When COVID patients are intubated in ICU, the trauma can stay with them long after this breathing emergency

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Deb Massey, Southern Cross UniversityThe current wave of COVID cases is leading to more hospital and intensive care (ICU) admissions. Frontline health workers and experts use the term “intubation” for the extra breathing support some patients need in an emergency.

But many people don’t know what this procedure involves and the trauma it can cause.

Patients with COVID-19 who deteriorate and need additional support with their breathing require intubating and ventilating. That means a tube is inserted and a ventilation machine delivers oxygen straight to the lungs.

Inserting the tube

Intubating a patient is a highly skilled procedure and involves inserting a tube through the patient’s mouth and into their airway:

1. patients are usually sedated, allowing their mouth and airway to relax. They often lie on their back, while the health-care professional stands near the top of the bed, facing the patient’s feet
2. the patient’s mouth is gently opened. An instrument called a laryngoscope is used to flatten the tongue and illuminate the throat. The tube is steered into the throat and advanced into the airway, pushing apart the vocal chords
3. a small balloon around the tube is inflated to keep the tube in place and prevent air from escaping. Once this balloon is inflated, the tube must be tied or taped in place at the mouth
4. successful placement is checked by listening to the lungs with a stethoscope and confirmed via a chest x-ray.

A laryngoscope is used to guide a tube into the airway.
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Can breathe, can’t speak or swallow

While intubated patients are attached to a ventilator and their breathing is supported, they are unable to talk or swallow food, drink or their saliva.

They often remain sedated to enable them to tolerate the tube. They can’t attend to any of their own needs and disconnection from the ventilator can be catastrophic.

For this reason any patient who is intubated and ventilated is cared for in an intensive care unit with a registered nurse constantly by their bedside.

American lawyer and editor David Latt recalled his experience of being intubated and ventilated following a diagnosis of COVID-19, saying:

When they were giving me anesthesia to put me to sleep so they could put a tube in my mouth that would enable me to breathe, I just remember thinking, ‘I might die.’ Sometimes in the abstract, you think, ‘If it’s my time, it’s my time.’ But when I was on that table […] I just thought, ‘No, I don’t want to go.’

Latt feared he would never see his two-year-old son or his partner again.

Taking the tube out

The length of time a COVID patient requires intubation and ventilation varies and depends on the reasons for it and the response to treatment. However, there are reports of patients being intubated and ventilated for over 100 days.

Once a patient’s respiration improves and they no longer require breathing support, the tube is removed in a procedure called “extubation”. Like intubation, extubation requires highly skilled health-care workers to manage the process. It involves:

1. a spontaneous breathing trial, which assesses the patient’s capacity to breathe unassisted before extubation to decrease the risk of respiratory failure
2. an assessment by the treating doctor, intensive care nurse, speech pathologist or physiotherapist of the patient’s ability to cough (so they can effectively clear their own throat and prevent substances entering the lungs)
3. treatment from a physiotherapist is usually required before and after extubation if the patient has had mechanical ventilation for more than 48 hours. This is to ease the process of weaning the patient off the ventilator and help them learn to breathe independently again.

Once extubated, patients remain in ICU and are closely monitored to ensure they can safely maintain a clear and effective airway. Once they are able to do this and are stable enough to transfer to the ward they are discharged from the ICU.

Intubation, ICU and trauma

Patients with COVID-19 who require intubation and ventilation have witnessed a number of stressful events in the ICU, such as emergency resuscitation procedures and deaths. This may increase the risk of post-traumatic stress disorder, anxiety, and depression.

Although we don’t have definitive long-term data, patients who have been critically ill from COVID often have a long and difficult journey of recovery. They will likely remain dependant on health care services for some time.

Many patients who have been intubated and ventilated recall it as being one of the worst experiences of their lives. Clearly it is something we should try to avoid for as many people as possible.

There are currently 138 patients patients intubated and ventilated in ICUs across Australia. That’s 138 patients who cannot communicate with their loved ones, who are scared, frightened and vulnerable.

Most of these patients have not been vaccinated. The most important thing we can do to reduce the risk of being intubated and ventilated as a result of COVID-19 is get vaccinated.

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Deb Massey, Associate Professor, Faculty of Health, School of Nursing, Southern Cross University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

We’re seeing more COVID patients in ICU as case numbers rise. That affects the whole hospital

Deb Massey, Southern Cross UniversityRising COVID cases in several Australian states means demand for intensive care unit (ICU) beds and specialist critical nurses will rise.

This increase in demand is on top of the typical workload ICUs might see.

And because of the nature of COVID itself and other factors, this puts pressure on the entire hospital system.

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What happens in ICU?

The ICU is where we care for the most critically unwell patients, where treatments are designed to support breathing and circulatory problems affecting the heart, blood, or blood vessels.

The most unstable and sickest ICU patients require airway support in the form ventilation to help them breathe. They also need circulatory support in the form of drugs to improve blood pressure and heart function.

Patients come to ICU as a planned admission (for example, after a complex operation), or as an emergency admission (for example, after a serious car accident).

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Patients stay for, on average, three days in ICU before recovering enough to be moved to a ward, or sadly, dying.

Because patients in ICU are unstable and critically unwell, there is usually one nurse to care for each patient. This is a highly skilled job. Most ICU nurses have extra postgraduate qualifications.

