people out of Nazi-occupied Europe. And our first employee worked in Marseille in Nazi-occupied France. He issued fake passports to 2,000 people. People like Marc Chagall, the painter, escaped from, effectively, the alternative was Nazi death camps, thanks to the IRC. So there's this extraordinary history. We span what we call the arc of crisis. And we're trying to rescue people from poverty and from vulnerability and from danger...

With the cause being the conflict and disaster that is sadly growing in our flammable world. And health is a very important part of the work we do. About 40% of our international work is in the health field because obviously health is a basic human need. And in emergency situations, it's especially compromised. So how does IRC fit in that space? And what do you do that's different?

Yeah, that's a good question. And there are two parts to the answer. First of all, we're unique because of the focus that we put on research and innovation alongside 20,000 people working around the world in 330 field sites. We've got this brains trust element that I think is genuinely unique, 30% of all impact evaluations. We've done 400 cost effectiveness and cost efficiency studies. No one else is in that kind of space.

So there are aspects that make the organization unique. On the other hand, we're not monopoly providers at all. We're in a very, we're working very complex places where there are a range of players. And the good news is that although it's confusing at a global level, UN, ICRC, which is a multilateral legally established organization originally for

Prisoners of War, International Committee on the Red Cross, then other so-called sister NGOs, Save the Children, etc. Although it's complex at a global level, at local level, we actually work pretty closely together. And I've been quite pleased by that. You don't get three different NGOs turning up in the same African village to deliver the same program. I mean, there's quite good sectoral arrangements, but the sector as a whole really needs reform. And the big problem, the one reason it's so complex is

is the different government donors don't actually align their activities in a very coherent way. And so that leads to inefficiency and also it leads to politics. I mean, we're going to get a big, big change with the Trump administration coming in. They're going to bring big changes. Yeah. Well, I hope we get a chance to talk about that. The other thing you mentioned was about the research, which I think, again, will be news to quite a lot of people.

in those conflict settings and in refugee settings is notoriously very difficult to do. How do you... That's just an excuse. I mean, that was the excuse that's used for years. People used to say, well, because it's matters of life and death, we can't do impact evaluations. Our position is, because it's a matter of life and death, you must do it. And on malnutrition, on violence against women, on...

immunization on maternal health. We've really been proud to say randomized control trials, impact evaluations, you can do them actually. Now, you've got to be ethically careful. We're not going to deny people food as a way of testing what happens if people are hungry. But you can do serious work. We've just done a very interesting randomized control trial in northern Nigeria, conflict

ridden part of northern Nigeria. One side of a valley, give cash distribution to farmers before the flood hits. Okay. Because you can use predictive analytics to... No. The other side of the valley, give it afterwards and then compare the results. I mean, that's ethically sound. And I think that this...

focus on impact and evidence. Your listeners and viewers and readers can go on to the, if they type in IRC outcomes and evidence framework, they'll see our outcomes framework, which has 17 sub-outcomes, five meta-level outcomes. But then we'll see in there what the evidence base is and where the evidence base is lacking. And I think that's really important. But we want to be able to say to our donors that,

We're investing in programs that either we know work or we're testing whether they work. And secondly, we've done the cost effectiveness, cost efficiency studies as well to make sure that we're using the money well. Now, obviously, research, I mean, that covers a lot of things. We talk about impact evaluations and we talk about innovation. And we have a very disciplined approach to innovation as well because that's another side of the equation.

Okay. Well, if anybody ever says that to me again, that it's hard to do, I'm going to refer them back to this conversation. So on that basis, with that approach, where are you particularly active at the moment in terms of your organization?

Well, we're guided by what we call our emergency watch list. This is an annual study. I've got it here. We're publishing the next one on December 11th, which will look at 2025. This has the 20 countries of greatest humanitarian need. And it's not a straight jacket for us, but it's a good way of answering your question. Top of our emergency watch list is Sudan. Why? Because there are 26 million people in humanitarian need in that.

