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Yemen’s cholera outbreak now the worst in history as millionth case looms

The cholera epidemic in Yemen has become the largest and fastest-spreading outbreak of the disease in modern history, with a million cases expected by the end of the year and at least 600,000 children likely to be affected.

The World Health Organization has reported more than 815,000 suspected cases of the disease in Yemen and 2,156 deaths. About 4,000 suspected cases are being reported daily, more than half of which are among children under five, who account for a quarter of all cases.

The spread of the outbreak, which has quickly surpassed Haiti as the biggest since modern records began in 1949, has been exacerbated by hunger and malnutrition. While there were 815,000 cases of cholera in Haiti between 2010 and 2017, Yemen has exceeded that number in just six months.

Save the Children has warned that, at the current rate of infection, the number of cases will reach seven figures before the turn of the year, 60% of which will be among children. In July, the International Committee of the Red Cross predicted there would be 600,000 suspected cholera cases in the country by the end of the year.

Tamer Kirolos, Save the Children’s country director for Yemen, said an outbreak of this scale and speed is “what you get when a country is brought to its knees by conflict, when a healthcare system is on the brink of collapse, when its children are starving, and when its people are blocked from getting the medical treatment they need”.

Kirolos said: “There’s no doubt this is a man-made crisis. Cholera only rears its head when there’s a complete and total breakdown in sanitation. All parties to the conflict must take responsibility for the health emergency we find ourselves in.”

More than two years of fighting between the Saudi-led coalition and Houthi rebels has crippled the country, causing widespread internal displacement, the collapse of the public health system, and leaving millions on the brink of famine.

When I see a mother lose her baby because of cholera, it makes me so angry

Dr Mariam Aldogani, Save the Children

The crisis was exacerbated when sanitation workers whose salaries had gone unpaid went on strike. This meant garbage was left on the streets, which was then washed into the water supply. It is estimated that 19.3 million Yemenis – more than two-thirds of the population – do not have access to clean water and sanitation.

The government stopped funding the public health department in 2016, meaning many doctors and hospital staff have not received salaries for more than a year. Healthcare has since been provided mainly by international organisations, the efforts of whom have been hampered by the conflict.

The spread of the disease has nonetheless slowed. At the beginning of the most recent outbreak, in May this year, between 5,000 and 6,000 new cases were detected daily. That rate has since dropped to just under 4,000 a day. The mortality rate has also declined, from 1% at the beginning of the outbreak to 0.26% now.

“Whatever decline we’re seeing now is due to the heroic efforts of workers at the scene,” said Sherin Varkey, the officiating representative of Unicef Yemen.

Varkey said the situation would not be solved until there was peace in the country.

“There are no signals that give us any reason for optimism. We know that both parties to the conflict are continuing with their blatant disregard of the rights of children,” he said. “We’re at a cliff and we’re staring down and it is bottomless. There seems to be no hope.”

A worker is pictured in a government hospital’s drug store in Sana’a, Yemen

A worker is seen at a government hospital’s drug store in Sana’a, Yemen. Photograph: Khaled Abdullah/Reuters

Cholera should be easily treatable with oral rehydration salts and access to clean water. But Mariam Aldogani, Save the Children’s health adviser for the city of Hodeidah, said conditions in the country had made this very difficult.

Aldogani said: “All the NGOs are trying to increase the knowledge of how to prevent the disease, because it’s preventable, you have to boil the water. But if you don’t have money to buy gas, and you have to walk a long way to get the wood, how can you boil the water?”

Aldogani, who has been a doctor since 2010, said witnessing the suffering of her patients was deeply painful. “I saw one young man, he had cholera and severe dehydration. He was in a coma and he died in front of his mother. We tried our best, but he came too late and she was crying, and I cried. It makes me angry. When I see a mother lose her baby, especially a stillbirth, she waits for this baby for a long time and then she loses it because of cholera, it makes me so angry.

“The war is a big problem for us, it’s a wound. But with the cholera, you have the wound and you put salt in the wound. It hurts. I hope this war can be stopped. We need peace for the children of Yemen. Our situation before the war was not good, but it was not like this.”

