An extraordinary burden was placed on the healthcare community as the COVID-19 crisis kept unfolding over the past year and a half, affecting 219 million people and causing 4.5 million deaths, many of whom were frontline workers. It put tremendous pressure on the existing healthcare systems across the world leading to many instances of collapse, which led to people being left without the needed care. It is now apparent that we must build a resilient and sustainable healthcare system across countries that can withstand such crisis.

As we witnessed in Dubai, agility in addressing key needs, swift and thorough implementation of risk mitigation strategy supported by smart management of resources, talents, public-private partnership and fast implementation of digital tools, supported by conducive policies became imperative to bring back stability into the healthcare system. Today, Dubai has emerged as a world leader in efficient management of the pandemic and Expo 2020 Dubai provides confidence to the world to think beyond COVID-19.

Related: The importance of accessible and sustainable healthcare

With patients increasingly wanting to access healthcare services from the comfort of their homes or work, many hospitals and healthcare providers have pivoted with the implementation of digitised, virtual solutions to strengthen logistics and better serve customers remotely. This model of care enables provider communities to reach a wider customer base beyond geographical boundaries and addresses the key concern of access to quality care. This also ensures delivery of high-quality, cost-effective care; and maximise precious resources by reducing spending on physical infrastructure.

For example, by enabling the availability of virtual and/or AI-powered healthcare services, digitised solutions such as telemedicine, have successfully impacted the primary care model of seeking an appointment, consulting the doctor, accessing lab tests, accomplishing the purchase/delivery of prescription medicine, and shifting care to patient homes. Many believe that the next 10 years may prove to be the decade when digital technology will reshape the health system, as strong continued uptake, favourable consumer perception, and tangible investment in this space contribute to the continued growth of telehealth and digital solutions in 2021.

Related: Aster Volunteers: Lending a helping hand

Another prerequisite for resilient health systems is to move towards low-carbon healthcare – decarbonising the health sector and integrating environmental safety as a transversal element into the way we deliver care. Moving to onsite renewables or purchasing energy-efficient medical devices, for example, will not only reduce emissions but also improve energy security in times of disaster. The Expo 2020 Dubai brilliantly explains how sustainability is the future for mankind. The Sustainability District has some of the world’s most advanced technology in action where countries champion sustainability and show how the human race can enjoy living in harmony with nature in a high-tech future.

While we aim to build a world-class sustainable healthcare system it would be pertinent to keep the 5s theory in mind: Safety – a place where global standards are met; Savings – getting the same quality or better quality of affordable care; Speed – better quality of life with a shorter waiting time; Service – a place with higher service and Staff – skilled labour.

Our concept of sustainability at Aster DM Healthcare is to build a sustainable future by giving back to the societies while defining a path that creates shared values benefitting the organisation, community, and the environment. It goes without saying that now is the time to be proactive in planning sustainable future responses to environmental and health emergencies which are inextricably connected.

Alisha Moopen

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

Recently, Mayo Clinic researchers reported that the combination of casirivimab and imdevimab, two monoclonal antibody treatments under the U.S. Food and Drug Administration emergency use authorisation, keep high-risk patients out of the hospital when infected with mild to moderate COVID-19.

Nearly 1,400 Mayo Clinic patients were enrolled in the study. 696 patients received the drug combo between Dec 2020 and early April and an equally matched cohort who did not receive it. Their status was evaluated at 14, 21 and 28 days after treatment. At each point, the numbers for hospitalisation were lower in the treated group.

Related: Timing of antibody testing in relation to onset of symptoms is key to detecting COVID-19

At Day 14, 1.3 per cent of the treated group was in the hospital, compared to 3.3 per cent of those who had not been treated. At Day 21, only 1.3 per cent treated was hospitalised, compared to 4.2 per cent of those who had not been treated. At the end of 28 days, 1.6 per cent of those treated was hospitalised versus 4.8 per cent of those who had not been treated. This translated to a 60 –70 per cent relative reduction in hospitalisation among treated patients. Of those who were subsequently hospitalised, the rates of ICU admission and mortality were low.