11 million people displaced by conflict. One and a half million have fled to countries like South Sudan and Chad, which themselves are incredibly poor countries. And so Sudan is very high. Gaza, very significant effort there. We work with medical aid for the Palestinians on 13 emergency medical teams have been working in hospitals in Gaza. We have nutrition teams. We have child protection teams. We have local partners there.

Very difficult, dangerous situation. Huge humanitarian need among 2 million people there and obviously still 100 hostages plus there. South Sudan, I mentioned Burkina Faso and Mali in West Africa, very significant conflict there.

Myanmar, probably not on most people's radar, but a growing conflict there. Somalia, I mentioned. Those are the kind of places that are top of our watch list. A lot of those countries you mentioned are very rarely discussed, if ever, in the media. I mean, Sudan is discussed, but not in proportion with the impact that the conflict is having.

How can we address that? Because there are these big conflicts that we never talk about. Well, if I knew the answer to that, I don't know. If I knew the answer to that, I'd be a rich man. I mean, look, I think we've got to realise there's two or three aspects to this. One is that there's more conflict and disaster, this sense of a flammable world. I think itself...

has an aversive response or produces an aversive response from people because it just seems overwhelming. So the first problem is how do you make the problems a bit more granular and a bit more manageable? That's why I think this watch list is important. If you say to people, 300 million people in humanitarian need, they think, oh my God, that's like climbing Mount Everest. If you say there are 20 countries where more than 70% of the people in humanitarian need are located, you can sort of say, okay, I can begin to get a fix on that.

I think in the end, just advertising the suffering is hopeless. Going for the solutions is hopeful. And what I can say, for anyone who...

of the IRC, they'll be confronted with, well, if you care about malnutrition, this is what we do. If you care about immunisation, this is what you do. If you care about maternal health, this is what we do. If you care about violence against women, this is what we do. If you care about education and interrupted education or adult conflict, this is what we do. If you care about the livelihoods, we work...

not just to help people survive, we try and help them thrive. If you care about livelihoods, this is what we do on small-scale credit unions. This is what we do on small business formation. And I think breaking this sense of disempowerment, you speak to people's search for agency. Yeah. Okay, well, let's talk about other solutions that, unfortunately, that aren't working. Because if we take Gaza...

And one of the issues that matters a lot to our readers and listeners is attacks, not just in Gaza, but elsewhere, Sudan and Ukraine and all the other conflicts that you mentioned. The attacks on health care, on health professionals and civilians. And we have humanitarian laws. We have Geneva Conventions. But it seems that these attacks continue to increase.

And we're kind of helpless. We don't have agency to stop them or to limit the behaviors of certain countries that are behaving in this way. How do we fix that? Nothing seems to make a difference. There's a relentless onslaught on health care and health professionals. This is incredibly distressing and incredibly dangerous. I...

We had two IRC health workers driving an ambulance in northwest Syria in 2016, and they were hit by a Russian missile that targeted their ambulance and killed those two people. And it really woke me up to this march of impunity in conflict zones. And I started writing quite a lot about it.

I chair the advisory board of something called the Atlas of Impunity, which ranks every country in the world on five dimensions of impunity. And I think you're right. And the attacks on health care is increasingly a sort of feature of the conflict zones that we work in, whether in Gaza or in Sudan or in Ethiopia or in Ukraine. Civilian infrastructure is becoming increasingly

part of the battle space. Australia sponsored in the 2019 or 2020 a UN Security Council resolution specifically about protecting aid workers and health workers, but it's been obeyed in the breach rather than the observance. And

I think this march is incredibly dangerous. And I don't want to offer a sort of happy talk to your listeners that says that there's an easy solution out there, because at the moment, there is more impunity than there is sanction on impunity. Yeah, but I think we're saying that the world order hasn't done its job. It's failed. Do we need a new world order? Because the countries you're talking about,

they're not actually following the international rules. And if there's a Security Council motion, sorry, they're not abiding by it. Well, I mean, in the case of Russia and Ukraine, obviously, it flouted the most basic aspect by invading its neighbour. But the...

