Health Inequality

I read an article this week on health inequality. Health inequalities are essentially differences in the status of people’s health, but can also be the differences in care that people receive and the opportunities that they have to live a healthy life. Health inequalities can, therefore, involve differences in:

  • Health status (e.g. life expectancy and prevalence of health conditions).
  • Access to care (e.g. availability of treatments).
  • Quality and experience of care (e.g. levels of patient satisfaction).
  • Behavioural risks to health (e.g. smoking rate).
  • Wider determinants of health (e.g. quality of housing).

You can loosely group the differences in health to groups of people. In England, health inequalities are often analysed and addressed by policy across four factors:

  • Socio-economic factors (e.g. income).
  • Geography (e.g. region or whether urban or rural).
  • Specific characteristics including those protected in law (e.g. sex, ethnicity or disability).
  • Socially excluded groups (e.g. people experiencing homelessness).

Looking first at life expectancy, which is a key measure of a population’s health status, we see that it is closely related to people’s socio-economic circumstances. The index of multiple deprivation is a way of summarising how deprived people are within an area, based on a set of factors that includes their levels of income, employment, education and local levels of crime. In England, there is a systematic relationship between deprivation and life expectancy, known as the social gradient in health. Males living in the least deprived areas can, at birth, expect to live 9.4 years longer than males in the most deprived areas. For females, this gap is 7.4 years. This relationship has become known as ‘the Marmot curve’ because of its prominence in Sir Michael Marmot’s report ‘Fair society, healthy lives’.

Figure 1 inequalities in male life expectancy and disability-free life expectancy

Inequalities in female life expectancy and disability-free life expectancy

In recent years, in addition to growth in life expectancy stalling in the population as a whole, inequalities in life expectancy by deprivation have widened. Between 2012–14 and 2015–17, the gap in life expectancy at birth increased by 0.3 years for males and 0.5 years for females. Life expectancy for females in the most deprived areas fell by almost 100 days during this period.

There are also geographical inequalities in life expectancy. The north of England has a higher concentration of deprived neighbourhoods than the south of England, and therefore a greater proportion of communities where life expectancy is likely to be lower. But in addition to this, for any given level of deprivation, life expectancy in the north of England is lower than in the south of England.

Not only does deprivation affect life expectancy, but it also has an effect on the rate of avoidable mortality. In 2017, more than 140,000 (almost a quarter) of deaths were considered avoidable (delayed or averted through timely, effective care – amenable mortality, or wider public health interventions – preventable mortality). In England, in 2017, males in the most deprived areas were 4.5 times and females 3.9 times more likely to die from an avoidable cause than males in the least deprived areas.

In addition, people in lower socio-economic groups are more likely to have long-term health conditions, and these conditions tend to be more severe than those experienced by people in higher socio-economic groups. Deprivation also increases the likelihood of having more than one long-term condition at the same time, and on average people in the most deprived fifth of the population develop multiple long-term conditions 10 years earlier than those in the least deprived fifth.

Mental illness has a few more factors at play. This is a challenging one to measure because rates of recognition, reporting and diagnosis are likely to vary between groups. Existing evidence, although in many cases patchy and inconsistent, suggests a number of important patterns. Evidence suggests that inequalities in various types of mental ill-health exist across a range of protected characteristics, including sexual orientation, sex and ethnicity. People in the United Kingdom who identify as lesbian, gay, bisexual or transgender (LGBT), for example, experience higher rates of poor mental health, including depression, anxiety and self-harm, than those who do not identify as LGBT. Furthermore, women were found to be more likely than men to report experiencing a common mental health disorder, with one in five women reporting symptoms compared to one in eight men. But both alcohol and drug dependence were found to be twice as likely in men as in women. Disparities in mental ill-health by ethnicity have also been found. For example, rates of psychotic disorder experienced by Black men (3.2%) and Asian men (1.3%) were higher than among White men (0.3%), although for women there was no significant difference by ethnicity. Several socially excluded groups have also been shown to experience higher rates of mental ill-health than the general population. For example, more than 80% of people experiencing homelessness report having a mental health difficulty, and people in this group are 14 times more likely than those in the general population to die by suicide.

People’s behaviour is a major determinant of how healthy they are. Public Health England’s 2020–25 strategy identifies smoking, poor diet, physical inactivity and high alcohol consumption as the four principal behavioural risks to people’s health in England today. Behavioural risks to health are more common in some parts of the population than in others. The distribution is patterned by measures of deprivation, income, gender and ethnicity, and risks are concentrated in the most disadvantaged groups. For example, smoking prevalence in the most deprived fifth of the population is 28%, compared to 10% in the least deprived fifth, and evidence suggests that some people’s circumstances make it harder for them to move away from unhealthy behaviours. In addition, recent estimates suggest that households in the bottom fifth of income distribution may need to spend 42% of their income, after housing costs, on food in order to follow Public Health England’s recommended diet.

Other wider determinants of health:

  • Income
  • Housing
  • Environment
  • Transport (those living in deprived areas have a 50% higher chance of dying in a road traffic accident).
  • Education
  • Work

To conclude, based on factors often outside their direct control, people in England experience systematic, unfair and avoidable differences in their health, the care they receive and the opportunities they have to lead healthy lives. Interventions to tackle health inequalities need to reflect the complexity of how health inequalities are created and perpetuated, otherwise, they could be ineffective or even counterproductive. For example, efforts to tackle inequalities of health status associated with behavioural risks (such as poor diets) should address the wider network of factors that influence these behaviours (such as access to affordable healthy food, marketing and advertising regulations) and the impact that these behaviours have on health outcomes (such as access to clinical services).

The Future of Healthcare

This week I read an interesting article on the future of medicine. This has always been something of interest to me, not least because it determines the sort of workplace that I hope to be stepping into. A future where medicine will be a team sport, with humans and machines working together, and consumers playing an important role seems a very positive one to me. To prepare for this future, healthcare and medical leaders should shift the focus of both training, and the definition of physicians’ work: from an ability to memorize and quickly retrieve complex scientific information to even greater empathy and cultural competence; from autonomous decision-making to being team players and team leaders; from sick care to well-being and prevention; from periodic continuing medical education seminars to lifelong learning, enabled and supported by their organizations. To set priorities for physician workforce development, organizations could zoom out to envision themselves 10 years from now, considering where they want to be. Then, leaders can zoom in to identify some key initiatives that they can undertake in the near future, to solve short-term problems in a way that can accelerate the progress toward a long-term vision.