To learn more about these findings, we spoke with Raymund Razonable, M.D., a Mayo Clinic infectious diseases specialist and senior author of the study. Excerpts.

What are monoclonal antibodies? How can they help treat COVID-19?

Related: COVID-19 is mutating: what does this mean for us?

Monoclonal antibodies are proteins that are made in the laboratory to provide immediate immune protection against COVID-19. The monoclonal antibody proteins bind to the SARS-CoV-2, preventing the virus from entering the cells.

Is a treatment for COVID-19 as important as developing a vaccine?

Vaccination is still the most important measure to prevent COVID-19. Monoclonal antibodies are given to patients who are already infected in order to prevent them from developing severe disease. Therefore, preventing infection through vaccination is a better strategy to avoid COVID-19.

Dr Raymund Razonable

Are there any treatments that have successfully been developed that can help prior to hospitalisation?

Monoclonal antibodies are the treatments that are given in the outpatients before patients need hospitalisation. They are intended to treat patients with mild to moderate COVID-19, prevent them from getting a severe illness, and avoid hospitalisation. The treatments are given by intravenous infusion, or less preferred is by subcutaneous injection. Monoclonal antibodies are highly effective in treating mild to moderate COVID-19. However, they have to be given early after the onset of symptoms. Patients should not wait too long until they are too sick to get the drug. Once the patients develop severe disease, then monoclonal antibodies may no longer work for them.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

From Hurricane Katrina to earthquakes in Japan, cybercriminals have long used crisis situations to further their own agendas. Regrettably, the COVID-19 pandemic is the latest to be exploited with organisations across healthcare industries – from hospitals to clinics, laboratories, and pharmacies – now finding themselves in the crosshairs.

In recent months, there have been numerous cyberattacks on these organisations around the world. Given that this pandemic will likely continue for some time, these threat actors will likely continue to exploit the situation.

Related: Is healthcare losing the cybersecurity battle?

A report by Kaspersky in 2020 states that according to public sources, 10 per cent of all organisations hit by targeted ransomware between January and September 2020 were hospitals and other medical institutions. Furthermore, 2020 also saw the first confirmed case when a patient died due to delays in receiving emergency care after medical equipment was infected by ransomware.

Lucrative industry

Our research into underground forums has shown that medical records are sometimes even more expensive than credit card information. This can partly be ascribed to how it opens potentially new methods of fraud: armed with someone’s medical details, it is easier to scam the patient or their relatives. Additionally, the number of attacks on medical facility devices in countries that are just starting the digitalisation in the field of medical services will continue to grow. It is especially hospitals in developing countries that will be targeted. And the pandemic has put renewed attention on this.

Related: Overcoming healthcare’s cybersecurity challenges

Today, cybercriminals are usually looking to gather sensitive or scientifically significant information and either hold it for ransom or sell it on the black market. State actors have also launched attacks against healthcare organisations for purposes of intelligence gathering. But regardless of the reason, it is important that these healthcare organisations practice increased vigilance because any type of attack could interfere with them being able to provide critical care for their patients.

Continuity of operations and data protection is extremely critical for healthcare organisations. This is more so the case today with the sector under extreme pressure. For hospitals and medical institutions, it is important to ensure the stability of medical equipment and that data is constantly available for personnel, while also protecting the privacy of their patients’ critical information.

The reality is that hospitals and research labs generate and house assets that have a high value not just for stakeholders, but cybercriminals as well. Disruption to healthcare services may have a devastating impact on patients’ health and the ability for healthcare workers to carry out their roles effectively. Furthermore, a cyberattack, regardless of its nature, will damage credibility if disclosed to the public.

Best practice

There are several cybersecurity best practices available that healthcare organisations must adopt if they are not doing so already.

Schedule basic security awareness education for both medical personnel and administration employees that cover the most essential practices such as passwords and accounts, email security, use of USB devices, PC security, and safe Web browsing. Healthcare providers should also review their existing cybersecurity solutions and ensure they are up to date, configured properly, and cover all employees’ devices. Even something as basic as using a firewall can make a massive difference to the environment.