The way I put it is slightly differently. I don't think we need to invent a new set of rules. We need to live by the rules that have been established, because actually the rules were pretty good. Now, the institutions, I don't want to be misunderstood, I'm not saying that the UN Security Council doesn't need reform. It reflects a distribution of economic and political power from 80 years ago, which obviously the UK benefits from, but which is...

is increasingly divorced from the reality of where economic and political power lies around the world. But I think if you start rewriting the rules, whether about war or refugees or human rights, they're going to get worse. What we should be doing is trying to hold accountable...

living up to those rules. Okay. So there are two thing points I want to pick up there. The first one is around the global majority countries, parts of the world. I mean, clearly, there is the sense, as you're saying, I think it's clear, that the current world order is dominated by Western, Northern, richer powers. How do we re-engineer... Just be careful. The formal institutions of global order...

on paper, are dominated by those nations. But the lived reality of global disorder is not run by those nations. Because the truth is that in the Middle East, the United States is not the biggest player by a long chalk. Yeah. But the US still, if it doesn't, you know, put pressure on Israel, for example, I mean, it seems like nobody else is able to. Yeah, but my point is that you've got

an Israeli politics that makes its own decisions. You've got a Saudi Arabian politics that's making its own decisions. You've got a Qatari politics that is making its own decisions. You've got Turkish politics that's making its own decisions. You've got an Iranian politics that's making its own decisions. You could make the argument

that those five countries are more important than any other countries outside the region. You can argue about it, and obviously the US, I'm not trying to say in the US, is still an important player, but my point is that you've got these formal institutions that are meant to be keeping order, but actually the lived reality of

disorder is not dominated by those. Anyway, we're into high geopolitics, we're a long way away from healthcare. Well, but it impacts on health. I mean, David, because ultimately, you'll agree, unless we change this dynamic, people are still going to be killed, hospitals are going to be bombed, healthcare professionals are going to be killed. So, it seems we've got to a stage where we've gone through the mechanisms, but as you're saying, they're not being implemented, they're not being enforced. Well, there's one other thing, though, which is that the greatest damage

Oh, that's the wrong way of putting it. A serious source of damage and loss of leverage is when Western states that have commitments don't live up to them. And I think getting our own house in order is important as well. Yeah, no, very good point. And then that brings us on to Donald Trump. I mean, clearly...

His election is going to have an impact on global health, on the work that you do in crisis settings. What are you expecting to change or how are you expecting to change to kind of adapt to the new reality? Well, the first thing to say is obviously one has to look at actions, not just words, but words are indicative. It seems, let me take two things that seem highly likely to happen.

One is that the first Trump administration issued in its first day sweeping restrictions on funding and action around sexual and reproductive health in developing countries funded by the US government. We know that a majority of our clients are women and girls, that sexual and reproductive health services are unbelievably important, absolutely fundamental to life.

And we're bracing ourselves for that change to be real.

repeated and we're very fearful of the real-life consequences. I mean, that example I gave you earlier about the program for unintended teenage pregnancies and reducing the death rate by 30 percent, we're really fearful about that. Of course. We also know that President Trump in his first term severely reduced from about 90,000 to 12,000 the number of refugees being allowed into the country under the refugee resettlement program.

the commitments or comments so far suggest that is also likely to be on the chopping block. So I would say that there's real need to not to leap into a rhetorical to and fro, but on the other hand, take seriously and take literally what's said. And we appealed in 2017, just on the first example, to

a wider donor base to support our sexual and reproductive health programming. And we'll do that again. And the success of your appeal, I don't want to say the success of the BMJ Christmas Appeal is everything, but the BMJ Christmas Appeal funds things like sexual and reproductive health in emergency situations.

Yeah. Can we talk a little bit more about that? Because that's the question I did want to come to. If our readers and listeners donate to this appeal that we have running with you, we're delighted that we're working with you on this. What impact might their donations have, David? Well, obviously, it partly depends how long you've been to string. So the bigger, the better. I mean, I don't want to beat about the bush. Yeah.

Flexible money is very rare. I mean, of our $1.5 billion budget, only $300 million is flexible money. And of that, we have to spend $45 million on our IT systems, because otherwise you can't run yourself. So there's a lot of pressure. But what the money will go into is our most impactful, most cost-effective programs.