Over the past few months, physicians have been at the forefront of patient care, making challenging decisions under enormous stress and personal risk. The article that I read, gathered its information from interviews conducted with American physicians, who seemed to have an optimistic outlook on technological and scientific advances in medicine. They believe technology and new models of care can augment, not replace, physicians and help them focus on meaningful work.

As the Fourth Industrial Revolution (a fusion of technologies that is blurring the lines between the physical, digital, and biological spheres. It is marked by technological breakthroughs in robotics, AI, nanotechnology, quantum computing, fifth-generation wireless technologies, 3D printing, and material science) takes hold, technological and scientific advances—such as artificial intelligence, robotics, data visualization, and genomics—can transform the practice of medicine in positive ways. For example, technology can:

  • Automate mundane tasks such as clinical documentation, patient scheduling etc..
  • Consolidate and analyse data from multiple sources.
  • Provide clinical decision support for diagnosis and treatment in line with the most up-to-date research and evidence base.
  • Help physicians deliver personalised concierge-like care that focuses on prevention, providing actionable recommendations to support patients’ well-being (holistic care) and to delay and even avert disease.

The physicians interviewed believe that big changes are coming to the practice of medicine. Furthermore, they believe that the composition of clinical teams is expected to evolve. Physicians estimate that 30% of their current work can be performed by nonphysicians and 18% can be automated. In addition, the role of the consumer is expected to change: Consumers will own their health data and control who can access this information. They will assume greater ownership in their care and become an important part of the care team. In fact, 65% of physicians expect that in 5–10 years, it will be standard practice for consumers to own and control their health data. Collectively, these changes can improve outcomes, increase physician productivity, and optimally allocate resources, but most importantly, they can improve work for physicians, freeing them from rote tasks, restoring the humanity in patient care.

In the future, there will be a shift in the skills required of physicians, but will this look like? This article suggests that the following will be important:

  • Empathy, cultural competence (knowing how to deal with people of different cultural backgrounds), and storytelling to get at motivational levers for patients. As our patient population and health care workforce get increasingly diverse, physicians should be able to connect with patients and colleagues of different cultural backgrounds, and often do so using remote rather than face-to-face modalities.
  • Leadership and influencing capabilities to be an effective team leader and team player might be required for physicians in leadership positions and in everyday clinical practice.
  • The ability to accurately interpret genetic information, even if aided by AI, might be required not only for clinical decision-making around treatment but also for prevention and preserving well-being.
  • The ability to look under the hood and understand the algorithms behind clinical decision support systems, so that physicians can critically assess weaknesses in software and research results.
  • Better knowledge base on prevention, which would include a deeper understanding of diet and nutrition, the interplay between clinical and nonclinical drivers of health, ability to integrate information across body systems, and think more holistically about physical, mental, and spiritual well-being.
  • The business and economics of medicine, which involves understanding of cost and revenue drivers, direct and indirect costs from the perspective of the organization, the patient, and the health care system. This can better equip physicians to apply a population health lens, something that many find difficult today.

Surveyed physicians believe that for the next generation of physicians understanding the business of medicine and a focus on prevention will be important

In the future, this article suggested that physicians can forget the cumbersome and archaic acts of having to document what they do, as technology will record, filter, and edit everything needed for documenting an encounter. Furthermore, they think that many routine activities (medication refills, diagnosis of acute illnesses, or even dose titration) will move to self-service. Lastly, they thought that technology would be able to relieve physicians from having to remember differential diagnoses and trying to sort therapeutic options based on limited data the human brain can store. This can create opportunities for physicians to focus more of their energy on patient care—restore the humanity of physician work and allow more time with the patient. Even if all AI is doing is guiding physicians through a decision tree, that reduces the cognitive burden so physicians can use the cognitive bandwidth for all the other important things: empathy, asking intuitive questions, connecting the dots. AI gives physicians superpowers through computational and visualization infrastructure.

Like today, they suggest that consumers will turn to physicians with issues that cannot be resolved through other means, at times when they are vulnerable and confused. And physicians’ role will be to help them navigate complex decisions about treatments and consequences, using critical thinking, intuition, and compassion to ask the right questions, identify tradeoffs, and offer comfort.

Dealing with clinical as well as social and psychological barriers to health—hard topics such as end of life conversations, why patients don’t take their drugs, or why they choose not to vaccinate—may require a renewed focus on relationship-oriented capabilities. Just giving people information does not address the concerns, nor does it get at the issues that bother them or lie at the root of their problem. For example, in an encounter with a person who opposes vaccination, what levers can a physician pull to get through? Is it fear of the government? Do the parents believe vaccines make their child’s body dirty? Or is it because no one else in their community vaccinates?

As family history is augmented with genomic data, care may become proactive and personalised. Consequently, the information about risks and probabilities that physicians must explain to patients and parents will be vastly greater than today, and knowledge of genetics will be routinely incorporated in medical decision-making just like weight, activity level, and LDL cholesterol. At the same time, use of clinical decision support algorithms can give rise to questions about medical liability (similar to the classic driveless care question, of who gets the blame when it crashes) and this amplifies the need for a deeper skill set around probability, uncertainty, clinical decision-making, and basics of computer science. I think that when a health system uses a predictive algorithm about a patient, as a physician you are legally accountable, whether it’s used accurately or not.

Here is an example that they gave of how personalised medicine might work in the future:

“Jim had his genome sequenced at birth and it became part of his medical record. At age 16, new research indicated that a specific combination of genes that Jim had was associated with a particularly high risk of colon cancer. A genetic virtual assistant alerted Jim’s doctor to this fact and provided updated clinical guidelines for patients such as Jim. Because Jim’s genetic risk came through the maternal side, his doctor set up a meeting with Jim and his mother to explain the new research and guidelines to begin regular colorectal screenings at age 35 and offered personalized nutritional recommendations.”

The amount of data to inform wellness-oriented care will continue to grow. In addition to motion tracking, sleep monitoring, and data from clinical information systems, health data could include DNA and microbiome analyses, as well as data trails from purchasing decisions, consumption patterns, voice searches on smart speakers, or even keystrokes (that might be indicative of early dementia or neurological concerns). This would be amazing, because imagine a gastroenterologist or endocrinologist who manages the issues in the right way at the right time working hard upstream, preventing consequences from particular issues so the patient does not need bariatric or heart surgery down the line.

So, healthcare leaders need to begin to ‘zoom-out’ and then ‘zoom-in’ to begin to prepare for the future. Furthermore, they need to begin teaching relationship-oriented, and hiring based on these skills, which can be targeted interview feedback, online assessments, or even more advanced programs that use technologies such as AI or VR.