Crisis looms for social policy agenda as Brexit preoccupies Whitehall

Ever since Theresa May set out her vision to govern for everyone and not just the privileged few last July, those in the charity sector who work to reduce poverty and inequality have waited patiently. Campbell Robb, the chief executive of the Joseph Rowntree Foundation, was one of many charity leaders who hoped for progress. He wanted to see a revamp of the government’s much-criticised “troubled families” programme, a £1bn scheme set up by David Cameron in 2011 and billed as the Tories’ flagship social policy initiative.

But when the Department for Communities and Local Government issued its first annual report on the programme , the charity sector was hugely disappointed. Robb described the document that emerged as “thin” and a “testament to the vacuum” that exists where we need to see “big political and social change”. It was barely noted in the media, which focused instead on a range of austerity-driven changes to the tax and benefit system, announced originally by George Osborne, which came into effect at the beginning of the new tax year. The changes hit the poorest hardest, while helping millions of the better off. The view increasingly held by thinktanks, and across the public sector, is that May’s government – even if well intentioned in wanting to reduce inequality and enhance opportunity for all – is too distracted and too constrained by the state of the public finances to do so.

“There is a danger that Brexit could suck the oxygen out of attempts to implement a sweeping programme of social and economic reform that is badly needed at home,” Robb said.

Even within parts of the Tory party, MPs and others worry that Brexit is now the only show in Whitehall, one so all-consuming, so draining of civil service and ministerial energies that everything else – the May agenda included – is on the back burner.

“David Cameron came into office with a new social vision of Conservatism and promptly sacrificed it on the altar of austerity,” says Phillip Blond, director of the ResPublica thinktank. “It is vital Theresa May does not let her one-nation Conservatism experience a similar sacrifice at the behest of Brexit. The trouble with Brexit is that those who voted against the EU as a proxy for globalisation and its general destruction of working-class security, risk finding May’s ‘global Britain’ to be far, far worse for them.”

Ryan Shorthouse, director of the liberal conservative thinktank Bright Blue, says he always suspected Brexit would syphon the energy out of Whitehall and voted against it partly for that reason: “A persuasive argument for voting Remain, I thought, was the lengthy and disproportionate focus that would be required of politicians and policy-makers to undertake the process of Brexit, which is indeed what we are now experiencing. There are other important and pressing issues that urgently require deeper thinking and discussion: the affordability and quality of social care, the upskilling of those on the lowest incomes, the financial sustainability of the NHS, and decarbonising our economy.” The green agenda, once central to May’s predecessor, hardly registers these days.

When the financial crisis broke in 2008, Nick Pearce, now professor of public policy at the University of Bath, was in charge of the No 10 policy unit under Gordon Brown. “It was the biggest economic shock the UK had faced since the second world war,” he says. But it did not preoccupy every government department as Brexit does. “It was largely dealt with by the prime minister, his advisers, the chancellor and Treasury officials, and the Bank of England. It was not like Brexit. Most of Whitehall now has Brexit at the top of the in-tray.”

It has already been decided that the next Queen’s Speech will be dominated by Brexit-related bills. Ministers have been told to limit their bids for domestic legislation so the way is clear for parliament to focus on the “great repeal bill”, which will incorporate the mass of EU law into UK law, and on other Brexit-related bills including one on immigration. A recent report by the National Audit Office says the civil service has already created more than 1,000 extra roles in the two new Brexit departments – for International Trade and for Exiting the EU.

‘Lego bricks and boiled eggs’: the three Brexiteers explain everything

And that is just the start, as the search for trade experts – outsourced over the last four decades to Brussels – intensifies. Many civil servants have shifted from domestic roles to Brexit posts in a huge, destabilising, but necessary, reconfiguration of Whitehall. Jeremy Heywood, the cabinet secretary, has described the task of managing his Brexit troops in Whitehall as “the biggest, most complex challenge facing the civil service in our peacetime history”. The NAO says new skills have to be learnt and found – a process which inevitably means less use of expertise gathered over decades by senior mandarins.

