Innovations in Public Health with Prof Moyez Jiwa

Author: Curtin University

When Susanna asked me to do this talk, I was reminded of a conversation at our dinner table when I was 17 years old. So you can picture the scene, we're all sitting around the table. There's me, mum and dad, and my brother. And dad announces I know about women, he said, and what 17-year-old doesn't want to hear about the exploits of his father. He says yeah, I know about women. Says, take a look at your mum. I am in the winner's circle. He says, do you know what the secret is? The secret is let her do all the talking on your first date, then you're sure to be asked for a second date.

So later on dad was doing the washing up, mum takes me aside and she says I know about men, take a look at your father doing the washing up. She said, you know what the secret is? The secret is don't reveal everything on the first date. [Laughter] So you're hear to hear me wrap on about a half an hour uninterrupted, and I promise not to reveal everything on this, our first date, so that I'll be asked again.

There are really three messages in this talk. The first is that innovations that would change healthcare will be welcomed into people's lives. This is a critically important point. There will be a push from scientists, but there will also be a pull from people who will be invited to use these innovations. The innovations that will make the most difference in my view are intuitive, creative, cheap, and developed by people with a real understanding of healthcare.

And thirdly, tonight I invite you on this very evening to innovate with me. Now Apple don't just make computers and phones, Apple make tools that connect people. Apple is a company that we'd most like to emulate as innovators. And this video tells the story. [music] This picture tells the story of health innovation. This is how amputations were done in the 1800's. And what you see there is a child with a gangrenous leg being strapped down into a gurney by two Burly men, she's been given some whiskey to drink, and the chap with the rusty saw is going to take her leg off.

Innovations in Public Health with Prof Moyez Jiwa

And this will take between three and ten minutes. Three and ten agonising minutes. There are two things wrong with this picture that we recognise today. The first is the child has no anaesthetic, and the second is that there's no sign of mask or a glove, and there's lots of bad hairdos. So what happened is that in 1846 anaesthesia was announced or discovered. There was a chap working in the Massachusetts General Hospital called Morton who administered a gas to a chap who was having a tumour removed from his jaw.

He refused to tell anybody what was actually in that anaesthetic because he said, oh, well, it's all going to be patented, so I'm not letting this out of the bag. So within six months -- within six months it became a global phenomenon. In other words, somebody said well, I think it was ether, and the rest, as they say, was history.

It took six months for that to take off. At the same time, about 1867, published in the lancet was the story of how infections were caused by bugs, and this was a major cause for asepsis and death in surgery. But it took a generation for that to take off in -- and to be accepted as routine practice. Why is that? There was one crucial difference between the two things, and it is the story of innovation. First, the first one, the anaesthetic combatted a visible and immediate problem which is pain.

The other combatted an invisible problem, germs, whose effects wouldn't be manifest until well after the operation. So the patient died, well, it took a few -- they paid their bill first. Second, although both made life better for patients only one made life better for doctors. Anaesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considerate procedure. Listerism, as it was called, and that's aseptic techniques, required the operator to work in a shower of carbolic acid. Even low dilutions burn surgeon's hands, and you can imagine why listerioses crusade might have been a tough sell. So this is where we think, certainly in popular culture where innovations happen. There's years of research, big grants, and hope for cancer, a cure for cancer, or the Gardasil vaccine that will make us the next billion dollars for the economy.

Or maybe this is where geniuses work, up into the [Inaudible] institute in Singapore. It's got nine stories of glass-fronted offices, in prime city-centre location, with a gazillion dollars of government money, and you know, it's where we expect great things to come from. But in my experience this is where heroes really work. Intuitive, creative, problem solvers. They see people at their most vulnerable. As Seth Golden says, just about all the big decision innovations and perfect solutions around you didn't start that way. In other words, the way of the [Inaudible] institute and so on. They weren't the result of a ten-person committee carefully considering all options, testing the reasonable ones, and putting in place a top-down implementation that went flawlessly.

The idea behind Amazon, the mail [Inaudible] logo, the medical approach to childhood Leukaemia and so on. No, they were the result of one person in a jam or in a hurry or somewhat inspired, one person flipping a coin or tweaking a little bit more, or saying this might not work, and then again taking a leap. It reminds me of the story about the four doctors in a pub. So there was a surgeon, a physician, a [Inaudible] and a GP. And the GP had had a couple of pints. We do occasionally have a couple of pints. And he said to his colleague, said to the surgeon, well, you know nothing, but you can do a lot. And he said to the physician, well you know a lot, but you can't do much.