Introduction to Rashes

A rash is a change of human skin which affects colour, appearance or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cracked or blistered, swell, and may be painful. The causes, and therefore treatments for rashes, vary widely. Diagnosis must take into account such things as the appearance of the rash, other symptoms, what the patient may have been exposed to, occupation, and occurrence in family members. The most common acute rashes tend to be due to infection, due to a reaction to something, or rashes that are a marker of something else going on in the body.

As such, a rash is not a specific diagnosis, instead it refers to any sort of inflammation and/or discoloration that distorts the skin’s normal appearance. Some common rashes include eczema, poison ivy, hives, and athlete’s foot, and I will look into more detail at some rashes later on in the post. Infections that cause rashes may be fungal, bacterial, parasitic, or viral. Over-the-counter products may be helpful treatments for many skin rashes, but, rashes lasting more than a few days that are unexplained should be evaluated by a doctor.

All rashes can be described in terms of the appearance of the lesions on the skin. The terms are used to describe the rash and not necessarily point to the diagnosis. The most common terms that are used are: macular (flat lesions), papular (raised lesions), vesicular (fluid filled blisters), urticaria (hives), petechiae (dark red spots that do not temporarily disappear when the skin is stretched or pressed on) and purpura (bruises). Now I am going to look into more detail at some common rashes (n.b. don’t use the following to self-diagnose):

  1. Atopic dermatitis, often called eczema, is a common disorder of childhood that produces red itchy, weeping rashes on the inner aspects of the elbows and in back of the knees as well as the cheeks, neck, wrists, and ankles. It is commonly found in patients who also have asthma and/or hay fever.
  2. Seborrheic dermatitis is the single most common rash affecting adults. It produces a red scaling often itchy eruption that characteristically affects the scalp, forehead, brows, cheeks, and external ears. In infants, it may involve and scalp (cradle cap) and diaper area.
  3. Contact dermatitis is a rash that is brought on either by contact with a specific chemical to which the patient is uniquely allergic or with a substance that directly irritates the skin. Some chemicals are both irritants and allergens. This rash tends to be weepy and oozy and affects the parts of the skin which have come in direct contact with the offending substance. Common examples of allergic contact dermatitis are poison ivy, poison sumac, poison oak (same chemical, different plant) and reactions to costume jewelry containing nickel.
  4. Stasis dermatitis is a weepy, oozy dermatitis that occurs on the lower legs of individuals who have chronic swelling because of poor circulation in veins.
  5. Psoriasis causes a bumpy scaling eruption which does not weep or ooze. Psoriasis tends to occur on the scalp, elbows, and knees. The skin condition produces silvery flakes of skin that scale and fall off.
  6. Hives (urticaria) are red itchy bumps that come on in a sudden fashion, and then resolve in about eight hours. They tend to recur frequently. If hives are caused by a drug, that drug should be avoided in the future.
  7. Nummular eczema is a weepy, oozy dermatitis that tends to occur as coin-shaped plaques in the wintertime and is associated with very dry skin.
  8. Drug eruptions can occur as certain drugs (like antibiotics) can produce a skin rash as an unwanted side effect. The common appearance is similar to rashes produced by certain common viral infections. On the other hand, drugs may produce a wide variety of other types of rashes.
  9. A heat rash (miliaria) is a skin eruption caused by the occlusion of sweat ducts during hot, humid weather. It can occur at any age but is most common in infants who are kept too warm. Heat rash looks like a red cluster of acne or small blisters. It is more likely to occur on the neck and upper chest, in the groin, under the breasts, and in elbow creases. Treatment involves moving the individual to a cooler environment.

Rashes not caused by infectious organisms, can be treated with over-the-counter 1% hydrocortisone cream for a week or so prior to seeking medical attention. Over-the-counter oral antihistamines like diphenhydramine (Benadryl) or hydroxyzine (Vistaril, Atarax) can be helpful in controlling the itching sensation.

Rashes caused by fungal infections are fairly common. Yeasts are botanically related to fungi and can cause skin rashes. These tend to affect folds of skin (like the skin under the breasts or the groin). They look fiery red and have pustules (blisters) around the edges. Fungus and yeast infections have little to do with hygiene. Fungal rashes are not commonly acquired from dogs or other animals. They seem to be most easily acquired in gyms, showers, pools, or locker rooms, or from other family members.

Rashes produced by bacterial infections: The most common bacterial infections of the skin  are folliculitis and impetigo. Staph or strep germs may cause folliculitis and/or impetigo, two conditions that are much more common in children than adults. Eruptions caused by bacteria are often pustular (the bumps are topped by pus) or may be plaque-like and quite painful (such as with cellulitis).

One of the most common rashes from a parasite infection is scabies. Scabies is produced by a small mite (related to a spider). This mite is usually contracted by prolonged contact with another infected individual. The mite lives in the superficial layers of human skin. It does not produce symptoms until the host becomes allergic to it, which occurs about three weeks after the initial infection. It can resemble eczema. Bedbugs cause a series of eruptions where they pierce the skin.

Rashes that characteristically occur as part of certain viral infections are called exanthems. Many rashes from viruses are more often symmetrical and affect the skin surface all over the body, including roseola and measles. Sometimes certain viral rashes are localized to the cheeks, such as parvovirus infections (fifth disease). Other viral infections, including herpes or shingles, are mostly localized to one part of the body. Patients with such rashes may or may not have other symptoms like coughing, sneezing, localized burning, or stomach upset (nausea). Viral rashes usually last a few days to two weeks and resolve on their own.

Dermatologists, pediatricians, infectious diseases specialists, and many internists are the main specialists who treat rashes. This is a hard task, as they are not easy to diagnose, due to the lack of specificity when talking about a rash. Dermatologists have developed various terms to describe skin rashes. The first requirement is to identify a primary, most frequent feature. The configuration of the rash is then described using adjectives such as ‘circular’, ‘ring-shaped’, ‘linear’, and ‘snake-like’. Other characteristics of the rash that are noted include density, colour, size, consistency, tenderness, shape, and even temperature. Finally, the distribution of the rash on the body can be very useful in diagnosis since many skin diseases have a predilection to appear in certain body areas. Although certain findings may be a very dramatic component of the skin disorder, they may be of limited value in producing an accurate diagnosis. These include findings such as ulcers, scaling, and scabbing. Using this framework, it is often possible to develop a list, called a differential diagnosis, of the possible diseases to be considered. An accurate diagnosis of a skin rash often requires a doctor or other health care professional. On the basis of the differential diagnosis, specific laboratory tests and procedures can be conducted to identify the cause of a particular rash.

Regarding the treatment of rashes, most are not dangerous. Many rashes last a while and get better on their own. It is therefore not unreasonable to treat symptoms like itchy and/or dry skin for a few days to see whether the condition gets milder and goes away.

