Utilizing the PSBH Model and EBM to Improve World Health PSBH China Symposium Shanghai, China Russell Nassof, JD April 17-18, 2015 使用 PSBH 和循证医学模式来 改善世界健康 解决问题、促进健康 中国区域年会 上海，中国 拉斯. 那索夫 2015 年 4 月 17 、 18 日

Broken Yet Interconnected World 分裂却连接的世界 Lessons of Ebola 埃博拉疫情的教训 Humanitarian vs. Pandemic Response 人道援助与医学瘟疫的反应 Evidence Based Medicine (EBM) Model 循证医学模式 The Problem Solving for Better Health (PSBH) Model PSBH 模式 PSBH Implementation PSBH 执行 Program Outline 节目程序

 No one is safe or immune… “Interdependence of all humanity” 无人是安全或有免疫的。。。 ‘ 人类是互相依存的 ’ People, products, services, and disease move rapidly around the world. 人类，物品，商业和疾病能迅速的传播 Pandemic-an epidemic of infectious disease spread through human populations across a large region” 瘟疫－在众多环境里迅速传播的病菌 HIV/AIDS, Cholera, Influenza, Typhus, Measles, Tuberculosis, Malaria, Leprosy, Yellow Fever, SARS, Antibiotic Resistance, MERS, H7N9, Viral Hemorrhagic Fevers including Ebola and more to come 艾滋病毒 / 艾滋病，霍乱，流感，伤寒，麻疹，肺结核，疟疾，麻风病，黄热病 ， SARS ，耐药性， MERS ， H7N9 ，病毒性出血热，包括埃博拉病毒等 Broken- BUT Increasingly Interconnected 分裂－却渐渐的更有联系

 International Impact-China??? 国际影响－中国？ Guinea, Sierra Leone, Liberia, Spain, United States, Mali, Senegal, Nigeria, Germany, Norway, France, United Kingdom 几内亚，塞拉利昂，利比里亚，西班牙，美国，马里，塞内加尔，尼 日利亚，德国，挪威，法国，英国 Peter Piot “It’s only a matter of time before the high volume of Chinese working in Africa bring the disease within China’s borders.” 彼得. 彼奥： ‘ 因在非洲工作的中国人非常多，病菌从非洲传播 至中国只是迟早的事。 ’ Lessons of Ebola 埃博拉疫情的教训

 Failures 没有做足的地方 To understand local livelihood patterns 了解当地生活方式 To understand local customs and practices 了解当地文化与习 俗 To understand fear of notifying local authorities concerning illness thereby negating contact tracing 了解当地人通知官员的 恐慌，导致无法追踪接触者 To understand longstanding attitudes towards governments and impact of brutal civil wars 了解当地人对政府以及国家内乱的 态度 To understand the importance of “touch” which is precisely what must be avoided to stop Ebola 了解 ‘ 触碰 ’ 的重要性 － 要埃 博拉疫情结束，这一点很紧要 Lessons of Ebola 埃博拉疫情的教训

 The Importance of the Questions 对问题的重要性 How can we have the answers if we don’t know the questions to ask? 如果我们不懂该问什么，我们又怎能得到我们所要的答案？ If we don’t ask the right questions, the answers are of little value 问了无关紧要的问题，得来的答案是无用的  The Problem of Sierra Leone (SL) 塞拉利昂的问题 WHO and MSF (Medecins Sans Frontieres) busy responding in Liberia and Guinea while infection silently spreading in SL 当世 界卫生组织与无国界医生组织在试图控制在利比里亚与几内亚的疫情 时，埃博拉疫情正在塞拉利昂扩散 Had the right questions been asked, the situation in Sierra Leone might have been contained 如果当时 ‘ 正确 ’ 的问题被发问 了，疫情在塞拉利昂可能就被控制住了 Lessons of Ebola 埃博拉疫情的教训

A Tale of 2 Approaches 两种门径的对比 Pandemic Response 医学瘟疫的反应 Pandemic Response 医学瘟疫的反应 Typical top down response 典型的至上而下反应 Typical top down response 典型的至上而下反应 Wait for directions from distinct hierarchy 等待着上级的指令 Wait for directions from distinct hierarchy 等待着上级的指令 Works under preconceived ideas of what works and what does not 以假定知识决定该做什么 Driven by Western medicine and Western cultural ideas 执行于西方药方与思想 Inflexible/TELLS 无弹性／指挥 Reluctant to innovate 抗拒创新 Reluctant to listen to local ideas 厌恶听取当地人的思路 Reluctant to listen to local ideas 厌恶听取当地人的思路 Humanitarian Response 人道援助的反应 Humanitarian Response 人道援助的反应 Embraces local culture and incorporates into practice 了解以及囊括当地文化 Flexible responses/LISTENS 灵活／倾听 Less hierarchy 或少的等级制度 Utilize technology to make decisions in the field based on need 伶俐地利用科技 Clearly defined roles/responsibilities 清晰地分配工作／责任 Clearly defined roles/responsibilities 清晰地分配工作／责任 Employ locals/volunteers to assist/educate 聘请当地人／义工 来帮忙／教育 Often lack funding/access 时常欠缺资助／通路 Often lack funding/access 时常欠缺资助／通路