COVID changed the type of patients we see

Patients who are critically ill with COVID are often sicker than other ICU patients and may require more support for their breathing and circulation. Often, they need to stay in ICU longer than other patients.

This creates challenges for hospital systems, because beds in ICU become blocked, and planned operations may be cancelled because of the lack of ICU beds.

Once patients with COVID no longer need ventilation or circulatory support, they are transferred to the ward for additional care. They may have experienced painful procedures and have a degree of physical impairment.

They may also have witnessed a number of stressful events in the ICU, such as emergency resuscitation procedures and deaths, which may increase the risk of post-traumatic stress disorder, anxiety, and depression.

Although we don’t have definitive long-term data, patients who have been critically ill from COVID often have a long and difficult journey of recovery and will likely remain dependant on health care services for some time.

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COVID changed how we nurse

ICU staff looking after COVID patients have the additional demands of working in full personal protection equipment (PPE), which can be hot and uncomfortable and very challenging to work in.

The need to use PPE correctly, and the constant concern about becoming infected or dying if there’s an infection breach, adds to nurses ongoing stress.

The International Council of Nurses’ latest analysis shows the number of nurses who have died after contracting COVID-19 globally is greater than 2,200 – more than any other health-care worker. This data are from earlier this year, so we expect those figures to have risen since then.

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COVID challenges Australia

In Australia, there has been more time to respond to the challenges of COVID. In many states, the numbers of ventilators increased, models of care were developed for COVID-positive patients, and snap lockdowns ensured scarce ICU resources were not overwhelmed.

However, the increasing number of positive cases in New South Wales in particular, coupled with the highly infectious Delta variant, means ICUs risk reaching capacity.

At the time of writing, 109 patients were in Australian ICUs and 37 of these patients required ventilation.

Australia has 191 ICUs with 2,378 beds and the capacity to increase this by by up to 4,258 beds.
But there may not be enough specialised nurses or equipment match this bed increase.

Surge capacity also varies between ICU categories and jurisdictions, with tertiary hospitals reporting more capacity. So deteriorating patients may need to be air-lifted to major metropolitan or regional centres.

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What can happen in the future?

Fortunately, public health measures have meant Australia has been spared the horrors of countries that were unable to successfully increase their ICU resources to meet demands, for example, Spain, Italy and the United Kingdom.

Yet, hospitals are still feeling the impact of a rise in critically unwell COVID patients in many ways, and will do so in the future.

Undergraduate student nursing placements, for example, have been delayed and many universities have moved their education online. So student nurses may struggle to achieve the clinical hours required to graduate. This may mean a shortfall of clinically competent and educated ICU nurses in the future.

The best we can do

So the next time you hear the latest number of COVID patients in ICU, think of what’s behind those numbers and what this means for the whole hospital system and its staff.

Protect them, yourself and others by sticking to the public health advice, including getting tested with the mildest of symptoms. Most importantly, get vaccinated. People fully vaccinated against COVID rarely end up in ICU.

Deb Massey, Associate Professor, Chair of Nursing, Faculty of Health, Southern Cross University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Introducing Edna: the chatbot trained to help patients make a difficult medical decision

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David Ireland, CSIRO; Clara Gaff, Walter and Eliza Hall Institute, and Dana Kai Bradford, CSIRO

Allow us to introduce Edna — Australia’s first “genomics chatbot”.

The opening dialogue of Edna the chatbot.

Edna (short for “electronic-DNA”) helps patients make informed decisions about seeking “additional findings” testing.

Additional findings testing looks for variants in patients’ genes that aren’t relevant to their current health, but may be later on. For example, it can reveal if someone has an above-average chance of developing a hereditary heart condition.

But these tests can have major implications for patients and their families. Thus, individuals deciding whether they want such a test need support — which Edna can provide.

This chatbot was developed by us and our colleagues at the CSIRO and other members of the Melbourne Genomics Health Alliance.

Genomic and genetic testing

A range of medical conditions have underlying genetic causes. Historically, this has been tested with genetic testing, by looking at either a single gene or a panel of genes related to one particular condition.

In genomic testing, however, almost all the genes in a patient’s DNA are analysed using a biological sample (such as blood).

In Australia, genomic testing is done for patients with certain medical conditions, to provide more information about the condition and medical care required.

But genomic data can be analysed further in an additional findings test, to report on potential gene variants responsible for other preventable and/or treatable conditions.

Although available in the United States, additional findings tests are currently beyond immediate medical need in Australia and are only carried out in research settings. That said, conversations have started about them becoming mainstream here, too.

If additional findings tests were offered in Australia, genetic counsellors would have to spend a large proportion of their time helping patients decide whether they want one. This is where chatbots come in.

Edna the chatbot in training

For chatbots to accurately recognise human speech and provide a meaningful response, their “brain” needs to draw on a large body of data.

Many chatbot brains are developed from open source data, but this is inadequate for highly specialised fields. We developed Edna by analysing transcripts of actual counselling sessions that discussed additional findings analysis.

Edna can emulate the flow of a real patient-counsellor session, explaining various conditions, terms, concepts and the key factors patients should consider when making their decision.

For example, it prompts them to consider the personal and familial implications of undergoing an additional findings analysis. As we all share genes with our family, results from genomic testing can lead to serious conversations.

Edna’s database contains myriad details of medical conditions and terminology.