Over-the-counter treatments include the following:

  • Anti-itch creams containing 1% hydrocortisone cream can be effective
  • Oral antihistamines like diphenhydramine and hydroxyzine can be helpful in controlling the itching.
  • Moisturizing lotions
  • Fungal infections are best treated with topical antifungal medications that contain clotrimazole (Lotrimin), miconazole (Micatin), or terbinafine (Lamisil).

If these measures do not help, or if the rash persists or becomes more widespread, a consultation with a general physician or dermatologist is advisable.

Note that this article is not meant as a tool to self-diagnose, but instead a simple introduction to skin rashes. If you have a rash which is persisting, it is advised that you go to see a dermatologist.

Structure of the NHS

On 5th July 1948, the NHS was founded by Aeurin Bevan. Over recent years there have been changes to the way that the NHS is structured. The likelihood is that you may have not even noticed this, as it won’t have affected how you access your local doctor or hospital. But the changes have affected who makes decisions about health services and who holds the budget to pay for these services. This means that the NHS is now a very complex system, which can sometimes make it difficult to understand, especially when working out who is responsible for what. It’s made up of a wide range of different organisations with different roles, responsibilities and specialities. These organisations provide a variety of services and support to patients and carers.

It all starts with the government, who decide how much money the NHS receive, and do top level priority setting. The Secretary of State for Health is in charge of the Department of Health, which is smaller than it used to be, and it passes money, gained from taxes, on to a range of other organisations.

Some goes to NHS England, which started in 2013, as part of sweeping reforms aimed at improving services by increasing competition, cutting red tape (which Andrew Lansley said there was a lot of in the NHS – he wanted to give all money to GPs, but this was not agreed upon), and keeping the government out of the day to day running of the NHS. NHS England is in charge of the commissioning (planning and buying) of NHS services. In practice, it also sets a lot of NHS strategy, and behaves like an NHS headquarters. It commissions some services itself, but passes most of its money onto about 200 clinical commissioning groups (CCGs) across England, which are made up of GPs, nurses, hospital staff and members of the public.

Here is a diagram showing the funding flows in the NHS:

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CCGs identify local health needs, and plan and buy care for people in their area. They buy services from organisations of different shapes and sizes, from NHS trusts that run hospitals, to GPs and others the provide NHS care, including charities and other organisations in the private sector, all of whom have to be registered with the Care Quality Commission.

There are two main bodies that support CCGs. The first is commissioning support units, which provide technical support to CCGs. There are about 20 of these. They crunch data, do contract negotiations, and do some technical contract management. The second is clinical senates. When Lansley said that he wanted to give all money to GPs, there was outcry from many people, including hospital doctors who said that the complexity of some of their patients is far beyond the knowledge of GPs, so it is going to be difficult for them to commission services that they don’t fully understand. So, clinical senates bring together a whole range of medical professionals, working in a variety of fields, to give advice to CCGs on particular patient groups or conditions.

Alongside NHS England is NHS Improvement. This oversees NHS trusts, and at the moment it is mostly focused on managing the financial aspects of trusts, making sure that they don’t spend too much, that they operate efficiently, and overall, improve.

Public health, keeping the public healthy, has long been the territory of the NHS, with things such as healthy eating and smoking cessation campaigns. Recent health reforms have moved their budget to local government and Public Health England. Local governments also establish Health and Wellbeing boards, which bring together key players in the health and social care system, including local counselors, to improve health in a joined up way across health, social care, and other public services.

Healthwatch is another organisation which exists at a national and social level to represent the views of patients, and for people to engage in how services are planned. There are also a whole load of other bodies with their own remits and acronyms, including: NHS Digital, NICE, Health Education England (HEE), HSCIC (health and social care information centre), NHR, MHRA (medicines and healthcare products regulatory agency) and many more. The upshot is that these organisations can, at times, issue seemingly contradictory messages. There are also unclear boundaries as to exactly which organisation is responsible for what prompting questions about who is really in charge.

Here is a basic structure of the NHS diagram:

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Some definitions:

NHS England and NHS Improvement are responsible for providing national direction on service improvement and transformation, governance and accountability, standards of best practice, and quality of data and information. They came together in 2019 to act as a single organisation (maintaining separate boards). The aim of the merger is to work more effectively with commissioners and providers, making more efficient use of resources, and removing duplication.

The Care Quality Commission’s (CQC) role is to register care providers and monitor, inspect and rate their services in order to protect users. CQC publishes independent views on major quality issues in health and social care.

Regional NHS England and NHS Improvement teams are responsible for the quality, financial and operational performance of all NHS organisations in their region. Increasingly, they are working with local systems (ICSs/STPs) to oversee performance, support their development and make interventions when necessary.

Sustainability and transformation partnerships (STPs) bring together NHS providers and commissioners, local authorities and other local partners to plan services around the long-term needs of local communities. STPs cover populations of 1-3 million people.

In some areas, integrated care systems (ICSs) have evolved from STPs. ICSs are a closer collaboration in which organisations take on greater responsibility for managing local resources and improving health and care for their populations. According to the NHS long term plan, every part of England will be covered by an ICS by 2021.

Integrated care partnerships (ICPs) are alliances of providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care, independent and third sector providers may also be involved. NHS England and NHS Improvement is developing an ‘integrated care provider contract’ as an option for formalising these partnerships.  ICPs cover populations of 250–500,000 people.

Primary care networks (PCNs) bring general practices together to work at scale with other local providers from community services, social care and the voluntary sector. Together they provide primary care by using a wide range of professional skills and community services. Since 1 July 2019, all except a handful of GP practices in England have come together in around 1,300 geographical networks. PCNs cover populations of 30–50,000 people.

But the NHS, and the way that these organisations work together is always changing. The most recent changes started in 2014, when NHS England published a vision on the future of healthcare, called the ‘NHS Five Year Forward View’. This called for more of a focus on preventing people from getting ill in the first place, and giving patients more control of their own care. It also set out a range of new models of care, which aimed to get services working together to provide joined up care for patients. There hasn’t been much progress on the prevention part, but lots of energy has been put behind the new models. Examples of what this aims to do include providing treatment traditionally administered in hospitals in people’s homes, such as chemotherapy, and get people to work differently, such as dementia specialists carrying out clinics in GP surgeries. This new way of working is particularly designed to meet the needs of increasing numbers of people who need support to manage long-term conditions, particularly older people.

Over the past couple of years, 50 areas across England, known as Vanguard sites have been trialing the delivery of more joined up care. This is all part of a broader shift towards organisations working together more closely to meet patients physical and mental health needs, and away from an NHS market place. The NHS has invented/adopted a whole range of acronyms to describe this approach.