He turns to the [Inaudible] and said well, you know a lot, and you can do a lot, but it's always too late. So the guys were getting fed up and they said to the GP, well, you know nothing and you can do nothing. And the GP said, well my patients always get better and they can always get an appointment.

[laughter] The clever idea, the gizmo, the gadget is only going to make an impact if it's part of someone's story and it's delivered in a context of people's lives. Now I'd like to present you three case studies which will tell something of the story of innovations which have been crafted within the story of the people involved. And I want to start back in the UK. In the 1990's when I was working as a GP in a little town called Redford In North Nottinghamshire. And this was the usual scene, the demand for a GP appointments had gone through the ceiling. It was a buyer's market as far as GP's were concerned, I could get a job almost anywhere in the country. Queues were out the door.

And as my receptionist pointed out, there's a seasonal pattern she said, to this demand for same day appointments, people who want to be seen by a doctor you are gently. There's a week around February and a trough around about October time. So it's an interesting observation.

So what was the doctor's story in this situation? Well I remember it well because we were struggling to keep the doctors we had, particularly the female doctors who had young families and had to get bath home and be involved in bath time and story time, and all the rest of it. Doctors were getting fed up because they're having to fit patients into already booked surgeries, they felt they were providing poor service and most of them were voting with their feet and either moving practice, and I think quite a number ended up coming to Australia at the time. What was the receptionist's story? The receptionists were often members of the local community, someone's neighbour, someone's friend, someone's aunt, and they were turning people away or having to deal with grumpy doctors when they were having to fit people into these overfull surgeries. What was worse was, and I remember standing there listening to this conversation, this patient phoned up, and I could hear my receptionist talking, and she said, well, Janice, would you just give him a little bit of cow pull, and if he's not better phone me first thing in the morning and I'll fit him into surgery. And I was thinking that receptionist without any medical qualifications is giving somebody advice for which I have a vicarious liability. If that turns out to be meningitis tonight, we've all had it.

And what was the patient's story? The patients wanted simply to know is it urgent, is it serious, and are you qualified to advice me on this issue. They were tired of getting a call that says for emergencies press one, if it's a prescription, press two. They just wanted to talk to somebody. And that's exactly what we did.

We put doctors at the forefront of speaking directly to patients when they wanted a same-day appointment. So there's a point in the surgery where the receptionist said these five people have phoned this morning, they want an urgent appointment, I've said you'll call them back, and you decide whether or not they need an appointment. Now we knew there was a seasonal demand for same day appointments, and as it happens, I was working at Sheffield University, next door to my [Inaudible] is an expert on time series. And he said whatever intervention you put in place here I'll be able to tell you if it is a robust effect over the course of a year.

And that's exactly what happened. We dropped the demand for same-day appointments by 40%. And what made it possible I am quite convinced is the fact that our doctors were going home on time, they were able to be with their families, they were able to have a better quality of life, and at work, and became part -- very quickly became part not just of our practice but there's another story, and it ended up as national policy in the UK, telephone triage, for same-day appointments. Right, move forward now to Australia of today around what innovation could we put in place that might help.

I want you to picture this scene. This is called Gardi, this is a town as you know here in Western Australia, 800 people living there. It's a town that is struggling to survive particularly because medical cover is really quite difficult. So what we did was we thought, well, soon this town, if you believe the rhetoric, will be linked up on the national broad band network, and it will be possible for people to access -- may be possible for people to access doctors on line.

So why not do that, why don't we have this happen. So what we did was we presented six videos of patients who might conceivably contact a doctor, a GP, about a problem. And we wanted to know what doctors would do about this -- in theory what we would do about this. And here's one of the videos. Hello, I'm -- I've had a sore throat for about three days, a bit of a cough. And I -- I've got no -- I've had no fever, only just at the very beginning. And I feel I've got no cold symptoms, I'm not sneezing, and I haven't got a runny nose. I'm sleeping well, I've got a good appetite, and my breathing is fine.

But I feel if I could have some antibiotics it would just help me, it would get rid of it a lot more quickly. Well, I've had a cold before, I've had antibiotics, and they've been fantastic. And within a day I'm back at work and shouting as usual. So antibiotics would be fantastic. Antibiotics would be fantastic.