Edna has several other capabilities, such as:

• knowing when to connect a patient with a genetic counsellor, if needed

• providing general information covered in most genetic counselling sessions, allowing counsellors more time to focus on patients with complex needs

• collecting a patient’s family history

• detecting various forms of common language, such as “nan” instead of “grandmother” and “heart attack” instead of “myocardial infarct” (the medical term for heart attack)

• recognising certain temporal markers. For instance, if a patient says “my mother died around Anzac Day two years ago”, Edna will know their mother died around April 25, 2018.

Edna asks about the medical conditions of a patient’s family members.

Edna is currently undergoing a feasibility trial with patients who have already had additional findings analysis done in a research setting, as well as genetic counsellors and students.

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The Eliza Effect and other hurdles

Past research has suggested people prefer chatbots that interact with empathy and sympathy, rather than unemotionally giving advice. This is called the “Eliza effect” — named after the first ever chatbot. Eliza was able to elicit an emotional response from humans.

Edna is quite advanced on this front. It can detect negative sentiment and even some forms of sarcasm. Still, this isn’t the same as true empathy.

Chatbots can’t yet match genetic counsellors’ ability to detect and respond to emotional cues. And “sentiment analysis” remains a significant challenge in natural language processing.

Edna can identify when a user likely needs to be connected to a real counsellor.

Since Edna provides generic information, it can’t discuss the implications of a future or previous genomic test for a specific patient. It also can’t link the patient with a support group, or provide expert medical advice.

Still, Edna represents a significant move towards a digital health solution that could take some pressure off genetic counsellors.

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Providing more genomic healthcare

Edna’s main advantage is accessibility. It can support people living remotely, or who are otherwise unable to attend face-to-face genetic counselling.

It can also be accessed at a patient’s home, where family members may be present. They can then share in the information provided and engage Edna themselves, potentially improving the chances of an accurate history capture.

As a digital interface, Edna is almost endlessly modifiable. It can be updated continuously with data compiled during interactions with patients — whether this be information on new topics, or a new way to respond to a question.

A larger-scale patient trial is planned for the near future.

David Ireland, Senior Research Scientist at the Australian E-Health Research Centre., CSIRO; Clara Gaff, Executive Director, Melbourne Genomics Health Alliance, Walter and Eliza Hall Institute, and Dana Kai Bradford, Principal Research Scientist, Australian eHealth Research Centre, CSIRO

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Patients with COVID-19 shouldn’t have to die alone. Here’s how a loved one could be there at the end

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Melissa Bloomer, Deakin University and Stephane Bouchoucha, Deakin University

While the number of new COVID-19 cases in Victoria continues to trend downwards, we’re still seeing a significant number of deaths from the disease.

The ongoing outbreaks in aged care, and the fact community transmission is continuing to occur, mean it’s likely there will be many more deaths to come.

As a result of strict infection control measures restricting hospital visitors, tragically, many people who have died from COVID-19 have died alone. Family members have missed out on the opportunity to provide comfort to the dying person, to sit with them at their bedside, and to say goodbye.

But it doesn’t have to be this way. We have cause to consider whether perhaps we could do more to preserve the patient-family connection at the end of life.

Who can visit?

There’s some variation between Victorian health-care facilities in how visitor restrictions are applied. Some allow visitors to enter hospitals for compassionate reasons, such as when a person is dying. But visitors are not permitted for patients with suspected or confirmed COVID-19.

The latest figures show 20 Victorians are in an intensive care unit (ICU) with 13 on a ventilator. This indicates their situation is critical.

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Despite hospitals, and particularly ICUs, being adequately prepared and resourced to provide high-level care for people diagnosed with COVID-19, patients will still die.

Family-centred care at the end of life in intensive care is a core feature of nursing care. So in the face of this unprecedented global pandemic, we realised we needed to navigate the rules and restrictions associated with infection prevention and control and find a way to allow families to say goodbye.

Not having the chance to say goodbye may compound relatives’ grief.
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Our recommendations

We’ve published a set of practice recommendations to guide critical care nurses in facilitating next-of-kin visits to patients dying from COVID-19 in ICUs. The Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control have jointly endorsed this position statement.

The recommendations are evidence-based, reflecting current infection prevention and control directives, and provide step-by-step instructions for facilitating a family visit.

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Some of the key recommendations include:

• family visits should be limited to one person — the next-of-kin — and that person should be well

• the visitor must be able to drive directly to and from the hospital to limit exposure to others

• they should dress in single-layer clothing suitable for hot machine wash after the visit, remove jewellery, and carry as few valuables as possible

• on arrival, staff should prepare the visitor for what they will see when they enter, what they may do, and what they may not do (for example, it would be OK to touch your loved one with a gloved hand)

• a staff member trained in the use of personal protective equipment (PPE) should assist the visitor to put on PPE (a gown, surgical mask, goggles and gloves) and after the visit, to take it off, dispose of it safely and wash their hands

• where possible, the visitor should be given time alone with their loved one, with instructions on how to seek staff assistance if necessary.

We also highlight the importance of intensive care staff ensuring emotional support is provided to the family member during and immediately after the visit.

ICU staff can help facilitate safe visits to patients who are dying from COVID-19.
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Tailoring the guidance

It’s too early to know the full impact a loved one’s isolated death during COVID-19 may have on next-of-kin and extended family. But the effect is likely to be profound, extending beyond the immediate grief and complicating the bereavement process.

