Thursday, November 30, 2006

There are far too few PhDs on public health in the former Soviet Union. This week saw a small but significant increase. Last Friday Kirill Danishevski, one of my students, successfully defended his thesis in London, on “Maternal health care in Russia: understanding clinical practice in an information poor setting.” In brief, Kirill was looking at the use of clinical evidence in Russia, a subject that I spoke about in the Cochrane Lecture earlier this year (“Cochrane on Communism”), where I benefited from Kirill’s insights. He chose obstetric practice because it was an area where the evidence on many aspects of care is clear, set out in the excellent book “Effective Care in Pregnancy and Childbirth”. Using this as a starting point, he looked at how far official Russian guidance was consistent with best evidence and then at how well actual practice complied with it. The answer was, unexpectedly, not very closely at all. The challenge then was to understand why and his research provided valuable new insights into this situation. This involved analysis of the correlates with different practices, detailed interviews with health professionals, and a statistical technique known as conjoint analysis, which uses case histories to reveal the principles underlying clinical decisions.
Some papers arising from the thesis have already been published; others are on their way. However, all in all they paint a rather worrying picture of the quality of clinical care in Russia today and remind us of how far we have to go to a situation in which ordinary Russian people can be sure that the care they get will at least do them no harm.
The second thesis defence was the same day, but in Stockholm. My colleague Andy Stickley was defending his thesis on interpersonal violence in Russia (See: ). Although I obviously wasn’t there, his opponent was my colleague from here, Ellen Nolte. PhD defences in Sweden and the UK are very different – in public in Sweden and in private in the UK. What’s more, in Sweden the opponent begins by giving a public lecture on the candidate’s thesis, to ensure that it can actually be understood I guess! Andy’s thesis was another superb contribution to our knowledge of Russia, using imaginative analysis of statistics going back to Tsarist times to track the changing nature of Russian society and, in particular, the role played in domestic life (and death) by alcohol.
The third defence was on Monday at Oxford – and this time I was the examiner. Dana Sumilo was defending her thesis on the epidemiology of tick borne encephalitis in the Baltic States, work she did under the supervision of Sarah Randolph, who is the expert on this disease. In 1993 there was an almost simultaneous and very dramatic increase in the incidence of tick borne encephalitis in Estonia, Latvia and Lithuania. The question was why? As always, one learns an enormous amount by examining theses and I now feel much better acquainted with the two species of tick found in European forests. This is a disease where one wonders how it ever survived. It needs very special climatic conditions and animals to feed on, and humans are really only at risk if they go into affected forests at certain times. The virus is spread from one generation of tick to another only when the conditions are right for the two forms (larval and nymphal) of the tick to feed together!
Inevitably, sorting out what was going on was incredibly complex, involving climate, agriculture, and human activity. I will leave it to Dana to describe what the findings were when she writes the papers on her research. However, for me an important message was how difficult it can be, with current epidemiological and related methods, to understand the health effects that arise from the changing world that we live in.

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