Yeah. No, GPs weren't buying this. They voted very much only one third would be to continue with consultations like this on line. Their biggest concern was that they wouldn't be able to examine the patient and therefore wouldn't be able to make a robust diagnosis, and so on and so forth.

Very interesting. Talk to the patient on the phone where you're not even seeing them, but not fine to talk to the patient on video, where you can see them and where you can potentially say, you know, get devices that would actually be able to make measurements and send you the information, et cetera. But it's not part of the doctor's story.

It's not part of the doctor's story because there is no incentive for this to happen in our country at the moment. We are not paid to carry out video consultations, there's this ongoing concern about our ability to examine the patient. And video consultations do not necessarily make life easier for us. Until that issue was addressed, it's not part of the story, and innovation like this will not become established practice. I want to go now to the second example of innovation. And who hasn't heard this message, who doesn't know that smoking kills? It causes lung cancer, it causes heart disease, it harms the unborn child. You see these on the side of cigarette packets. But here still we have a problem, because as had been said repeatedly in the recent past, smoking is still being taken up by young girls more than it used to be in some areas, and it is certainly still a problem among disadvantaged communities.

So why is this? Is it that young girls have lost the ability to read? That suddenly they are -- they don't realise that smoking kills? And what can we do about it? Well, perhaps dove has the answer. And I'm going to play you a video. Let's see what you think of this. It couldn't be more critical, she said. How many of you have got daughters don't think that our appearance doesn't matter to her. My friend, my colleague Oksana Burford spent two or three years of her life, I think, doing some research using software that photo aged people to show them the impact of smoking on the young people, the impact of smoking on their faces. And the results were quite fantastic because what you can see from here, the difference between year 55, smoking and non smoking, this research which has now been published in the Journal of Medical Internet Research demonstrated that you can stop one in seven smokers using this technology.

I, as a GP, would do well to get 1 in 20 to stop smoking, just by badgering them morning, noon, and night about their smoking habits. This intervention stopped 1 in 7. Some of this was picked up on -- recorded on video, and I want to play you that short video which shows the effect when people were shown their images. The software creates a stream of age images of faces from a standard digital photograph. The wrinkling or ageing algorithms are based on research on more than 7,000 people of all ages, ethnicity, and lifestyle habits, as well as unpublished data regarding facial changes associated with ageing. Additionally, the resulting aged images can be adjusted to compare how a person will age as a smoker versus a non smoker, if he or she adds excessive weight, or if they experience a high degree of unprotected sun exposure.

The subjects are photographed using a standard digital camera. The photographs are then photo aged with and without a history of cigarette smoking using the software which recognises specific landmarks on the subject's face. The impact of cigarette-related skin damage is vividly demonstrated to the subject of the study. At the moment I can see it, you're 65 years of age, you're smoking here. You ready to have a look at it. Okay.

Okay, you ready? So here we are, a smoker at the age of 65. Wow. Okay? That is shocking. It's not just a celebrity or model whose face is shown, this is a personalised health promotion message.

It appeals to young people because it offers them a rather rare glimpse into the future. The next issue that we face, similar issue, if you want to think of it that way, is that by 2025, 80% of the Australian population will be either overweight or obese, and the figures in America are even worse. You're talking about 90% of the population either overweight or obese. And you can imagine the impact on that on the incidence of diabetes, particularly in younger people. So we currently, even in Perth, have teenagers being admitted with type two diabetes, which is diabetes associated with, you know, much more common in much older people who put on a lot of weight, heart disease, cancer, and so on and so forth. What can we do about this using some of the techniques we've used with other problems.

So you might have seen this on channel nine last night, we unveiled it. And it's called Future Me. And what it does is takes a picture of you as you are now, you put it in your details. And then it shows you what you're going to look like in time, right through to whenever you would like to look like. So you pet in the number of calories, you put in the number of demand of exercise you're going to do, and it presents you with an image of yourself. What we imagine will happen is that people will use those images to sustain their motivation to lose weight by adhering to exercise and a diet regimen.

Now we know for example about 98% of people give up after four or eight weeks of, you know, suffering, as it were, diet and exercise, and just when they're going to make a change to how they feel and how they look, they give up. What we hope the Future Me will do is make that -- sustain that motivation. This is colorectal cancer, and this is my third case study. 80% of patients with this disease are diagnosed when they present with symptoms. 80% can be cured if they're diagnosed in time, before the disease spreads. But 40% are diagnosed only after the disease has spread beyond the bowel wall.

