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Some of us find the process of packing for a trip, tough. I consider myself lucky not to have this gene, but, sympathise with those who need to factor in variables from the medium term weather forecast in the various destinations to the range of possible social functions to time of day those might take place to potential minor medical needs en route…single or multiple elastoplasts, number of courses of quinolones even tweezers for hazards from clifftop gorse to Pacific spiky anemone under flipper unshielded heels. These, though are decisions for the privileged. What if you have forfeited control of any of the journey and any of the navigation? That’s when the baggage gets really heavy.
An elegant way (and there are plenty cumbersome ones) of defining Global Health is ‘the study of inequities and advocacy for those vulnerable to them’. Elegant, because this makes no assumptions about domicile or wealth income but, somehow covers all these exposures simultaneously. This (purposefully) means it is equally relevant in Lima as it is in Lagos, Laos or in London. Does this mean the boundaries are too broad? Emphatically, not. The universality of the philosophy is poignantly demonstrated by two papers this month. Both deal with the plight of child refugees after leaving their countries of origin. Stepping onto the shore of a high income country should be the start of a new chapter, rather than a continuation of the journey from the conflict, sexual violence, mental illness burdened, human rights bereft environment of origin. But sadly that’s rarely the case. Nuria Sanchez-Clemente from University College Hospital, London and colleagues describe that the ‘welcome’ the UK profers does these children a huge disservice. Having opted out of the Dubs amendment to the Immigration Bill and (once EU membership and the attendant accountability was rescinded) the Dublin III amendment, hands were washed of responsibility… The accountability-theme baton is passed seamlessly to Lahiru Amaresena’s group from the University of Sydney and other Australian centres. The ‘Nauru scheme’ began in the early 2000s, sold as a way of regulating refugee boat traffic, but in essence a stalling mechanism. Here in the stifling heat under unlaundered tarpaulin, children (mainly from South Asia) went slowly (or quickly) downhill, many trapped there for years, the last only released in 2019 when the advocacy issues could no longer be suppressed. By this stage, of course, it was too late for many, the scars overt, the damage done, mental illness the norm, a barometer of their years in this offshore prison. See pages 160 and 185
How far is too far
Adding yet another new flavour to the always-thought-provoking Clinical Law series, Rob Wheeler (Southampton, UK) swings his case analysis lens to the emotive, intangible area of the lengths one can reasonably go to administer a treatment. In stark contrast to the policy deficiencies refugees have had to endure, the legal processes in this and similar cases all have the same aim: the best interests of the child. The problem is that the ‘best interests’ aren’t always clear and can be so subjective that colleagues even within a specialist team might have quite different views. Sedation is used routinely to make the intolerable, tolerable. But, is ventilation for weeks simply a continuum of that spectrum or does it transgress tacit boundaries of force? See page 172
One of the positives of the pandemic was that, as a consequence of limited inpatient space, it forced the rethinking of old (sometimes tired even) approaches. Thomas Jackson (UCL, London) and UK oncology-centre colleagues provide an excellent example describing the revision and testing of the Covid-induced revision to the febrile neutropenia guidance by the Children’s Cancer and Leukaemia Group (CCLG). The recommendations were based on the validated, risk stratified, Australian-UK-Swiss (AUS) guidance, the main difference in treatment approach simply the substitution of oral antibiotics from early ambulatory intravenous equivalents. Time to home was shortened dramatically, family time and ‘normal life’ enhanced and with no hint of adverse effects. How often, have discharge decisions traditionally been put on hold from the end of 1 week to the start of the next on the basis of lab availability. See page 192
Missing the boat
Children with asthma are equivalent in cardiovascular terms as others (*), right? Johan Moreau in Bordeaux, France and colleagues present the findings of a comparison of VO2 max by standard cardiopulmonary exercise testing (CPET) between a large group of tertiary care-managed asthmatic children and non-asthmatic controls. Asthma alone predicted significantly worse VO2, lower FEV1 and high BMI being additional risk factors. As with any cross-sectional data, it pays not to jump to causal inference, but, it’s no leap to say this association is worthy of testing prospectively… and that, if it meets the proviso of temporality, then might have potential as a treatment-modifying test in a clinic-user friendly form. Home VO2 max and exhaled nitric oxide diaries, anyone? *We have a responsibility to make sure they are… See page 204
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
- Original research
- Clinical law for clinical practice
- Original research
- Original research