The Lesson of Papua/New Guinea 巴布亚／新几内亚的教训

 Utilizing the Pandemic Approach When Public Support /Values are Lacking… 当使用医学瘟疫 门径欠缺着公众支持／观念时。。 Doctors chased out of villages 医生被内村居民驱逐 Survivors stigmatized 康复者被歧视 Unsafe practices (body washing/touching) continue unabated 不卫生的行为持续着 Sick are kept away from treatment centers and/or are hidden 患病者没有受治疗／被隐藏起来 Blame is placed on healthcare/government 大众斥责医 务人员／政府 AND THE OUTBREAK CONTINUES 疫情持续蔓延 Lessons of Ebola-Results? 埃博拉疫情的教训 － 最后呢？

 “A systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical experience and patient value” “ 一个循序渐进对待 疫情问题、融合最先进研究，医学经验和患者观念的门 径 ”  Thoughtful integration to combat “this is how we have always done it” 击败 “ 我们一直以来都是这样做的 ” 的观念  Incorporates both the Pandemic as well as the Humanitarian Approach 融合了医学瘟疫与人道援助的门径 Evidence Based Medicine (EBM) 循证医学的模式

The EBM Triad 循证医学三元群 Individual Clinical Expertise 各医方的专门 知识 EBM Best External Evidence 最可信的 证据 Patient Values & Expectations 患者的观念与期望

Start with the PATIENT and care surrounding that PATIENT 从患者与照顾患者的角度开启 1 Construct a well defined QUESTION based upon the clinical problem or care of that PATIENT 启发关 于患者或照顾患者的问题 2 Select the best APPROPRIATE and AVAILABLE RESOURCES and research 筛选最合适以及完善的设 施 3 APPRAISE the evidence for validity and APPLICABILITY to the question 严格剖析证据来回答 问题的适应性 4 INTEGRATE the evidence with CLINICAL EXPERTISE and PATIENT PREFERENCES and apply it to practice 把证据、医学经验与患者观念融合起来，然后施于练习 5 EVALUATE RESULTS through patient performance 以患者的表现来评估成绩 6 EBM Process 循证医学的程序

 Combines Humanitarian Approach with EBM 把人道援助融入循证医学模式 Focus on SOCIAL mobilization involving local people to IDENTIFY and take RESPONSIBILITY for the problems they face using AVAILABLE RESOURCES 专注于让当地人民辨认他们所面对的问题以及为这些问题负责 Build from the bottom-up and not from the top- down 使用从 下至上的门径 Build broad-based coalitions at the local level to improve the quality of life and healthcare 建设当地联盟来提高生活与健康水平 EBM BRINGS MORE VALUE TO THE PSBH MODEL 循证医学会为解决问题、促进健康模式加值 PSBH Model 解决问题、 促进健康的模式

 PSBH Process 模式的行程 Define the problem- nature, size, cause, contributing factors 为问题下定义 Prioritize parts of the problem that can be solved 把能够解决的部分优先解决 Ask the good question- (i.e. define a solution) 问 ‘ 正确 ’ 的问题 － 建议解决办法 Create action plan (why, what, how) using available resources 以现有的资源来规划行动计划 Take Action- Implementation 开启行动计划 PSBH Model 解决问题、 促进健康的模式

Humanitarian 人道援助 PSBH EBM 循证医学 Pandemic 医学瘟疫 The PSBH Triad 模式的三联盟

The PSBH Triad Overlap 模式的三元群 Humanitarian 人道援助 Social Mobilization- bottom up approach 从下至上的门径 Listen don’t tell 倾听而不指挥 Embrace local culture and incorporate into solutions 了解以及囊括当地文化 Social Mobilization- bottom up approach 从下至上的门径 Listen don’t tell 倾听而不指挥 Embrace local culture and incorporate into solutions 了解以及囊括当地文化 EBM 循证医学 Construct a well define question based on the problem at hand and prioritize 问 ‘ 正确 ’ 的问题 Utilize the best appropriate and available resources 使用现有最先进的资源 Highlight the importance of patient preferences 患者的喜好是重要的 Construct a well define question based on the problem at hand and prioritize 问 ‘ 正确 ’ 的问题 Utilize the best appropriate and available resources 使用现有最先进的资源 Highlight the importance of patient preferences 患者的喜好是重要的 Pandemic 医学瘟疫 Incorporate technology when appropriate 适当地采用科技 Incorporate government and western healthcare solutions when practical 适当地融合 政府与西药解决方案 Utilize access to funding mechanisms 利用筹资机制 Incorporate technology when appropriate 适当地采用科技 Incorporate government and western healthcare solutions when practical 适当地融合 政府与西药解决方案 Utilize access to funding mechanisms 利用筹资机制