The poorest third of households are faring even worse than they did after the 2008 crash

The Resolution Foundation

Its report says: “Departments which have had large amounts of EU-derived funding and legislation, for example, will need legal, economic and sector experts to deal with the implications of leaving the European Union, and will have to do so using their remaining staff while also seeking to achieve pre-existing priorities.” Lord Kerslake, a former head of the civil service, says it is entirely right that the focus is on delivering a successful Brexit, but he fears problems will develop down the line in unrelated but vitally important areas as eyes are taken off the ball. “Nobody has quite got the measure of this because of the dominance of Brexit,” Kerslake says.

“Of course there is a need to equip government for Brexit but there is also a need to carry on with the rest of the business of government. There is a risk for the government in this: that things that would have surfaced through being debated and being challenged in normal times will now not surface early, and not until they become crises.”

Angel of the North

The Angel of the North statue. The fate of English devolution – formerly a priority – is in question. Photograph: Christopher Thomond for the Guardian

Emma Norris, programme director at the Institute for Government, says the repercussions are already being felt on issues of critical importance. “After trailing a big decision on airports, a parliamentary vote on Heathrow was pushed to late 2017. Key social reform policies in education have been delayed too, like the national funding formula, which was originally due to be implemented this year, but will be delivered at least 12 months late.

“The fate of English devolution – formerly a major priority – is also in question. Adult social care and hospitals are being pushed to breaking point and, in the case of prisons, beyond it. Ambitions to reduce demand, make better use of technology and find new ways of working have yet to be realised. Without action, within the next two years the government could face a disastrous combination of failing public services and breached spending controls against the backdrop of Brexit.”

She adds: “Even the prime minister’s personal priorities are moving slowly. David Cameron’s life chances strategy was scrapped in favour of a new focus on social mobility. But many of the details of this are yet to come and, as the Social Mobility Commission recently reported, inequality is rising.”

The Resolution Foundation maintains that the need to address stagnating living standards and rising inequality is “the non-Brexit challenge of this parliament”. It points out that typical incomes are set to grow by 3% over this parliament – barely any faster than during the Blair/Brown Labour governments, which coincided with the financial crisis and its aftermath. The thinktank says May’s priority, the “just managing families”, are doing worst of all, with the poorest third of households faring even worse than they did after the 2008 crash. This, it predicts, means we are heading for the “biggest rise in inequality since Margaret Thatcher was in Downing Street”.

Pearce points out that Brexit will also skew spending priorities, creating new pressures on finite resources for a government struggling to keep public finances on a tight rein. “Economic priorities – such as R&D, skills and infrastructure spending – will get higher priority in public spending. Brexit will also create powerful new lobbies, such as farmers, universities and key business sectors, who will be arguing for funding to replace lost European Union resources. These lobbies will find themselves competing with the public services that have lost most from austerity, such as social care. And they will also be up against a neo-Thatcherite wing of the Conservative party that wants to use Brexit to cut corporate taxes and public spending even further.”

Torsten Bell, the Resolution Foundation director, says May cannot afford to overlook problems at home as she conducts her Brexit battles with the EU. “The living standards outlook is bleak and risks giving us the inequality rises of the 1980s, without the feelgood factor of rising incomes. But it can and should change. After all, Theresa May knows her record will be judged as much on the Britain she builds as the Brexit she delivers.”

Another NHS crisis looms – an inability to analyse data

Public institutions such as the National Health Service increasingly want—and are expected—to base their actions on nationally agreed standards, rather than anecdote. The collection and analysis of data, when done responsibly and in a trusted manner, has the potential to improve treatment and improve the social and economic value of healthcare.

However, the goal of using data to improve the NHS and social care is hampered by a talent gap – a lack of personnel with data analytical skills – that stands in the way of uncovering the rich insights that reside in the NHS’ own data. The NHS is not unique among institutions that are struggling to identify, hire and retain people with data science skills and the ability to apply these.