These recommendations are not meant to be prescriptive, nor can they be applied in every circumstance or intensive care setting.

We encourage intensive care teams to consider what will work for their unit and team. This may include considerations such as:

• whether there are adequate facilities in which the visitor can be briefed and don PPE

• whether social distancing is possible with current unit occupancy and staffing

• whether an appropriately skilled clinician is available to coordinate and manage the family visit

• each patient’s unique clinical and social situation.

Rather than just using a risk-minimisation approach to managing COVID-19, there’s scope for some flexibility and creativity in addressing family needs at the end of life.

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Melissa Bloomer, Associate Professor, Nursing, Deakin University and Stephane Bouchoucha, Associate Head of School (International), Deakin University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

1 in 10 patients are infected in hospital, and it’s not always with what you think

Drips and other medical devices were potential sources of infection. But no-one expected to find hospital-acquired pneumonia and urinary tract infections.
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Philip Russo, Monash University and Brett Mitchell, University of Newcastle

Most people expect hospital treatment to make them better. But for some, a stay in hospital can actually make them sicker. Their wound might get infected after an operation or they might get a blood infection as a result of a medical procedure.

Our study, published today in the international journal Antimicrobial Resistance and Infection Control, found one in ten adult patients in hospital with an acute (short-term) condition had a health care associated infection.

In the first study of its kind in Australia for over 30 years, we also uncovered unexpected infections, like pneumonia and urinary tract infections, as well as high numbers of patients with multi-drug resistant organisms (superbugs).

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Why do we need to keep track of infections?

Most of these infections can be prevented. So it is important to know what type of infections they are, how common they are and which patients get them. Once we have this information, we can work out a way to prevent them.

Left unchecked, these infections can make already sick patients sicker, can divert hospital resources unnecessarily, and can kill.

Most hospitals in Australia have ongoing surveillance for specific infections, such as wound and bloodstream infections.

Some states have well coordinated programs like the Victorian program VICNISS, leading to detailed data on health care associated infections. This data is then used to inform hospital strategies on how to prevent infections. However, this type of surveillance method requires extensive resources and does not capture all infections that occur in a hospital.

Instead, we conducted a “point prevalence” survey, which takes a snapshot of the current situation on any given day. This is less resource intensive than ongoing surveillance and it provides valuable information on the distribution and occurrence of all infections in a hospital.

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In Europe, the European Centre for Disease Prevention and Control co-ordinates national point prevalence studies every four years. These have provided valuable insight into the burden of health care associated infections. They have also been used to track the emergence of multi-drug resistant organisms in Europe. The US, Singapore and many other countries also run them.

Most hospital infections can be prevented.
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Unlike most OECD countries, Australia does not have a national health care associated infection surveillance program and does not undertake national point prevalence studies.

The only national data routinely collected relates to bloodstream infections caused by the microorganism Staphylococcus aureus. These infections are serious but rare and only represent a tiny fraction of all infections in hospitals.

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To improve our understanding of health care associated infections across Australia, we used the same study method as the Europeans. Over a four month period in 2018, we visited 19 large hospitals across Australia and collected information on all infections in adult acute inpatients. Four of the hospitals were regional, the others major city hospitals.

What infections did we find?

Of the 2,767 patients we surveyed, we found 363 infections in 273 patients, meaning some patients had more than one infection. The most common infections were wound infections after surgery (surgical site infections), pneumonia and urinary tract infections. These accounted for 64% of all the infections we found.

This is important as most hospitals do not normally look for pneumonia or urinary tract infections and there is no routine statewide or national surveillance for these.

Our findings mean these infections are commonly occurring but undetected. A potential source of information on these types of infections is hospital administrative coding data. However, these codes were mainly designed for billing purposes and have been shown to be unreliable when it comes to identifying infections.

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We also found patients with a medical device, such as a large intravenous drip, or urinary catheter (a flexible tube inserted into the bladder to empty it of urine), were more likely to have an infection than those who did not.

Intensive care units treat patients who are gravely unwell and at greater risk of infection. So it was unsurprising to find that 25% of patients in intensive care units had a health care associated infection.

The emergence of multi-drug resistant organisms (superbugs) is a concern worldwide. Previously unknown, our study revealed that 10% of the adult acute inpatients in our study had a multi-drug resistant organism.

What have other studies found?

For the first time in 34 years we have a glimpse of how common health care associated infections are in Australian hospitals. Although the only other previous study was larger, a major strength of our study is that we used the same two trained data collectors to collect the data from all hospitals.

This reduced the potential inconsistency in finding infections that might occur if hospital staff collected their own data. It also minimised the use of hospital resources to undertake the survey.

Importantly though, we did not survey all types of hospitals. It is possible that if the same survey was extended to include children, babies and cancer hospitals, higher rates of infection may be found given the vulnerability of these patients.

What can we do better?

As one of the authors has previously noted, a major gap in Australia’s effort to combat health care associated infections, and the emergence of multi-drug resistance organisms, is the lack of robust national data.

This means we cannot measure the effect of national policy or guidelines despite significant investment.

In the absence of a national surveillance program, we recommend that large-scale point prevalence surveys, including smaller hospitals, specialist hospitals and the private sector be undertaken regularly. Data generated from these studies could then be used to inform and drive national infection prevention initiatives.