Facilities must ensure all medical devices are properly configured and updated, such as ventilators. If there is a chance that the number of such devices increases rapidly, they should develop a dedicated procedure to quickly install and configure all new devices, safely. Some hospitals have had to urgently hire new staff. This means an increase in the number of endpoints that must be protected.

The rapidly evolving market today means that no healthcare organisation can be considered safe from a cyberattack. It is, therefore, critically important that they embrace a more security-conscious approach to operations.

Amir Kanaan

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

Precision medicine is an emerging approach for disease treatment and prevention that considers individual variability in genes, lifestyle, and environment. According to a recent report, the precision medicine market was valued at approximately US$58,450 million in 2020 and is expected to reach about US$98,550 million at a CAGR of 9.2 per cent by 2026. In an interview with Omnia Health Magazine, Peter Raouf, Director, GCC Oncology Business, AstraZeneca, discussed the benefits and challenges that precision medicine presents today. Excerpts:

What are your thoughts on precision medicine, and where does it stand today?

Precision medicine is the natural evolution of medicine. For instance, whenever one has an infection, it is important to ensure getting access to the right antibiotics so that the condition is appropriately treated, and immunity is not compromised. But here, we are not talking about a simple infection but cancer. Everyone is aware of the difficulties and side effects that patients could face while going through traditional treatments such as chemotherapy. While chemotherapy is an essential part of the treatment and will continue to be so, it will be complemented with more targeted therapies or precision medicine as we move forward – with the expectation that these will improve patient experiences and outcomes.

What are some of the potential benefits of precision medicine in oncology?

Related: The 2021 Oncology Report

From a patient perspective, the benefits would be getting a treatment directed to the origin of the root cause. Instead of giving one treatment that could stop working after a while or require lots of other medications to manage side effects, this treatment method would ensure that the efficacy would be at its maximum and the side effects would be low. Precision medicine is not just important for the treating physician and caregivers but also for the whole healthcare ecosystem. Moreover, there are many long-term benefits for precision medicine. When you give the proper treatment, you ensure that the overall burden of treating the cancer patient is reduced.

What are some of the challenges when it comes to bringing precision medicine to the mainstream?

The biggest challenge would be building the knowledge and the speed of conveying this knowledge, along with the proof of concept, introduction to the customers, physicians, and authorities. This is where AstraZeneca comes in. Our role is to make sure that we convey the latest information and adequately educate the healthcare community about the tools required for precision medicine, as well as ensure patients are aware of the options available to improve their experience as they undergo treatment. Today, many of the new cancer treatments are coming with what are called ‘companion diagnostics’. So, for instance, if a patient tests positive, this means that they would benefit from this additional treatment. I wouldn’t term these as challenges but more about prerequisites for precision medicine. Therefore, proper education and knowledge must be made available as soon as the data is out there, and regulatory approvals are in place. It is also vital to support the infrastructure to accommodate tests that will help physicians or healthcare professionals identify the right patient profile for each of these new precision medicine treatments.

What are some of the initiatives introduced by AstraZeneca in this area?

Related: Precision Oncology: Shaping a New Diagnostic and Treatment Frontier

At AstraZeneca, we are leading a revolution in oncology to redefine cancer care. Our ambition is to provide cures for cancer in every form. We are following the science to understand cancer and all its complexities to discover, develop and deliver life-changing treatments and increase the potential for cure.

To this end, and on a global level, AstraZeneca was one of the pioneers in targeted therapies. In fact, the first targeted therapy in lung cancer was discovered and introduced by AstraZeneca. In the last six years, we have introduced more than three targeted treatments, which we are very proud of. But we are not stopping here as we continue to accelerate the documentation process for the authorities to approve, impart education, and support the medical community. By doing this, we are helping to build an interconnected diagnostic landscape by linking regional hospitals and medical laboratories with international laboratories. We are also working on more long-term goals by building infrastructure. Today, several of our tests are part of the mainstream treatment of lung, ovarian and brain cancers.

What role is technology playing in advancing precision medicine?

Technology plays a key role as we continue to develop newer and more cost-effective techniques. For example, in our regional team here, we have people dedicated to diagnostics to ensure that they catch up with the progress and evolution of technology and introduce the latest testing tools to the region.