 Once the “good question” has been asked and the response plan developed, it must be converted to actual practice 问了 ‘ 正确 ’ 的问题，就要实施应对的计划  Successful implementation 成功的实施 : Implementation 模式的实施 Improvements (Interventions) 进步（改变） Sustainability 可持续 Communication 沟通 Innovation/Technology 创新／科技 Uniformity/Consistency 划一／连贯 Surveillance 监查

 Improvements (Interventions) 进步（改变） Will doing what with whom, where, and for how long solve the problem identified and achieve the objective? 对谁做什么？地方？为期？可否有效 的解决问题？ May be medical or not 或许与医疗无关 May be preventive or response based 预防或应对方式 Options must take resource availability and needs into consideration 必须 经过资源与需求的考量 Must be affordable and attainable (realistic) 必须经济实惠（实际） Must be consistent and uniform 必须划一与连贯 PSBH Project Example: Homemade sharps storage container 项目：自制锐器存储盒 Implementation 模式的实施

 Sustaining Improvement 维持进步 What will work varies from nation to nation, facility to facility, individual to individual 解决方法会依照国家、机构、 个人而异 What worked for SARS did not work for Ebola 对 SARS 有效 的措施未必会对埃博拉有效 A 2 day training session in a low resource country from a high resource country healthcare educator will NOT result in sustained improvement 在低资源国家举办为高资 源国家而设的培训课程是不会照成能持续的增长 Implementation 模式的实施

给人一鱼，养之一日。教人以渔，食之终生。

 Sustaining Improvement 维持增进 Train the Trainer 训练培训者 Why is this NOT happening? 为何这没有发生呢？ Bottom Up Approach 从下至上的门径 Sanctions/Rewards? 制裁／奖励？ Make adjustments as needed 做出适当的调整 Incorporate cultural/human factors 融入文化／社会因素 Proper means of communication? 妥当的沟通  PSBH Project Example: Intervention on PICC line maintenance for brain cancer patients in the community 项目：肿瘤患者在社区开展 PICC 管维护的需求干预 Implementation 模式的实施

 Communication-Tailor to your Audience 沟通 － 必须为观众而调整  PSBH Project Example: Health education to the chefs-Peking University  项目： 社区骨关节病健康知识宣教 Implementation 模式的实施

 Innovation/Technology 创新／科技 Can facilitate implementation of interventions however; 可以促进适当的调整，不过 Incorporate only when suited for local environment 要为当地的环境妥当地改变 Brings new risks-awareness / response 带来新的知识／认同 Must be culturally sensitive 必须经过当地的文化的考量 Interventions may need to be revised to align with technological improvements 调整该因科技而改变  PSBH Project Example: Innovative follow up system for patients on peritoneal dialysis 项目：基于即时通讯软件创新腹膜透析患者随访模式 Implementation 模式的实施

 Consistency/Uniformity 划一／连贯 Response Plan should establish a Standard of Care 应对计划应有护理标准 Policies, practices, procedures should align with the standard of care 方 针、行为与计划应并行护理标准 Develop only those policies, practices, procedures that can be FULLY implemented, monitored, and complied with (i.e. if clean water is not available you cannot use it for hand hygiene but once it becomes available you MUST use it.) 只允许可以完全遵守与监控的条规 （不干净的水是 不能用来清洁手部，但清洁的水一旦可得到，就一定要使用） Failure to comply with established policies, practices, procedures is worse than not having any in place 不遵守条规比差无条规  PSBH Project Example: Reducing incidence of pulmonary complications in post-op patients 项目：降低危重症手术患者肺部并发症的发生率 Implementation 模式的实施

 Surveillance 监查  “If you don’t look, you don’t know and if you don’t know, you can’t identify” “ 若你不看，你就不会知。若你不知，你就 不能鉴定 ” Process Surveillance- Compliance with a specific practice 过程监查 － 有 目地的实行 Outcome Surveillance- How well did you comply facilitates quantification/prioritization of issues 后果监查 － 应对方案有效吗？ Evaluating the impact of the intervention － 对表现而反省 In EBM- evaluating results through patient performance 以患者的表现解读 方案的功效 May result in identification of new problems, new questions, and require restarting the cycle again 从而获知新问题，过程可能需要重来过  PSBH Project Example: Emotional support in nursing home 项目：养老院老人护理情感陪护模式探讨 Implementation 模式的实施

 The failures of Ebola must be understood and corrected to improve world healthcare and response to future pandemics 我们必须了解埃博拉的教训，从而改进应对未来瘟疫的方案  The PSBH model is an integrated approach using humanitarian, pandemic, and EBM components which could have prevented many of the Ebola failures PSBH 模式融合了人道援助，医学瘟疫以及循证医学门径－它是可以阻 止埃博拉的失利的  Developing the “right” question(s) are critical if we ever hope to find suitable answers 要得到应用的答案必须发问 ‘ 正确 ’ 的问题  To formulate the “right” question we must 要发问 ‘ 正确 ’ 的问题我们必须 Listen not direct 倾听而不指挥 Work from the bottom up and not the top down 采用从下至上的模式 Encourage flexibility 提倡灵活 Understand and use the power of local culture 了解与利用当地文化 Summation 总结