Philip Russo, Associate Professor, Director Cabrini Monash University Department of Nursing Research, Monash University and Brett Mitchell, Professor of Nursing, University of Newcastle

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Are private patients in public hospitals a problem?

A new report has claimed public patients are worse off with increased numbers of private patients in public hospitals.
from http://www.shutterstock.com.au

Peter Sivey, RMIT University and Terence Cheng, University of Adelaide

Recently, hospital and aged care provider Catholic Health Australia (CHA) released a report sounding an alarm bell at recent increases in the number of patients in public hospitals being urged to “go private”.

Public hospitals may encourage their patients to “go private” because it allows them to bill the patient’s health insurance and Medicare for costs incurred, rather than having to dip into their own limited budgets. Patients may be persuaded to use their private health insurance after being assured by the public hospital of no out-of-pocket costs, or being promised added extras such as a private room.

The report argued this trend may harm the private hospital sector by affecting profitability and investment decisions. It may also harm the interests of public patients if public hospitals discriminate in favour of treating private patients.

While aspects of these concerns may be valid, there may also be some benefits to public hospitals treating more private patients.

A look at the figures

The report is correct that the numbers of private patients in public hospitals are increasing, at an average of 10.5% per year since 2011-12. Public patients in public hospitals and private patients in private hospitals have also been increasing, but at slower rates of only 2.7% and 4.5% per year respectively since 2011-12.

But percentage rates of change can be misleading. In raw numbers, the increase in public patients in public hospitals (527,467) and private patients in private hospitals (576,135) has actually outstripped the raw increase in private patients in public hospitals (287,473). This is because public patient numbers are increasing from a much larger base (over five million) than private patients in public hospitals (less than one million).

Concerns with this trend

The CHA report notes several concerns with the trend of increasing private patients in public hospitals. They note anecdotal evidence of public patients being pressured to “go private” with incentives including drinks vouchers, better food options and free parking. While these reports may seem concerning, it’s hard to base any change of policy on anecdotal reports.

More worrying is the suggestion that publicly-admitted patients in public hospitals are being discriminated against, for example by being made to wait longer for treatment. The CHA report cites data from an Australian Institute of Health and Welfare report, which shows waiting times on public hospital waiting lists for public patients (at 42 days) was more than twice that of private patients in public hospitals (20 days).

But this difference is hard to interpret. There may be many differences in diagnosis and disease severity between public and private patients, which may explain the waiting time gap. So we can’t conclude this is evidence of any form of “discrimination” against patients without private health insurance in the public hospital system from these figures.

More robust evidence from public hospitals in NSW in 2004-05 does show private patients were prioritised over public patients. In this study, waiting times for elective surgery were found to be considerably shorter for private patients, despite having similar clinical needs as public patients.

Differences in waiting times between public and private patients were found to be largest for patients assigned to the lowest two urgency levels. In these cases, waiting times for public patients were more than twice as long as for private patients.

There is further evidence, also from NSW public hospitals, that public and private patients may be treated differently when they are assigned to an urgency category for waiting lists for elective surgery. The study suggested private patients were more likely to be assigned into more urgent admission categories, which corresponds with a shorter maximum wait for admission into hospital.

This study also found private patients were likely to receive more medical procedures while in hospital, but found no difference for length of hospital stay or, importantly, for mortality rates.

Potential benefits

One claim of the CHA report is that there has been relatively “stagnant” growth of activity of private patients in private hospitals, potentially affecting their profitability and investment decisions.

First, the figures don’t seem to back this up. The increase in numbers of private patients in private hospitals is actually higher than the increase in numbers of private patients in public hospitals.

Second, even if private hospitals were losing business to public hospitals, it could be a welcome demonstration of competition in the health care market. The trend may be explained through public hospitals providing better amenities, higher quality, or lower costs than private hospitals.

There are some arguments to support continuing the practice of public hospitals admitting private patients. There can be efficiency gains to the health system given that the fees and charges for private patients in public hospitals are usually lower than those in private hospitals. So this form of competition could lower the costs in the health system as a whole.

Additional revenue raised by public hospitals could also support the continual provision of services and programs for public patients, which may have been curtailed due to budget cuts to the public hospital system.

The public hospital system is often seen as unfairly treated by the private sector in how it bears costs for training junior doctors (which takes place overwhelmingly in the public system), and treating the most severely ill patients. From this perspective, it seems only fair to allow public hospitals to take their “share” of the more profitable private patients.

Why we need better data

It’s important to figure out whether private patients are receiving preferential treatment at the expense of public patients. One study found abolishing preferential access for private patients and admitting patients according to when they were listed for an elective procedure would only lead to a small improvement in waiting times for public patients.

This is because long waiting times for public patients are primarily due to budget constraints in public hospitals, and not because private patients are skipping the queue.

The available robust evidence on the treatment of private patients in public hospitals is from more than a decade ago, and it’s unclear if the disparities between how public and private patients are treated have improved or worsened.

One reason for the lack of high quality research on this topic is the restriction on access to detailed hospital data in Australia, which we need for robust studies. If we had access to more detailed data, we could better understand what’s happening now, and ensure timely access to high quality hospital care for both public and private patients.

Peter Sivey, Associate Professor, School of Economics, Finance and Marketing, RMIT University and Terence Cheng, Senior Lecturer, School of Economics, University of Adelaide

This article was originally published on The Conversation. Read the original article.