What are your thoughts on the future of precision medicine?

Precision medicine will continue to be a significant focus area for the whole medical community in the coming years. Its impact has been observed in the last five to six years, and research is available about how survival rates are improving for certain types of cancers. It’s all thanks to the increased utilisation of this medication. So, this will continue to be the route going forward for drug research, and guidelines need to be updated to include these kinds of treatments to evolve the diagnostic landscape further. Attention should also be paid to discovering more driver mutations because once you find out those for certain types of cancer, you will be able to identify the test for this mutation and the treatment. So, the starting point would be the identification of this driver mutation.

We also need to make sure that everyone is aware of these tests because, in some types of cancer, there are still some stigmas attached in terms of testing. A few years ago, we launched a campaign called ‘Believe in your identity’. The campaign focused on lung cancer, which is characterised by multiple mutations. It’s a tumour where you can find many driver mutations. Each patient is different, and that’s why the campaign focused on believing in identity because the patient, their family and the caregivers should ensure that the patients are being tested for whatever tests are available. This will help devise a treatment plan that is more optimised for that individual patient.

Peter Raouf has been associated with AstraZeneca for almost 15 years, working in different capacities across the GCC. Since 2015, he has been responsible for the Oncology business unit in the Gulf region. From 2020, his role was expanded to the GCC, including Saudi Arabia.

This article appears in the latest issue of Omnia Health Magazine. Read the full issue online today.

COVID-19 a human crisis highlighting need for greater investment

With COVID-19, we are experiencing a global crisis that is simultaneously paving way for change, according to Professor Morgan Chetty, Chief Executive Officer of KwaZulu Natal Managed Care Coalition, commenting on the need for universal healthcare and health security during Africa Health 2021:

Related: Africa's pandemic handling helped by intra-country learning and effective leadership

"COVID-19 exposed the fragile health systems in both high- and low-income countries. There is a need for health systems to not only strengthen the system but also embrace the notion of resilience.

Prior to the pandemic, we have witnessed health systems overstretched to adapt, casting a shadow on the ability to transform. COVID-19 is more than a health crisis, it is a human crisis with social, economic, and moral catastrophes.

Related: How the right policies can unleash digital innovation in African healthcare

It highlights the need for more investment in healthcare and the need for us to recognise that this is a global crisis. Nationalist policies in individual countries, especially superpowers are harmful in overcoming the pandemic. How can we have successful universal healthcare?"

Behavioural and lifestyle factors drive mortality

According to Dr. Maurice Goodman, Chief Medical Officer Discovery Limited in South Africa, healthcare should be delivered through multidisciplinary teams, with a variety of players at a variety of levels of expertise, working together in teams:

"We have globally witnessed, and Africa is included in that, notwithstanding the infectious disease burdens, that we carry that the greatest disease burden globally now with non-communicable diseases.

Behavioral and lifestyle modification wellness efforts, in preventing and treating the non-communicable disease burden is crucial. However, very interestingly, we discovered that even during the pandemic, after age, the second biggest driver of morbidity and mortality was behavioral and lifestyle factors.

Enablers who will empower us as a national and a global community to move forward is a very important component of public-private collaboration in South Africa.

It is known, we have parallel private and public healthcare systems and there have been some excellent examples in terms of our Electronic Vaccination Data System (EVDS), which was a system for delivering vaccinations nationally to both the privately insured and the noninsured population.

The departure from the archaic fee-for-service systems into more value-based healthcare delivery and funding systems and various regulatory changes will be required to empower these exciting new developments and systems.

We have two types of parallel healthcare systems in this country, and neither of them is perfect. Both have individual strengths, at the highest level, the way forward is to obtain the best of breed and merge the two healthcare systems.

Some examples of successes have been the national EVDS system which was implemented to manage the vaccination rollout nationally. There were growing pains, but overall, it worked and continues to work very well.

There were very close collaborations at a senior and ministerial level, alongside captains of industry. Healthcare is a broader economic sport, is not limited only to healthcare organisations, and witnessed senior government officials and the private sector coming together to address the various issues escalated by COVID.

It begins with a collaborative environment, driven from the most senior levels.