The prognosis is worse in men than in women, there are biological reasons for this. But also, as Dr. Durvayshioburro who I think is here today; finding in his research, health seeking reasons why men -- they're health seeking reasons why men are diagnosed later. I want to talk a little bit about that, and what we could possibly think about doing there. So the symptoms of bowel disease are diarrhoea, bleeding from the back passage, abdominal pain, passing mucous, and the feeling of incomplete evacuation of the bowel. So you experience all of this, and you want to go and tell your mates about it, don't you? Well, I'd like you to watch this video of a very brave man being -- having a chat with his doctor and imagine how he's feeling, particularly if you're a man. [laughter] Yeah, want to visit your wiping technique. Who wants to -- doesn't want to hear that from a perfect stranger.

No wonder men don't rack up for this kind of thing. So what happens, I mean, you know, who wants -- who wants to volunteer to have a rectal examination from a perfect stranger? Well, I don't anyway. Just in case. So where do they go? They end up -- sometimes end up at pharmacies. So they go up to the lady at the counter and they go, I'm passing mucus.

No, they don't. They go in and they rush in to get whatever they can get, and they run out the door and they procrastinate. And they procrastinate, and the prognosis gets worse. What we need in a situation like this is something that's private, reliable, that's convenient, and that's free where you can talk about your symptoms. And my colleague Deepashram is working on the Jodi Lee test, which is a test that will be administered in community pharmacies that does all of those things. We're coming towards the end of this presentation and I want to now focus on what it is medicine has to offer and how things can work in terms of creating innovation that's fit into our stories. Everyone owns a device that measures things.

It can measure your blood pressure, pulse, exercise, the amount of food you take, it can even diagnosis malaria, and we're current working on one that is going to diagnosis Dengue fever. So this device is set to take a huge -- play a huge role in our lives. So where does medicine fit into this? Is it likely we're going to stop going to see the GP. And I want to show you one photograph, and when I saw this photograph I knew that there is a future for us GP's.

And here it is. This child is looking straight into the eyes of the doctor, and he's telling himself a story. A story about trust, about hope, about caring. This is a visceral, emotional connection that in time will be central to the act of recovery from the disease.

The value of medicine in our ability to connect with people. So how do we translate this into the future? We did a little experiment a couple of years ago, and we presented photographs like this to people who were waiting to collect their prescriptions in a pharmacy. And we asked them based only on the photograph in front of you, the man sitting in front of you, knowing nothing else about him, can you say whether this man -- can you say how much this man is ethical, moral, honest, genuine, and trustworthy based only on the photograph? Then we showed them these photographs. And they were five times as likely to say this man was ethical, moral, honest, genuine, and trustworthy.

This symbolism may allow us to translate caring from a physical presence to a virtual presence and it's what we need to incorporate in our innovations. We yearn for frictionless, technological solutions, but people talking to people is still the way norms and standards change. Now here's your opportunity to do a little bit of innovating yourselves. And I want to illustrate to you a problem, and I want you to think about it on your way home tonight. So here it is, this box was taken from my surgery yesterday.

And it's exactly as it was when I -- when it was in the room. And I'm going to put some gloves on. So here's me, putting these gloves on. Assume the position. [Laughter] not quite. Right.

Who's got a leg ulcer? Anyone got a leg ulcer? Would you like -- would you be happy for me to examine your leg ulcer with my hands now that they've been gloved up? No? Why ever not? I'm perfectly okay. All right, the gloves come out of the box and the gloves are brand new. All right.

You're right. You don't want me to touch you with these. And here's the reason. What I loved about when Prince George was born the New Zealand newspapers had the headline it's a boy. When you go -- as you wend your way home tonight think about the issue of the design of that box, we will be running a competition at the Australasian medical journal to, you know, design a box that stops this problem, and there will be a small cash prize and a trophy for the winner.

Well, we think that people like you are going to -- going to have the solution to this. We're talking about, you know, cheap intuitive, creative solutions to problems that can make a real difference to the way that healthcare is delivered. Impact is not about disrupting the system, I think that there will always be a role for that consultation between the doctor and the patient. But it's about changing how people feel, it's making them party of the story, it's making life easier for the patients, but it's also about making life easier for the doctors. And you can read some more about this on my blog, it's, and please do visit the AM J. Thank you.

[Applause] [ Music ].

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