Those are programs around malnutrition, around immunization, around sexual and reproductive health, around economic empowerment. And I mention those because we're about survival, helping people survive and to thrive. And obviously, if we can spend another pound or 10 pounds or 100 pounds or 1,000 pounds or a million pounds or 10 million pounds, there's a bias towards the survival elements of our work, which health is 40%, as I said, 43% of our work.

Economic empowerment about 15%, education about 15%, child protection and women's protection about 15%. And so what we promise is that the money goes to the most impactful aspects of our work, and that's really important to us, and we're very...

keen to build our, the understanding, but also the donor base because we need to diversify. Okay. David, thank you very much. It's been really great to spare the time. Thank you. Great. And look forward to your podcast yielding great results. You've heard from David about the work the IRC is doing, and I think it's clear why we've chosen them as this year's appeal partner. If you're moved to donate, we've added links to the podcast notes.

Now, it wouldn't be the Medicine and Science podcast from the BMJ without some science. And this week, the BMJ has published a new retrospective longitudinal study looking at staff turnover and patient outcomes, including death, in England. Navjot Lada, the BMJ's UK research editor, finds out more. ♪

And so I'm Dr. Giuseppe Moscelli, I'm an economist and I'm an associate professor at the University of Surrey. Why are we interested in studying turnover specifically? Because obviously there have been studies of staffing levels previously. What was it about this specific question that interested you? That's a very good question, Avjot. I think that, so my interest is about, the problem is that lately it's very difficult to understand

to get workers, especially in making sure that we have the necessary staffing levels in the NHS or even in other healthcare systems just for the global shortages of healthcare workers that you see. But one of the solutions to this, well, a partial solution is making sure not to lose work.

So, the economics of retention is something that is increasing attention worldwide. And of course, the problem is that previous research has shown clear associations or effects of staffing levels. And that's the reason, for example, why safety ratios have been introduced in some countries for nurses.

But at the same time, it's important to understand that it's not only about the staffing levels, it's about the continuity of care of the healthcare workers within their job, making sure that this continuity of care is not disrupted. This generates value for both the workers and the patients.

Yeah, no, you're right. Staffing levels, I guess, is a very broad kind of term. And within that, there'll be so many facets that are behind the staffing levels. So it's really interesting to read your paper and to kind of see this association. Can you tell us a little bit, because I can't imagine it's the easiest thing to study. So how did you go about designing the study and deciding how you would...

what you would look at and how you would kind of study this further. Absolutely. So the first, the very first thing that one has to make sure in this case is making sure that like we are really measuring the association between turnover and the patient outcomes and not that we are actually mixing apples with pears in terms of like, you know,

having too many confounding factors. So that's the reason why our study actually compares hospital with itself over time. The hospital is a control for itself, essentially. So you're controlling for all those, you know, many other variables, as you say, that can go into quality. Let's talk a bit about the risk measure. How did you measure turnover?

So turnover is measured as the number of people that have quit the organization, a given hospital, NHS Hospital Trust, in a given month. But the idea is that turnover

behind the model is that for the hospital, it's bad for losing workers no matter what, whether they are lost to the NHS or whether they are lost to other competitor hospitals. Yeah, no, that makes sense. I think we'll all be, you know, there'll be interest in, okay, are these people leaving or are they people who are just moving on? But as you say, for the hospital and for the patients in the hospital. And for the patients. Yeah, the net effect is the same. And then,

Tell us a little bit about why you chose the outcomes that you did. There are clearly different choices that could have been done. Based on the data that we have available, we don't have such detailed data about patient satisfaction or other patient health gains for all patients.

admissions. We have only for a very few ones and they are subject to reporting bias. So the problem was like we wanted to some kind of to measure an outcome where we could really standardize the measure of outcome in order to anesthetize the fact that there are

in the pools of patients. And so we had to risk adjust it in order to make it sure that we could compare the performance of different hospitals and also of the same hospitals over time because the pool of patients might be time varying within the same hospitals.