Take two examples. The Healthcare Quality Improvement Partnership (HQIP) conducts forty annual audits comparing hospital and physician outcomes, and the implementation of National Institute of Clinical Excellence standards across England and Wales. But, as HQIP Director Dr. Danny Keenan admits, although they have the expertise to do the analysis, “we are woefully inadequate at translating such analysis into improvements. What’s the takeaway for the hospital or community provider Board or the medical director? They cannot understand what they have to do.”

Dr. Geraldine Strathdee chairs the National Mental Health Intelligence Network, based at Public Health England. Together with partners, this launched the Fingertips Mental Health data dashboard of common mental health conditions in every locality. Strathdee points out there is a tremendous need for such benchmarking data: to design services based on local need, build community assets, and improve NHS services.

Without it, NHS resourcing is just based on historical allocations, guesswork or the “loudest voice”. An example is psychosis: “you can spend sixty percent of your budget on poorly treated psychosis with people ending up in hospital beds, homeless or in prison, and less than ten per cent ever get employment,” says Strathdee. The data dictates investment in early intervention psychosis teams, which dramatically improves outcomes. Fifty per cent of patients get back to education, training or employment. However, there is a shortage of people able to draw these insights. “We have a major capability level problem everywhere,” says Strathdee.

Over the past twenty years, the NHS has amassed increasing amounts of data. There is an almost universal consensus that, when used ethically and responsibly, with respect for the confidentiality of all patients (especially of vulnerable populations such as immigrants), better use of data could bring about more high quality, accessible and effective services. But this requires more than just technology. The NHS needs data analytical talent, which comes from a variety of disciplines.

This includes the ability to ask the questions and identify patterns in both structured and unstructured records. For example, Leeds Teaching Hospitals analyse approximately one million unstructured case files per month. They have identified thirty distinct areas for improvement by using natural language processing to identify wasteful procedures such as unnecessary diagnostic tests and treatments.

Data analysis also requires people who know how to apply diverse statistical methods to determine future outcomes. EPSRC has funded five research centres around the UK that will apply mathematics and statistics to prediction models in order to help clinicians tackle health challenges such as cancer, heart disease and antimicrobial resistance.

Improving public institutions with data also requires strong communications, design and visualisation skills. Digital designers are needed who know how to turn raw data into dashboards and other feedback mechanisms, to support managers’ decisions. And none of this is possible without the legal and ethical training that allows for the development of policies, platforms and procedures that enable data to be shared and algorithms to be used responsibly and effectively.

So the NHS needs to be able to tap into a wide range of data analytic know-how, from computer scientists, statisticians, economists, ethicists and social scientists. It is impractical and expensive to meet all of these needs through more hiring. But there are other ways that the NHS can match its demand for data expertise to the supply of knowledgeable talent both within and outside the organization.

For example, to make better use of sensitive administrative data to measure what works, the NHS should expand efforts already underway to construct an NHS Data Lab, modelled on the Ministry of Justice’s Data Lab. The MoJ’s Data Lab is a secure facility that accepts requests from anyone wishing to test the effectiveness of a program by using the government’s administrative data. It has conducted over 173 analyses over the past three years.

The NHS should also create a variety of online knowledge networks for those inside and outside the NHS, especially in universities, who possess the skills and willingness to help with data analytical questions. For example, last week the Rockefeller Foundation launched the Zilient platform to connect resilience practitioners, and the GovLab and Justice Management Institute launched DataJustice. Both are designed to connect networks of professionals for mutual learning.

NHS Improvement and the Health Foundation created an online network for improvement practitioners called the Q Network. Now NHS England is taking steps to create a Population Health Analytics Network, bringing academics, commercial and charitable organizations together to accelerate learning. But it can do more and expand the agility and scale of such groups, using new technology.

Such networking platforms help to catalogue relevant skills and make them more searchable. For example, the World Bank’s SkillFinder tracks expertise across three dimensions: technical expertise, geography, and business processes. In New York City, the Mayor’s Office Volunteer Language Bank tracks only a single skill—translation—to match the supply of multilingual civil servants to the demand for translation services.