Motive for Aid Worker Killings in Afghanistan Still Uncertain

Taliban takes responsibility, but medical organization unsure of killers’ identity.

ISTANBUL, August 12 (CDN) — The killing of a team of eye medics, including eight Christian aid workers, in a remote area of Afghanistan last week was likely the work of opportunistic gunmen whose motives are not yet clear, the head of the medical organization said today.

On Friday (Aug. 6), 10 medical workers were found shot dead next to their bullet-ridden Land Rovers. The team of two Afghan helpers and eight Christian foreigners worked for the International Assistance Mission (IAM). They were on their way back to Kabul after having provided medical care to Afghans in one of the country’s remotest areas.

Afghan authorities have not been conclusive about who is responsible for the deaths nor the motivation behind the killings. In initial statements last week the commissioner of Badakhshan, where the killings took place, said it was an act of robbers. In the following days, the Taliban took responsibility for the deaths.

The Associated Press reported that a Taliban spokesman said they had killed them because they were spies and “preaching Christianity.” Another Taliban statement claimed that they were carrying Dari-language Bibles, according to the news agency. Initially the attack was reported as a robbery, which IAM Executive Director Dirk Frans said was not true.

“There are all these conflicting reports, and basically our conclusion is that none of them are true,” Frans told Compass. “This was an opportunistic attack where fighters had been displaced from a neighboring district, and they just happened to know about the team. I think this was an opportunistic chance for them to get some attention.”

A new wave of tribal insurgents seeking territory, mineral wealth and smuggling routes has arisen that, taken together, far outnumber Taliban rebels, according to recent U.S. intelligence reports.

Frans added that he is expecting more clarity as authorities continue their investigations.

He has denied the allegation that the members of their medical team were proselytizing.

“IAM is a Christian organization – we have never hidden this,” Frans told journalists in Kabul on Monday (Aug. 9). “Indeed, we are registered as such with the Afghan government. Our faith motivates and inspires us – but we do not proselytize. We abide by the laws of Afghanistan.”

IAM has been registered as a non-profit Christian organization in Afghanistan since 1966.

Dr. Abdullah Abdullah, a former political candidate, dismissed the Taliban’s claims that team members were proselytizing or spying, according to the BBC.

“These were dedicated people,” Abdullah said according to the BBC report. “Tom Little used to work in Afghanistan with his heart – he dedicated half of his life to service the people of Afghanistan.”

Abdullah had trained as an eye surgeon under Tom Little, 62, an optometrist who led the team that was killed last week. Little and his family had lived in Afghanistan for more than 30 years with IAM providing eye care.

IAM has provided eye care and medical help in Afghanistan since 1966. In the last 44 years, Frans estimates they have provided eye care to more than 5 million Afghans.

Frans said he doesn’t think that Christian aid workers are particularly targeted, since every day there are many Afghan casualties, and the insurgents themselves realize they need the relief efforts.

“We feel that large parts of the population are very much in favor of what we do,” he said. “The people I met were shocked [by the murders]; they knew the members of the eye care team, and they were shocked that selfless individuals who are going out of their way to actually help the Afghan people … they are devastated.”

The team had set up a temporary medical and eye-treatment camp in the area of Nuristan for two and a half weeks, despite heavy rains and flooding affecting the area that borders with Pakistan.

Nuristan communities had invited the IAM medical team. Afghans of the area travelled from the surrounding areas to receive treatment in the pouring rain, said Little’s wife in a CNN interview earlier this week, as she recalled a conversation with her husband days before he was shot.

Little called his wife twice a day and told her that even though it was pouring “sheets of rain,” hundreds of drenched people were gathering from the surrounding areas desperate to get medical treatment.

 

The Long Path Home

The team left Nuristan following a difficult path north into Badakhshan that was considered safer than others for reaching Kabul. Frans said the trek took two days in harsh weather, and the team had to cross a mountain range that was 5,000 meters high.

“South of Nuristan there is a road that leads into the valley where we had been asked to come and treat the eye patients, and a very easy route would have been through the city of Jalalabad and then up north to Parun, where we had planned the eye camp,” Frans told Compass. “However, that area of Nuristan is very unsafe.”

When the team ended their trek and boarded their vehicles, the armed group attacked them and killed all but one Afghan member of the team. Authorities and IAM believe the team members were killed between Aug. 4 and 5. Frans said he last spoke with Little on Aug. 4.

IAM plans eye camps in remote areas every two years due to the difficulty of preparing for the work and putting a team together that is qualified and can endure the harsh travel conditions, he said.

“We have actually lost our capacity to do camps like this in remote areas because we lost two of our veteran people as well as others we were training to take over these kinds of trips,” Frans said.

The team of experts who lost their lives was composed of two Afghan Muslims, Mahram Ali and another identified only as Jawed; British citizen Karen Woo, German Daniela Beyer, and U.S. citizens Little, Cheryl Beckett, Brian Carderelli, Tom Grams, Glenn Lapp and Dan Terry.

“I know that the foreign workers of IAM were all committed Christians, and they felt this was the place where they needed to live out their life in practice by working with and for people who have very little access to anything we would call normal facilities,” said Frans. “The others were motivated by humanitarian motives. All of them in fact were one way or another committed to the Afghan people.”

The two Afghans were buried earlier this week. Little and Terry, who both had lived in the war-torn country for decades, will be buried in Afghanistan.