Yeah. So as you say, 30-day mortality is one of those kind of classic quality outcomes for all of those reasons. The hospital episode statistics data that are available from English Hospital allows actually to capture both mortality and at the same time, all the patient characteristics like age, gender, comorbidities that allow to do this. Unfortunately, other outcomes don't allow it.

Yeah. As you say, there is that tension there, isn't there? Because I'm sure there'll be so many aspects of this turnover question that will be interesting. You know, the other dimensions in which it affects care, but then also you want to weigh that against being able to have this routinely collected, robust data set. I remember having very similar conversations about 30-day mortality as an outcome when we

There was lots of discussion maybe 10 or so years ago about seven-day working and weekend working for staff as well. And there was a lot of conversation about, well, is 30-day mortality the best outcome? And I think, as you say, maybe it's the best that we've got for those purposes that we

Although I would, as an economist, I would also think about, you know, if the patient had to choose between being treated a bit hastily, like being treated a bit roughly, but making out of the hospital alive, and actually the opposite, then they would probably...

prefer making it out of the hospital alive rather than... So I think that there is some... It is reasonable to also think that mortality is a reasonable outcome to use in this case. Absolutely, yeah. Let's move on from the methods then and to your results.

Yes, what we find is that when the turnover rate increases by one standard deviation in turnover of nurses is associated with 35 more deaths over 100,000 patients admitted to hospital. When it comes to doctors, it is...

increase in the number of doctors leaving in turnover rate is associated with 14 additional

additional deaths every 100,000 patients admitted to hospital. This is driven by emergency patients. So it's like what we find is that the thing that seems to be very sensitive to that is the mortality risk for patients that have been admitted to emergency, which is something that is reasonable to think about, to expect, because these are the patients that are more vulnerable

more for which the marginal changes in quality and in the workforce might matter more. So there's this association for both professional groups, but more so for nurses. Why do you think that is?

Well, that's a good question. I would say that there are two reasons for this. One is that quantity matters, size matters, and we know that nurses are a big share of the workforce. So definitely there is more variation there.

And so like the fact that there is a turnover of nurses might be very important quantity wise because they are the relative, the biggest group of oil care professional within the hospital. The other one is about the criticality of nurses, like the of nurses jobs. It's possible that in terms of

of the way that hospital operates. It's doctors will always try to expose as much as possible to do the best operations that they can. But then it boils down to all the care surrounding the patients in the preoperative and postoperative phases. And this is a trusted in narcissists. So like in this,

In this respect, there is much more scope for nurses to play a bigger role and being quantitatively more impactful to the patient health than perhaps doctors themselves. Very interesting. And so, I mean, taking all this together, I mean, Giuseppe, you're an economist, you study this in detail. What would be your message to people who are able to

control, you know, the management, policy makers. What's the big takeaway from your research? The big takeaway is that turnover matters and retention matters. The good news is that it is possible to reduce turnover. Yeah. And I mean, that's the thing, isn't it? There'll inevitably be some turnover, but maybe it's working out better.

Which ones were preventable or avoidable? Exactly. I would say so. We cannot eradicate turnover. It would be detrimental probably even for patient's health, but we definitely want to curb it down to a level that it is physiological, not harmful to the patient. What can realistically, do you think, be done to improve...

to improve retention? Are there any easy answers here? I guess not. I would say not, but actually we have other research having some results. So in one of the published papers from this stream of work, we actually show that, for example, engagement of nurses is paramount for their retention. So making their job interesting and recognized is very important because there are a lot of factors

that luckily are captured, for example, by NHS staff surveys and actually are very related and associated with the engagement. So having the workforce engaged, the nursing workforce engaged, plays a big role to increase their retention. The other interesting thing that we found in this other study is that the retention of nurses play a big role in the retention, seems to play a big role in the retention of doctors.

And this is something that shouldn't be surprising because nurses are kind of an input for doctors. They alleviated the ease and the burden to their workload. Thank you so much for joining us. Thank you. Thank you very much for this invitation. It was delightful. Thank you.

And that research is now available, open access, on bmj.com. That's it for this week's episode. We'll be back next week with a focus on food and health. Until then, I'm Cameron Abassi. Thanks for listening.