Firstly, STPs (sustainability and transportation partnerships), which aren’t organisations in themselves, but describe a way of working together in partnership. These were created when NHS organisations were asked to come together with local authorities, charities, and others, to agree how to improve health, and modernise services. There are 44 STPs in England, all focused on progressing the ideas in the Five Year Forward View.

Some STP areas are on track to develop into another acronym, ACSs (accountable care systems), which take inspiration from parts of the US, where organisations work together under a set budget, to improve health and coordinate services for people who live in a certain area. In part, these changes are about managing the limited resources available to the NHS. But they are also about working together with services outside the NHS, like social care and public health, that have a really important impact on our health. This requires much closer working with local authorities.

So far, there are many aspects of the NHS which have come together, for example, CCGs have been merging, hospitals are forming chains, and GPs are forming federations. What’s more, in places like Manchester, many more choices are being made locally about health and care services should work there.

So, what next? There is a lot of change going on at the moment, which leaves a lot of unanswered questions, not least, what does this mean for patients? It should result in a better continuum of care at home, and a push to keep the population more healthy. But, with the NHS already over-spending, and being stretched more than ever with an ageing population, change is hard to implement, and may be very slow.

Chronic Diseases

Chronic diseases are the leading causes of death and disability in the UK, and also account for 70% of the NHS budget. But, finding a clear and agreed upon definition of them isn’t an easy task. There is much variety in how popular internet sources classify chronic diseases. For example, MedicineNet describes a chronic disease as,

‘…one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics. Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear.’

According to Wikipedia a chronic disease is,

‘…a human health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months. Common chronic diseases include arthritis, asthma, cancer, COPD, diabetes and viral diseases such as hepatitis C and HIV/AIDS.’

Finally, the World Health Organization states that chronic diseases,

‘…are not passed from person to person. They are of long duration and generally slow progression. The four main types … are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes…’

In the UK, more than 15 million people have at least one chronic disease. It is important to note that chronic diseases are more prevalent in older people (58 per cent of people over 60 compared to 14 per cent under 40) and in more deprived groups (people in the poorest social class have a 60 per cent higher prevalence than those in the richest social class and 30 per cent more severity of disease – this can be seen in the King’s Fund graph below).

Link between socio-economic group and long-term conditions prevalence and severity

Key: I Professional, etc, occupations, II Managerial and technical occupations, III Skilled occupations, (N) Non-manual, (M) Manual, IV Partly skilled occupations, V Unskilled occupations.

The number of people with three or more long-term conditions is predicted to rise from 1.9 million in 2008 to 2.9 million in 2018. The ageing population and increased prevalence of long-term conditions have a significant impact on health and social care and may require £5 billion additional expenditure by 2018. Multi-morbidity is more common among deprived populations, and there is evidence that the number of conditions can be a greater determinant of a patient’s use of health service resources than the specific diseases. There will be rising demand for the prevention and management of multi-morbidity rather than of single diseases.

The effects that a chronic disease has on one’s life is heartbreaking. In addition to disease specific symptoms, people commonly complain of invisible symptoms such as pain, fatigue, and mood disorders. Pain and fatigue may become a frequent part of your day. Physical changes from a disease may affect your appearance. These changes can turn a positive self-image into a poor one. When you don’t feel good about yourself, you may prefer to be alone and withdraw from friends and social activities. Mood disorders such as depression and anxiety are common complaints of people with chronic conditions, but they are extremely treatable. Chronic illness can also influence your ability to work. Morning stiffness, decreased range of motion, and other physical limitations may force you to change your work activities and environment. A decreased ability to work may also lead to financial problems. If you’re a homemaker, your work may take much longer to do. You may need the help of your spouse, a relative, or a home healthcare provider. As your life changes, you may feel a loss of control, anxiety, and uncertainty of what lies ahead. In addition, there may be role reversals in families, as family members who were once stay-at-home now have to go back to work, due to their significant other’s inability to work. Stress can build and can shape your feelings about life. Prolonged stress can lead to frustration, anger, hopelessness, and, at times, depression. The person with the illness is not the only one affected; family members are also influenced by the chronic health problems of a loved one.

I read a touching personal account from Chiara Valentini which I would like to share:

‘Lately, it’s hard for me to remember the last time I felt good. A time when I had energy and didn’t wake up fatigued. A time when I got excited about my next meal, rather than dreading it because I am pretty sure it’ll make me sick. And I really don’t remember going for more than a week without having a flareup and being in excruciating pain. I’m always waiting for the pain to come. Always. I’m beginning to forget the last time someone asked me how I am and I replied “I’m good” — and actually meant it. These days, my “I’m good” really means I’m awful.’

Many chronic diseases unfortunately come on with no cause, but they are often caused by a short list of risk behaviors:

  • Tobacco use and exposure to secondhand smoke.
  • Poor nutrition, including diets low in fruits and vegetables and high in sodium and saturated fats.
  • Lack of physical activity.
  • Excessive alcohol use.

I am now going to look at some common chronic diseases:

Arthritis, which effects more than 10 million people in the UK, is inflammation of one or more of your joints that causes pain and stiffness. While arthritis is mainly an adult disease, some forms affect children. There are many types of arthritis. Some of these include osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, septic arthritis, and psoriatic arthritis. While each of these conditions have different causes, the symptoms and treatment are often the same. Pain, swelling, and stiffness are the primary symptoms of arthritis. Any joint in the body may be affected by the disease, but it is particularly common in weight-bearing joints such as the knee, hip, and spine. Although cost-effective interventions are available to reduce the burden of arthritis, they are underused. Regular, moderate exercise offers a host of benefits to people with arthritis by reducing joint pain and stiffness, building strong muscle around the joints, and increasing flexibility and endurance.

Heart disease, which effects 7.4 million people in the UK, 3.9 million men and 3.5 million women, describes a range of conditions that affect your heart. Diseases under the heart disease umbrella include blood vessel diseases, such as coronary artery disease; heart rhythm problems (arrhythmias); and heart defects you’re born with (congenital heart defects), among others. The term “heart disease” is often used interchangeably with the term “cardiovascular disease.” Cardiovascular disease generally refers to conditions that involve narrowed or blocked blood vessels that can lead to a heart attack, chest pain (angina) or stroke. Other heart conditions, such as those that affect your heart’s muscle, valves or rhythm, also are considered forms of heart disease. Many forms of heart disease can be prevented or treated with healthy lifestyle choices. Furthermore, three health-related behaviors – tobacco use, lack of physical activity, and poor nutrition – contribute markedly to heart disease. Modifying these behaviors is critical for both preventing and controlling heart disease. Modest changes in one or more of these risk factors among the population could have a profound public health impact.