Despite the brutal murders, Frans said that as long as the Afghans and their government continue to welcome them, IAM will stay.

“We are here for the people, and as long as they want us to be here and the government in power gives us the opportunity to work here, we are their guests and we’ll stay, God willing,” he said.

 

Memorial

On Sunday (Aug. 8), at his home church in Loudonville, New York, Dr. Tom Hale, a medical relief worker himself, praised the courage and sacrifice of the eight Christians who dedicated their lives to helping Afghans.

“Though this loss has been enormous, I want to state my conviction that this loss is not senseless; it is not a waste,” said Hale. “Remember this: those eight martyrs in Afghanistan did not lose their lives, they gave up their lives.”

Days before the team was found dead, Little’s wife wrote about their family’s motivation to stay in Afghanistan through “miserable” times. Libby Little described how in the 1970s during a citizens’ uprising they chose not to take shelter with other foreigners but to remain in their neighborhood.

“As the fighting worsened and streets were abandoned, our neighbors fed us fresh bread and sweet milk,” she wrote. “Some took turns guarding our gate, motioning angry mobs to ‘pass by’ our home. When the fighting ended, they referred to us as ‘the people who stayed.’

“May the fruitful door of opportunity to embrace suffering in service, or at least embrace those who are suffering, remain open for the sake of God’s kingdom,” she concluded.

 

Concern for Afghan Christians

Afghanistan’s population is estimated at 28 million. Among them are very few Christians. Afghan converts are not accepted by the predominantly Muslim society. In recent months experts have expressed concern over political threats against local Christians.

At the end of May, private Afghan TV station Noorin showed images of Afghan Christians being baptized and praying. Within days the subject of Afghans leaving Islam for Christianity became national news and ignited a heated debate in the Parliament and Senate. The government conducted formal investigations into activities of Christian aid agencies. In June IAM successfully passed an inspection by the Afghan Ministry of Economy.

In early June the deputy secretary of the Afghan Parliament, Abdul Sattar Khawasi, called for the execution of converts, according to Agence France-Presse (AFP).

“Those Afghans that appeared on this video film should be executed in public,” he said, according to the AFP. “The house should order the attorney general and the NDS (intelligence agency) to arrest these Afghans and execute them.”

Small protests against Christians ensued in Kabul and other towns, and two foreign aid groups were accused of proselytizing and their activities were suspended, news sources reported.

A source working with the Afghan church who requested anonymity said she was concerned that the murders of IAM workers last week might negatively affect Afghan Christians and Christian aid workers.

“The deaths have the potential to shake the local and foreign Christians and deeply intimidate them even further,” said the source. “Let’s pray that it will be an impact that strengthens the church there but that might take awhile.”

Report from Compass Direct News

Recent Incidents of Persecution

Karnataka, India, January 7 (CDN) — Police led by Hindu extremists accused a pastor without basis of forceful conversion, reprimanded him for praying without government permission and stopped the Sunday worship of his India People Ministry church on Dec. 27 in Koppa. The Global Council of Indian Christians reported that police further warned Pastor D.M. Kumar that he would be arrested if he conducted future worship services.

Karnataka – Members of the Hindu extremist Bajrang Dal accused Christian nurses at Pandapura government hospital of forceful conversion for conducting a small Christmas program on Dec. 25 in Mandhya. The Global Council of Indian Christians reported that at about 2 p.m., Sophia Parinamala Rani and two others identified only as Philomina and Bajamma organized a small, customary Christmas meeting for staff members and patients, inviting a guest to speak about Christ. Some 20 Hindu extremists reached the hospital and, manhandling the speaker, accused the nurses of forceful conversion. Pandapura police forcefully obtained an apology letter from the nurses, who received a show-cause notice ordering them to explain the meeting to hospital authorities.

Andhra Pradesh – A Hindu extremist roughed up two Christians at a worship meeting on Dec. 23 in Mahabubnagar. The All India Christian Council reported that a pastor identified only as Prabudas and a doctor identified only as Nehemiah were on their way to a service when a Hindu hardliner and karate master, Satya Narayana, pushed and punched them, threatening to file a case of forceful conversion against them. He threatened them with more violence if they continued Christian activities in the area. Local Christian leaders were taking steps to protect the two men at press time.

New Delhi – Hindu extremists assaulted Christians attending a Christmas program of the Full Gospel Church of God on Dec. 22 at Nagafgarh. A source reported that the Hindu hardliners threatened pastors Benny Stephen, K. Cherian and Stephen Joseph, claiming that the program they were attending aimed to convert people by force, and then attacked them. Pastor Joseph suffered injuries to his left leg and back, Pastor Benny to his back and face and Pastor Cherian to his head. Pastor Joseph told Compass that no police complaint was filed as the Christians forgave the attackers.

Tamil Nadu – Hindu extremists attacked a group of Christians on Dec. 20 in Mangalam, Nagercoil. The Global Council of Indian Christians reported that Hindu extremists objected to a digital sign Christians put up stating details of an impending Christmas celebration and warned them to remove it. When the Christians refused, the extremists beat them, and some of them received hospital treatment for their injuries. A police complaint was filed, but no arrests had been made at press time. 