To bring out the best in both our healthcare systems, there is a world of detail underneath that, and we can burrow into any of it to move forward and improve. That is a starting point."

Universal healthcare as an interative process

The population of the world, and South Africa specifically, has laboured under a COVID lockdown for nearly two years, commented Dr. Tony Behrman, CEO, Medical Protection Society in South Africa:

"We have all changed, we rarely go out and when we do, we are frightened of people getting too close to us.

Some younger generations are not as heedful, and think they are immune; however, we know they are not. We need to look at the mental health pandemic which is dawning upon us and the non-communicable diseases pandemic.

Telehealth gives us the advantage of performing real-time consultations for patients. Nevertheless, this has a very marked disadvantage as well.

It is challenging to trace and monitor non-communicable diseases such as cancer, hypertension, diabetes, peripheral vascular disease, asthma, chronic obstructive airways disease hyperlipidemia. It is especially very difficult to make that diagnosis on a telehealth platform.

Additionally, there is a pandemic of deep-rooted depression in children.

Universal healthcare will start as an iterative process, and one of the problems we have recognised in these attempts so far is legislation, which is perceived as a ‘big bang’ theory. Thought process more than an iterative process, and predominantly starting at a low level, would be ideal.

We need to dispel the urban myths and the incorrect statements which have been made, such as if you entrepreneur medical aid, the rest of the country has no access to healthcare. This is an urban legend and a political statement, which has, unfortunately, been over-emphasised.

There is a vibrant state sector, which over the last three or four years has seriously pulled up its socks, as far as the number of individuals that it employs, both specialists, nursing staff, and general practitioners. Therefore, universal healthcare does not take place due to certain people being on medical aid, while others have nothing.

The health of the country is the responsibility of the government of the country, and the government has inherited a system that was tilted towards excellence for one sector of the population. The infrastructure in place could have been tweaked, and rebuilt over the last 27 years, to improve the position we currently find ourselves in.

We are now looking at a complete change in bringing in national health insurance, which brings in a potential of enormous costs, and unilateral control over funds. However, we have a thriving vibrant medical aid sector and a relatively well run but poor outcome, state sector.

The key is to merge those two as combined centers of excellence but to learn one from the other. Therefore, you must start with total and utter transparency and humbleness. It cannot be a political decision, which is ladled in our soil."

While 31^st October marked the last day of global breast cancer awareness month, championing awareness and encouraging precautionary measures continues for oncologists.

Coping through a breast cancer diagnosis is life-altering, with the journey towards recovery being a process. Treatments and procedures may be overwhelming; therefore a multidisciplinary approach that helps patients navigate through options post-mastectomy is vital.

Related: Better chance of complete breast cancer tumour removal with new surgical technique

Dr. Raffi Gurunian, MD from Cleveland Clinic Abu Dhabi, breaks down the relationship between reconstructive plastic surgeons and surgical oncologists, and how it creates successful postoperative outcomes:

Initial steps

The initial diagnostic workup is conducted by the surgical oncologist to evaluate the patient. In Cleveland Clinic Abu Dhabi, we implement a multidisciplinary approach, and our breast cancer team includes medical oncologists, radiation oncologists, plastic surgeons.

Related: Breast cancer survival increases when time between diagnosis and concluding treatments is limited

When patients consult with surgical oncologists, they are referred to a plastic surgeon to discuss reconstructive options for the replacement of the tissue. It is extremely important to have a cohesive team with the breast surgeons working shoulder to shoulder as a successful reconstruction surgery relies on a good mastectomy, which is the removal of the entire breast tissue.

Therefore, if you have a skilled surgical oncologist paying attention to the finer details and performing a successful mastectomy, the planes and tissues are viable, which makes for a perfect foundation for the plastic surgeon to work on.

Again, it is very critical, both theoretically and, practically, that we work very closely with breast surgeons, and they do work closely with us as well to obtain the best possible outcome for an individual patient.

Personalised pre-operative evaluation for successful outcomes  

Once we receive referrals from breast surgeons, we evaluate patient history and conduct a physical examination. Some patients may have comorbidities therefore it is crucial to identify the problems prior to the surgery. In some cases, unfortunately, there are patients who would not be good candidates for reconstructive surgery.

