EPI: My understanding is that this commission represents the first time that emergency medicine is really getting a seat at the international non-communicable disease table. Is that true?
Lee Wallis: Yeah, it’s the first of its kind that I’m aware of. Emergency medicine is getting a lot of traction at the WHO, which is feeding into this commission.
EPI: How is the Lancet Commission tied to the WHO?
Wallis: A lot of the data inputs are provided by the WHO. The lead commissioner for the WHO has worked with Terry Reynolds for a long time, so she kind of nudged him to include emergency medicine in these discussions.
EPI: Is there something concrete that you hope to get out of this in terms of EM development? Besides just pushing it forward in general.
Wallis: There are several approaches going on at once. We want to define the minimum standard of care for emergency medicine, as well as the minimum resources necessary, minimum drugs, etc… What are the essentials? Also, in the Lancet commission, we’re going to try and show the evidence base for the whole emergency medicine package. If it was applied in a decent healthcare system that the poorest in the population could access, what size of impact would it make? So we’re really trying to produce some evidence for emergency medicine in terms of the scale of its impact on the whole population, so if we go from no emergency care system to a minimum EM system we’d save X number of lives and save X disability years, which would translate into this reduction of poverty leading to X effect on the GDP of the country. It’s that sort of stuff. So it’s not necessarily to put clinicians on the ground, but it is to say to ministers and policy makers and funders: look what you would get for your dollar investment in these poorest people.
EPI: How does the Commission line up with the goals of the International Federation for Emergency Medicine (IFEM)?
Wallis: IFEM has identified that in order to meet the needs of the 2016 EM world, we need to train new EPs. My personal take is that we should be promoting access to EM care to everybody, and not just via specialist emergency physicians. IFEM defines EM in the way I use the term emergency care, but I want to use EM to talk about specialty, and emergency care to talk about wider access to, for instance, a nurse who knows what’s going on. My vision for IFEM is that we should be promoting access to quality emergency care – not just emergency medicine – across the world. That’s not a vision that has been completely bought into. There are some very reasonable and well rationalized arguments as to why the focus should remain on specialist care. We’re still going through the process of working that out. We recognize that we need to either accept that we are what we are, with the current sides and functions, or IFEM needs to change. And I’m pushing to change, and several others in the leadership are pushing to change. But if we’re going to change we need to know to what. So the first thing—before we change—we need to say who are we as an organization, what we stand for, what we do, and how we should do it. The first step is to at least have a common vision. So that’s what we’ve been working on. It’s been three months now, and we have a good draft of the mission that the executives share support for, and we have it coming before the board soon for approval. Our next stage is to present that to the assembly electronically with a very specific ask of them to think about who we are, where we’re going, how we should do it, before the October assembly meeting at ACEP. At the ACEP meeting we’ll have a dedicated half-day small group brainstorm and trying to help us get the strategic document right.
EPI: I could see how that process is one you could get mired in for a while. Pretend you’ve gotten past that and tell me where you’d love for IFEM to be five years from now.
Wallis: It would be great if we had dedicated streams of funding that we were supporting on the ground work at country or sub-national levels. It may be working with individual hospitals, but as an international organization we shouldn’t be focusing on hospital-level buckets, we should be focusing on national and sub-national buckets. We would have, in my ideal, dedicated streams of funding to support those in countries where EM is in some degree of unity, working with local leadership to advocate change, build a platform of emergency care, and a prehospital system, and we’ll be building capacity. That’s a long way to get in five years, but I wouldn’t say it if I didn’t believe it was achievable.
EPI: What about specific initiatives? What is feasible on the local level?
Wallis: It’s always easy for me to frame it in African contexts. Let’s take Uganda. They’ve got a person in the ministry that’s been appointed to lead emergency care development. They’re developing a strategic plan for the country and they’re developing five-year deliverables for improving emergency care. But they don’t have the money to do it. They certainly don’t have the money to do it well. The partners they’ve engaged with—AFEM, and my university in Cape Town—we don’t have the money to do it. So it would be great for IFEM to be a main partner as a funding stream that puts IFEM people on the ground, whether it’s longitudinally or intermittently, but on the ground with the ministry, with the universities, to drive local development and training programs, specialty residency programs, helping them identify a career path for graduates of the residencies. We’d have dedicated undergraduate and post-graduate training for nurses, dedicated post-graduate training for clinical officers and EMS. We’d have IFEM experts set up their EMS policies and protocols in place, and do the equipment lists for their ambulances. We would be helping the hospitals put the clinical protocols, patient-flow protocols, triage protocols, and quality control trainings in place. Everyday emergency care in the US at a more basic level. It just didn’t exist there. These places might have a casualty unit if they’re lucky. They would benefit from doing it properly, and not from what we’ve been forced to do. We just don’t have the resources to do what we need to do, so having those resources would redirect our focus.
EPI: Any thoughts about how to get into those different streams of resources flowing, in an ideal world?
Wallis: This is one thing that we’ve been engaging in some dialogue about. We already have lots of relationships with ministry and universities, and we would go to them and ask them for their support on the basis that 20 or 30 small contributions add up to something decent. And then build a track record with those funds for 2-3 years, and then we’ll be able to attract larger funders. And at the same time start to lobby and get ourselves known among the larger funders. Funders need to be asked, not just by IFEM, but they need to be asked by countries, too. That is happening now, so I think in the next five years you’ll start to see a shift in more international funders. There’ll be money starting to come in to emergency care, which hasn’t been the case.
EPI: Switching gears, we’ve heard a lot of about ‘leapfrogging technologies’ recently, in our pages and elsewhere. Given your experience in Africa, do you think it’s true that the world’s most underserved markets will lead telehealth because of greater need and accelerated adoption of technology?
Wallis: I think that is absolutely true. Look at southeast Asia. There is a massive pride and a massive need, and the people are there, and the technologies are in everyone’s pocket.
In southeast Asia I think it’s going to be transformative. They are poor countries, but I think it’s easier to set clear guidelines, and what they’re doing with technology and emergency care is just astounding. They’re leaving us in Africa a very long way behind. India, Africa – that’s a different story. The regulatory framework is slow in those areas and it’s hard and slow to effect technology. The medical regulators tend to be very conservative in their approach to technology. I think in terms of wide impact in large parts of the world, I don’t see leapfrogging happening yet.
EPI: How do you feel about the stories coming out about drones delivering healthcare supplies in Africa?
Wallis: I hope it’s not just a gimmicky pilot—I hope it’s sustainable. I think in middle-income countries they’d be great. In low-income countries, I’d love to see them used more. The one that we used in Cape Town was stolen. But in Rwanda, I think if they can make it sustainable it’d be awesome.