Cancer, of which there are 367,000 new cases in the UK every year,1,000 every day, one new case every 2 minutes, is the name given to a collection of related diseases. In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues. Cancer can start almost anywhere in the human body. Normally, human cells grow and divide to form new cells as the body needs them. When cells grow old or become damaged, they die, and new cells take their place. When cancer develops, however, this orderly process breaks down. As cells become more and more abnormal, old or damaged cells survive when they should die, and new cells form when they are not needed. These extra cells can divide without stopping and may form growths called tumors. Many cancers form solid tumors, which are masses of tissue. Cancers of the blood, such as leukemias, generally do not form solid tumors. Cancerous tumors are malignant, which means they can spread into, or invade, nearby tissues. In addition, as these tumors grow, some cancer cells can break off and travel to distant places in the body through the blood or the lymph system and form new tumors far from the original tumor. Unlike malignant tumors, benign tumors do not spread into, or invade, nearby tissues. Benign tumors can sometimes be quite large, however. When removed, they usually don’t grow back, whereas malignant tumors sometimes do. Unlike most benign tumors elsewhere in the body, benign brain tumors can be life threatening. Cancer is largely controllable through prevention, early detection, and treatment. Reducing the nation’s cancer burden requires reducing the prevalence of the behavioral and environmental factors that increase cancer risk. It also requires ensuring that cancer screening services and high-quality treatment, such as chemotherapy, are available and accessible.

Finally, diabetes, which it is estimated that more than one in 16 people in the UK has diabetes (diagnosed or undiagnosed), that is 3.9 million people. Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. There are 2 main types of diabetes:

  • Type 1 diabetes – where the body’s immune system attacks and destroys the cells that produce insulin.
  • Type 2 diabetes – where the body does not produce enough insulin, or the body’s cells do not react to insulin (sometimes caused by bad diet).

Around 90% of people with diabetes have type 2 diabetes. Around 8% of people with diabetes have type 1 diabetes. About 2% of people with diabetes have rarer types of diabetes.

The amount of sugar in the blood is controlled by a hormone called insulin, which is produced by the pancreas (a gland behind the stomach). When food is digested and enters your bloodstream, insulin moves glucose out of the blood and into cells, where it’s broken down to produce energy. However, if you have diabetes, your body is unable to break down glucose into energy. This is because there’s either not enough insulin to move the glucose, or the insulin produced does not work properly. There are no lifestyle changes you can make to lower your risk of type 1 diabetes. You can help manage type 2 diabetes through healthy eating, regular exercise and achieving a healthy body weight. Regarding management, Type 1 diabetes is managed using insulin, which is often injected, or you can use a pump. Type 2 diabetes can be managed using insulin or tablets, though you might initially be able to treat your diabetes by eating well and moving more.

I would like to end with a short poem by Jenni Johanna Toivonen, which shows the reality of living with a chronic disease.

“If I only could explain
How much I miss
that precious moment
when I was free
from the shackles of chronic pain.”

 

Potential Treatment of COVID-19

I have recently done some research on viruses, and the potential treatments that might be successful in treating COVID-19. I would argue that it is almost undoubtable that a treatment will come before a vaccine, for reasons which I look at in the power point. I look at three different types of treatment:

  1. Antiviral treatments,
  2. Passive Immunisation,
  3. Treatment of Cytokine Storms.

Here is the power point, in pdf form: Potential Treatments for COVID-19.

 

Responsive Listening

Given that it has been Mental Health awareness week this week, with a particular focus on kindness, I thought that it would be apt to post the culmination of a research project that I did a while ago on ‘Responsive Listening’.

I have attached a booklet and a poster, which were both as part of our research. These outline the various types of listening, and how to develop the way that you lesson to become more of a considerate person. I recommend the ten question ‘quiz’ as a way of analysing your listening currently. By becoming a responsive listener, I strongly believe that you also become a kinder person. Therefore, I hope that you will be able to  put the tips in the booklet into practice, as it will not only help other people around you, but, being kind also has scientifically proven benefits for yourself. When you are kind, your body releases oxytocin, which aids in lowering blood pressure and improving our overall heart-health. Oxytocin also increases our self-esteem and optimism.

My thoughts on the current state of young people’s mental health: I would say that the biggest challenge at the moment is that of feeling alone. If you were then to start feeling disappointed, or sad about something, this issue is exacerbated by the feeling of being alone. Therefore, I would stress the importance of communication to friends (I know how much better I feel after coming off of a call with a friend), but also other hobbies too. For example, something which people are often encouraged to turn away from, computer games, can actually really help. Not only are you doing something that you enjoy, but also, it is often with a friend, and usually one feels better afterwards. Of course, this isn’t to say that you should sit doing this all day – but something of this nature can be good to relax in the evenings for an hour or so.

This brings me onto my next point of routine. With a dramatic change to our lives, our routines have been knocked off course, and it may be hard to find a new routine, but it should be strongly encouraged to do so. This routine should include exercise, nutrition, and sleep.

Finally, now is a great time to try meditation. Not only will this help now, but if learned properly, this can be carried forward into the future.

Overall though, be kind, as even the smallest action can make a massive difference!

Can we afford to give our healthcare workers a pay rise?

With the NHS in the spotlight currently, performing magnificently well, I thought that it apt to look at whether it would be possible to give a pay rise to our healthcare workers. The government, who are responsible for the amount of money that the NHS can use, gives a large portion of their budget to healthcare (18%), second only to pensions (20%).

But the NHS doesn’t have enough money for what they need to do. If you divide up the NHS budget between the 243 million treatments that the NHS gives out each year, you end up with about £600 per treatment. This means that the NHS makes a loss every time that they treat someone that has fainted (cost: £620) or has asthma (£690), or someone that needs surgery on a broken leg (£5,120) or their baby delivered (£2,790). As you therefore might expect, they overspend on their budget, and this year, if things continue, they are expected to overspend by £30 billion.