Andhra Pradesh – Police arrested Pastor P. Benjamin after a Hindu extremist filed a complaint against him of forceful conversion on Dec. 20 in Hyderabad. The Global Council of Indian Christians reported that Pastor Benjamin, of Holy Spirit Church, spoke of Christ with about 200 children at a Christmas program organized by a nearby area’s Christian youth leader. As Pastor Benjamin reached his home, local Christian leaders informed him that police had filed charges of forcible conversion against him under Section 295/A of the Indian Penal Code. Applications for bail were twice rejected. Area Christian leaders were taking an appeal to a higher court, and the pastor’s family was relocated as a security precaution.

Maharashtra – Hindu extremists from the Bajrang Dal on Dec. 20 attacked members of Christian ministry Operation Mobilization in Manchar and took their film equipment. The All India Christian Council (AICC) reported that about 100 extremists attacked the organization’s screening of a Christian film, organized by the area pastor with the permission of the village head. As the movie ended, the Hindu hardliners rushed in, verbally abused the Christians for their faith and took a film projector and DVD player. Moses Vatipalli of the AICC told Compass that area leaders of Hindu extremist groups were planning to meet with Christian leaders to settle the matter.

Andhra Pradesh – Hindu extremists in Karimnagar on Dec. 15 beat 65-year-old Pastor S. Devavaram and other Christians, accusing them of forceful conversion. The Global Council of Indian Christians reported that Pastor Devavaram and five youths were distributing Christmas literature after obtaining permission from the deputy superintendent of police. At about 9 a.m. a mob of 20 Hindu extremists stopped their vehicle, dragged the pastor out and accused him of forceful conversion. They beat the pastor, tied his hands and locked him and the other Christians in a room till 5 p.m. On learning that the pastor and the other five had been abducted, 10 Christians reported it to police. Officers arrived at the site of the assault and took the Christians to the police station, where the extremists filed a complaint of forcible conversion against the pastor and his team. Police took written statements from the Christians and released them without charges at 6 p.m.

The Church in Burma is growing despite obstacles

Devastating cyclones, bitter ethnic wars, and human rights abuses have all had a part in contributing to the poverty and spiritual darkness that characterizes Mynamar, which was formerly known as Burma, reports Michael Ireland, chief correspondent, ASSIST News Service.

Despite this opposition, the church in Burma is gaining ground against principalities, powers, rulers of darkness and spiritual wickedness in high places, according to a report from Christian Aid.

Christian Aid assists a number of ministries in Burma, which remain unnamed for their security, who submitted the following reports concerning their various strategies for spreading the gospel.

Faith with Works

“I am conducting meetings with the churches, pastors, and workers, exhorting them to stand firm in the faith,” said one ministry leader.

“These are fiery times for testing their faith. The government has put high restrictions on work among the cyclone victims. They presume that what we are doing is for political purposes. (Even Buddhist monks and laymen, interested in helping victims, are being persecuted. Some were caught and sentenced to very long jail terms — 45 to 65 years!).”

Local church planted by native missionaries

“Because of your faithful and consistent support, my workers and I were able to reach 300 Buddhists. We shared about the last days and distributed tracts among them. In another area we were able to distribute rice and used clothing, as well as medicine for the elderly and ailing. This particular tribe lives in a secluded area, so we were able to preach the gospel,” said another leader.

“The mobile clinic you helped open allowed us to treat 1,130 patients. Many of them were elderly, who shed tears of joy. They were so grateful for this display of Christian love.”

Bible Teaching and Training

Yet another brother, who leads a teaching ministry, remembers a time when confusion arose among the churches in Burma due to a lack of theological training.

“This was in the 70’s and even though a revival swept through the country, there were no reputable Bible schools. Church leaders of that era left the country and enrolled in schools in other areas of the world. When they completed their studies, they returned to Burma to launch an indigenous ministry.”

He added: “We began with only four faculty members and 77 students our first year. But despite opposition to the Bible, the Lord, and Christians in general, this ministry is going forward. With help received from Christian Aid recently, we were able to assist 20 more Bible students from the scholarship fund. We also have a Bible correspondence course available for those wanting to learn more about Jesus, or who find it difficult to leave their current ministry for an extended period.”

Church Planting meets needs, builds relationships

“Week-long evangelistic camp meetings in remote towns and villages are held wherever the Lord opens the door,” says another ministry leader.

“Relationships are built by providing for some of their needs, such as food, medicine, and nursing care. The Word is preached and Bibles are given out. When our evangelistic team leaves the village, we leave behind a church planter. In time he will disciple a vessel chosen from the tribe to become the church leader. This new disciple is then brought back to our training center for three months of training. When he returns to his village, he will take over as pastor. Our original worker is then ‘rotated’ into another un-reached area,” explains another Burmese leader.

Christian Aid says that while much has been accomplished, much needs to be done.

The ministry explains: “Many people who survived the cyclone are still without adequate shelter or other basic necessities. More follow-up is needed in the remote villages where the gospel has been heard for the first time. Income generating projects, such as raising pigs or ducks, will help the people re-establish their lives. (Businesses that were destroyed during the cyclone are no longer a source of income.)”

“Please continue to pray for our ministry,” writes Brother G. “My most pressing goal is to witness in every nook and corner of our country before the imminent return of our Lord Jesus.”

Christian Aid seeks to establish a witness f our Lord Jesus Christ among unreached people groups by assisting highly effective native missionaries who already know the language and culture and are getting the job done for less cost.

Report from the Christian Telegraph