Whether the NHS wants to know how to spot the most high-risk patients or where to allocate beds during a particularly cold winter, it can use online networks to find the talent hiding in plain sight, inside and outside the health and social care system. Regardless of the platform the NHS adopts, it needs to convene the different bodies already undertaking data analytical work, to compare research agendas, share learning, and identify gaps in its needs for data science skills.

Beth Simone Noveck is the Florence Rogatz Visiting Clinical Professor of Law at the Yale Law School and the Jerry M. Hultin Global Network Professor of Engineering at New York University, where she directs the Governance Lab. With support from NHS England, the GovLab published a report this week on “Smarter Health: Boosting Analytical Capacity at NHS England” which is available here.

NHS seeks to reduce winter deaths as sub-zero weather looms across UK

Sub-zero temperatures are expected to sweep across Britain this week after the first cold snap of the year, prompting warnings that vulnerable people should prepare for a freezing winter.

The chilly weather coincides with the launch of a major NHS campaign urging people with long-term health conditions and the over-65s to take action in an effort to reduce the 25,000 extra deaths that occur each winter.

Prof Keith Willett, medical director for acute care at NHS England, said: “It is vital that the most vulnerable people take preventative steps to keep healthy and stay well. We have a high number of A&E attendances over this time that are due to issues that could have been avoided had people sought advice at the first sign of illness.”

The Stay Well This Winter campaign will use TV, radio and social media to encourage people to wrap up warm and consult a pharmacist as soon as they feel unwell rather than waiting. It also encourages people, particularly those with long-term illnesses or mobility problems, to heat their homes to at least 18C (65F) and to check on friends and neighbours who may be vulnerable.

Prof Paul Cosford, director for health protection at Public Health England, said: “With winter on the way, now is a good time to make sure you, and those you know who may be particularly at risk from the cold, are as prepared as possible. If you qualify for the free flu jab, get it now.

“Also remember that eating a healthy, balanced diet and that staying physically active can keep you healthy.”

He added that assistance with heating costs is available to those who might need it. “There are a variety of ways you can apply for help to keep your house warm, such as winter fuel payments, warm home discounts and cold weather payments. If you meet the criteria, register for priority service with your energy and water suppliers.

“Try to maintain indoor temperatures to at least 18°C (65°F), particularly if you find it hard to get around, have a long-term illness or are 65 or over. You may prefer your living room to be slightly warmer,” he said.

Cold weather increases the risk of heart failure, kidney disease, stroke or dementia, as well as making heart attacks and strokes more likely.

For each degree centigrade the temperature falls below five degrees, there is a 10% increase in the number of older people seeing their GP about breathing problems, a 0.8% increase in emergency hospital admissions, and a 3.4% increase in deaths, research shows.

The UK shivered through a chilly Bonfire night, as temperatures fell below freezing in places, snow fell on higher ground and biting winds made conditions feel colder. On Sunday night temperatures outside the south-east were expected to fall below zero across much of the country.

Tom Crocker, a forecaster at the Met Office, said the cold snap is likely to last: “The forecast over the next few days is staying rather chilly.”

The BBC expects Monday night to be the coldest so far this winter, leading to widespread frost. Crocker expected Monday to be bright but cold across much of the country.

BBC Weather (@bbcweather)

Expect the coldest night of the season so far during Monday night. Widespread frost to greet you on Tuesday morning. Stav D pic.twitter.com/z4kNVZutss

November 6, 2016

“Tuesday looks like being another relatively bright day, but we have got quite persistent rain moving in from the west on Tuesday afternoon,” he said. Snow is expected to be widespread on higher ground.

The precipitation is likely to make Tuesday night warmer, he said, although it is still likely to be below freezing in rural areas.

“It will be turning a little bit milder towards the end of the week, but still chilly and unsettled,” Crocker said. Temperatures are expected to move into the low double figures, especially in the south.

Met Office (@metoffice)

It’s another #cold day – #temperatures will struggle but it will feel much #colder than this with a strong northerly #wind – wrap up warm! pic.twitter.com/EtlvuRFx02

November 6, 2016