But, I would argue that the NHS have a good system of cost-benefit analysis, called QALYs (quality adjusted life years). NICE’s (National Institute for Health and Care Excellence) definition of QALYs is a ‘measure of the state of health of a person or group in which the benefits, in terms of length of life, are adjusted to reflect the quality of life’. It essentially assumes that health is a function of length of life and quality of life and combines these values into a single index number. A year of life lived in perfect health is worth 1 QALY. A year of life lived in a state of less than perfect health is worth less than 1 QALY. Death is assigned a value of 0 QALYs, and in some circumstances it is possible to have negative QALYs in extremely serious conditions. So, for example, a long but painful life might be equal in value to a short but happy life. It can therefore be used to weigh up the value of one treatment against another treatment. For example, a treatment with terrible side-effects will result in lower quality of life and therefore an overall lower QALY. The price of one QALY varies depending on your time of life and many other factors, but £50,000 is a generally accepted, approximate value. NICE also evaluates every drug for cost-effectiveness before it can be used as standard by the NHS. Therefore, as you can see, there are stringent cost-effectiveness rules that are in place, and one might say, why not lower the value of a QALY, but what if it were one of your loved ones that you were talking about?

These measures therefore save the NHS money, so why don’t they have enough? It could be attributed to the exploitation of technological advances, which are highly desirable in healthcare as they can improve a variety of aspects of the work of healthcare professionals, including: speeding up routine tasks, which currently doctors spend a lot of time doing; improving the accuracy of diagnosis (in radiography, for example, a study compared pneumonia diagnosis of 112,000 X-ray images comparing to success rate of an AI algorithm to that of 4 radiologists and found AI outperformed them); empower patients to monitor their own condition (with wearable technology and devices such as Docobo, which is able to be taken home, and records  vital signs such as pulse, blood pressure, oxygen saturations and many more); public health-based modelling on population data (such as models made for the current pandemic); can predict outcomes of disease and hence allow for the allocation of resources to be more effective. These are all incredible advances in healthcare, and can, will and already have had revolutionary impact in healthcare, but money is required to get them off the ground.

Another reason that healthcare costs are going up is because we are all living longer, increasing the number of old people around, and the older you are, the more likely you are to fall ill. The average 85-year-old man incurs healthcare costs that are seven times larger than an average man in his late 30s. As you can see from the graph, prescribing costs are increasing.

Furthermore, Britain is not a healthy nation, with three-fifths of Brits being overweight. Just under a third are ‘physically inactive’, meaning that they do less than two and a half hours of moderate exercise (e.g. brisk walking) a week. Moreover, many Brits consume excessive amounts of harmful products, such as sugar, alcohol, and tobacco.

We are also acquiring new drugs and treatments that are becoming increasingly expensive (some say the NHS bills are going up by 7 percent a year). Lots of people think that this is because pharmaceutical companies are greedily trying to inflate their profits, but this could also be because medicines are becoming harder to discover, as the ‘easily-discoverable’ ones have already been found.

The interesting thing about buying more expensive drugs is that, while there is evidence that the value of increased health care spending exceeds the cost, there is also evidence that many medical interventions provide little health benefit. To see this, we need look no further than the United States, who spend more per capita on health care than any other country, but many countries achieve comparable or better population health outcomes.

In conclusion, we cannot just give money to the NHS, as other sectors would then lose much needed money. Of course, if the government did change the budget, or increase taxes, and give more to the NHS, the cycle would continue, as a healthier population means more people live for longer, and more people need treating, driving costs up again. My solution would be putting a large investment in developing AI in healthcare now, that can then be sustainable in the future, and eventually begin to cut down on staffing, whilst maintaining the health standards of the country. This would allow the staff that end up working in healthcare to have a bigger salary, and although this doesn’t reward those in healthcare now for their fabulous work, this seems like the only solution. So no, with the NHS already overspending, I don’t think that it would be feasible to give them a pay rise.

How do muscles grow?

In our current state of lockdown, people seem to have been digging out their weights from the back of their cupboards and pulling out their bikes from their sheds. In the vast majority of cases, it is simply to kill time, but it comes with the added benefit of building muscle. It is impossible to go through your life without going through this process of muscle growth; but what goes on underneath the skin in this process is often a mystery to most people.

Before I begin on talking about muscle growth, I think that it is important to first understand the anatomy of muscle tissue. There are three types of muscle: Skeletal (voluntary muscles that move the body, arms and legs), smooth (involuntary, found within the walls of internal organs, like stomach, intestine, bladder and blood vessels) and cardiac (the muscle of the heart). The only type of muscle relevant for this article is skeletal muscle. Each individual skeletal muscle cell is surrounded by a sarcolemma (cell membrane), which is structured to receive stimuli. The cell is filled with myofibrils, resulting in the other organelles and nucleus being squashed to the side of the cell. Myofibrils are the contractive units of the cell which consist of protein myofilaments which run longitudinally along the muscle. These filaments come in two types – thick (myosin) bands or thin (actin) bands. The thin (actin) bands are attached to a Z-line of a protein called titin, which anchors the other bands in position. The distance between two Z-lines is called the sarcomere, which acts as the smallest contractile unit. Between each of the muscle fibres is a liquid called the sarcoplasm, which is a glycogen store. When a stimuli occurs that results in muscle contraction, Ca2+ is released which results in the troponin-tropomyosin complex removing its block from actin, so the myosin heads can bind to the active sights of actin, and therefore swivel (the working stroke), pulling the Z-lines closer together and shortening the sarcomeres and hence the entire muscle. The process then reverses for the relaxation of the muscle.

striated muscle; human biceps muscleThere are two types of hypertrophy (muscle growth): myofibrillar and sarcoplasmic. But it is important to understand that when you first begin to lift weights and complete strength building workouts little hypertrophy occurs. Instead neural adaptation occurs, which is a vital part of strength. It refers to the ability of the nervous system to appropriately activate the muscles. Strength training may cause adaptive changes within the nervous system that allow a trainee to more fully activate prime movers in specific movements and to better coordinate the activation of all relevant muscles, thereby effecting a greater net force in the intended direction of movement. After appropriate neural adaptation has occurred, hypertrophy can begin to take over, with neural adaptation development continuing in the background.

Myofibrillar hypertrophy is what most people are aware of when people talk about muscles becoming damaged (damage could be in just a few macromolecules of tissue or result in large tears in the sarcolemma, basal lamina, and supportive connective tissue) which occurs when weights are lifted that are much heavier than what the person is comfortable with. These microtears in the myofibrils, when being repaired, increase the density of these myofibrils which increase the strength of the muscle. They are repaired by causing mechano-chemically transduced molecular and cellular responses in a cascade of events. Myosatellite cells, which are small multipotent cells and are precursors to skeletal muscle cells, are responsible for the reparation of muscle tissue, through the process of cell differentiation. If sufficient mechanical stimulus is imposed on skeletal muscle, these myogenic stem cells become aroused and fuse to existing cells to create new myofibers. They become aroused by the initial response which is likened to the acute inflammatory response to infection. Once damage is perceived by the body, neutrophils migrate to the area of microtrauma and agents are then released by damaged fibres that attract macrophages and lymphocytes. Macrophages remove cellular debris to help maintain the fibre’s ultrastructure and produce cytokines that activate myoblasts, macrophages and lymphocytes. This is believed to lead to the release of various growth factors that regulate satellite cell proliferation and differentiation. The satellite cells therefore contribute to muscle hypertrophy in several ways: they donate extra nuclei to muscle fibres to synthesise more actin and myosin; and they co-express various myogenic regulatory factors that aid in muscle repair, regeneration, and growth.