After evaluation, there are two ways of reconstructing the breast. One is implant-based reconstruction and the other is autologous tissue, which means that we harvest tissue from the patient to reconstruct their breasts.

Preoperative assessment and discussion with the patient as well as the family members are critical to a successful outcome. It is an in-depth, personalised approach during which we communicate with the patient and develop a definitive plan for them.

Innovation

In recent years, for implant-based reconstruction, we have started performing pre-pectoral breast reconstruction. In this procedure, we place the implant above the muscle, combined with a synthetic skin substitute, and create a pocket for the breast implant to sit on the muscle.

The standard for many years was subpectoral, in which the implant was placed beneath the muscle.

Although still performed in some practices, our experience demonstrated that these types of procedures are associated with patient discomfort post-surgery. There are some spasms, animation deformity recalls due to the implant being placed under the muscle, which means patients would feel displacement as they move the muscle.

Therefore, in recent years we have transitioned from subpectoral to pre pectoral which elevates patient comfort after surgery and prevents animation deformity. It also gave us a better ability in pain management.

Again, there will be certain cases where you would still have to do partially submuscular procedure, based on the viability of the tissue. However, in my practice around 90 per cent of the time, I am opting to do pre-pectoral reconstruction if I'm using an implant reconstruction.

In breast mount reconstruction, the first step is to eliminate cancer, and then provide the volume and reasonable shape. The surgeon then proceeds with revisions, such as nipple reconstruction until the patient is satisfied with the outcome.

Again, the size matching procedures on the other side could be a breast lift, breast reduction, also reduction, and augmentation, depending on the size and other elements of the reconstructive breast.

In lymphedema prevention surgery, immediately after the lymph nodes are cleaned up in the axilla, some patients may, unfortunately, encounter the metastatic disease in the lymph nodes. The breast surgeon would remove the lymph nodes.

After this procedure, plastic surgeons use the lymphatic vessels, draining the arm, and we hook them up to the remaining vessels in the veins, in the armpit immediately.  

This is for the prevention of upper arm swelling, what we call lymphedema. This is another, very detailed technology because it uses high-power microscopes and delicate instruments to reach lymphatic vessels that are 0.3 millimeters against 0.3 millimeters wide.

Connecting those vessels to the veins and things is a highly delicate procedure and although not a new procedure, it is becoming prevalent now in preventing the lymphedema occurrence in patients undergoing lymph node dissection, for cancer.

Patient eligibility

Certain patients benefit from a direct implant, which means after their mastectomy we immediately come in and place an implant into the breast pockets, provided that the skin envelope is healthy and mastectomy flaps viable.

This technique is mostly applicable in patients undergoing either preventive or what we call a prophylactic mastectomy.

In a nipple-sparing mastectomy, you can preserve the nipple based on the location of cancer. If performing a preventive surgery, direct implantation can be made into the breast pocket.

Now, if we're performing a skin-sparing mastectomy, which means that you're removing the nipple and part of the areola, we would perfume a tissue expander placement, until we can exchange it for a permanent implant.

Some patients may require post-mastectomy radiation for further treatment, and until the radiation is complete, you do not want to do any definitive reconstruction. This could be a reconstruction with the implant or the patient's own tissue.

Again, knowing that some of those patients would require post-mastectomy radiation, you don't want to burn any bridges. Because radiation comes in and it changes the skin envelope, causing issues such as burning of tissue creating scar tissue, poor outcomes, and failure of the implant as well.

So, therefore, in these patients, the situation is temporised, by placing a temporary device called the tissue expander. Navigating the patient throughout their treatment is key, which could be chemotherapy or follow-up chemotherapy with radiation.

Until after the radiation is complete, no further steps should be taken, except potentially expanding the tissue expander.

After completion of radiation, which is roughly three to six months, we take those patients back to the operating room to exchange their tissue expanders for a permanent implant.

This is a two-stage procedure, which gives surgeons the ability to revise the surgery and do touch-ups, such as size match with the contralateral other side, if only the patient has undergone a single, unilateral mastectomy.