But, the vital part of myofibrillar hypertrophy lies in hormones and cytokines which are secreted by muscle fibres to orchestrate skeletal growth. The  three major hormones in this process are insulin-like growth factor (insulin-like growth factor receptors are found in activated satellite cells and adult myofibers and it is released during exercise acting as a signalling pathway to satellite cells), testosterone (which interacts with receptors on neurons and thereby increase the amount of neurotransmitters released, regenerate nerves, and increase cell body size), and growth hormone (which stimulates the incorporation of amino acids to make proteins). Cytokines act as mediators to the entire response of the muscle, carrying out many tasks including: the regulation of swelling; binding to receptors to activate a series of target cells involved in cell proliferation and differentiation; and maintaining metabolic homeostasis of lipids and proteins along with many more.

Sarcoplasmic hypertrophy occurs as a result of working your muscles to fatigue. This is because the sarcoplasm is a fluid that acts as a glycogen storage and therefore fuels the muscle through the workout. When a workout is completed to fatigue, the volume of sarcoplasm will increase to maintain contraction for a longer period in the next workout. This is because metabolic stress manifests as a result of exercise that relies on anaerobic glycolysis for ATP production, which results in the subsequent build-up of metabolites such as lactate, hydrogen ion, inorganic phosphate, creatine, and others. This leads to larger muscles but not necessarily stronger muscles. Exercise regimes that cause an increased glycogen storage capacity also have the potential to augment cell swelling. Given that glycogen attracts three grams of water for every gram of glycogen, this may reflect an increased capacity for protein synthesis as cell swelling is known to stimulate anabolic processes, including an increase in protein synthesis. Furthermore, it also has been hypothesized that a greater acidic environment promoted by glycolytic training may lead to increased fibre degradation and greater stimulation of sympathetic nerve activity, thereby mediating an increased adaptive hypertrophic response.

Of course, the reality is that these processes always occur together. There are no examples of myofibrillar hypertrophy occurring without sarcoplasmic hypertrophy and there are no examples of sarcoplasmic hypertrophy occurring without myofibrillar hypertrophy. They have always been thought of as mutually exclusive, but they never occur without one another. They do occur at different rates however. For example, a muscle cell is, on average, made up of roughly 80% myofibrillar proteins and 20% sarcoplasm. When myofibrillar hypertrophy occurs, the ratio stays the same, as with more contractile proteins, more fuel (glycogen in the sarcoplasm) is needed to fuel the additional proteins.

The implications that this has on your workout is as follows: if you are looking to gain physical strength, low rep, high force workouts are ideal; this causes myofibrillar hypertrophy, and is what Olympic powerlifters do to lift the heaviest weights possible. On the other hand, if you are looking for a more toned body, with larger muscles, but not necessarily the strength which might be associated with the body shape, you should do lower weight, high rep workouts which tire your muscles to fatigue – this is what bodybuilders do. This results in a heavy use of anaerobic glycosis, and a subsequent build-up of metabolites and therefore the sarcoplasm. To get a balanced hypertrophic response, balancing both muscular volume, and muscular strength, current research suggests that training regimens that produce significant metabolic stress while maintaining a moderate degree of muscle tension are the most successful. This means medium rep exercises, with large rest periods, whilst ensuring that a wide variety of exercises are completed. Furthermore, some exercises should be completed to exhaustion.

But the most important thing is that you engage your muscles in some way, as, if no muscle growth goes on, the opposite occurs, which is called muscular atrophy. This is when the key mechanisms that regulate the turnover of contractile proteins and organelles in muscle tissue become impaired, which can be due to many reasons, including a sustained lack of physical activity (especially noticeable after a brace has been worn for a long period of time) or some metabolic and neuromuscular diseases. So now, hopefully you understand what happens when you exercise your muscles, and how they grow after exercise – I hope that you get the opportunity to apply this theory into practice.

I actually got this article published in a magazine (the one on the left), which contains many other fascinating articles.

Insect Repellents

You have probably used an insect repellent at some point in your life, or wish that you had. Bites from insects such as mosquitoes, biting flies, deer flies, black flies and sand flies leave a small lump on the skin and can cause discomfort and itching. Bites and stings are naturally red, swollen, itchy and uncomfortable; of course, each insect leaves a different size/shape/colour of bite. But occasionally the bite an become infected, cause a severe allergic reaction (anaphylaxis) or spread serious illnesses.

Have you ever thought about what is inside insect repellents and how they work? This is a poster that I made about what attracts insects to humans in the first place; what is in insect repellents; and potential future developments in the industry.

What I didn’t touch on in the poster was what insects actually do when they bite you. When they first land on your skin, they make a small hole in the skin. Most bite as a form of defence, and they therefore inject venom into the person. This venom is a liquid blend of biologically active substances, usually including toxins. Toxins damage enzymes and thus undermine countless bodily functions—inhibiting the production of hemoglobin in the blood, for example. Thus, they result in the immune response which causes the swelling that we see. Many insects bite to feed on blood (proboscis), such as mosquitoes. They feed on our blood for the protein and iron in our blood which is used to make eggs, which is why only female mosquitoes bite. In the process of feeding, the mosquito injects some of its own saliva, which contains an anticoagulant that prevents your blood from clotting around the proboscis and trapping the insect. Your immune system recognizes the proteins in the mosquito’s saliva as a foreign substance and releases histamine as part of the immune response. Histamine causes itching which you may have experienced. When bites break the skin, the bacteria that live on the surface of your skin can then enter those small puncture points and develop into an infection, or you may have an allergic reaction to one of the substances in the venom. These two things cause worsened effects from bites.

But, the worst effects from bites come from diseases which the insects transmit to us. For example, malaria, which is caused by he Plasmodium parasite is mainly spread by female Anopheles mosquitoes (only live in certain areas), which mainly bite at dusk and at night. When an infected mosquito bites a human, it passes the parasites into the bloodstream. Another transmitted disease is lyme disease. To contract Lyme disease, an infected deer tick must bite you. The bacteria enter your skin through the bite and eventually make their way into your bloodstream. Zika, dengue and chikungunya  viruses are transmitted to people primarily through the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus).

Therefore, if possible, I recommend that you use insect repellent.