The Truth About...

Dr Kevin Fong concludes his exploration of the boundaries between the medical profession and other industries for valuable lessons that might be of use to us all.

In this final episode, Kevin talks to people who have spent their lives investigating what it takes to make high-performance, high-reliability systems work safely when lives are on the line.

Since the days of Project Apollo, people have come to rely more and more heavily upon the digital computer. Whether it is aerospace, the automotive industry, medicine or even the financial sector, technology has become so central to the success of these complex systems, that it has become increasingly more difficult for the human to remain in control when these systems fail. Technology, some argue, is not just replacing us, it is displacing us.

Is this situation inevitable or is there a way to better protect ourselves from the risks that opaque, complex technological systems create?

(Photo: Kevin Fong and Paul Fjeld next to Lunar Module 2)

In the third programme in the series, Dr Kevin Fong explores the concept of ‘lean’ in healthcare. He visits Toyota’s largest car assembly plant in the United States and discovers how the company’s legendary management philosophy – the Toyota Production System – is being implemented in hospitals, in an effort to improve patient care. Toyota’s philosophy of continuous improvement aims to increase quality and flow whilst decreasing cost. But whilst this may work well for the mass production of cars, can it really improve the care of individual patients?

Dr Kevin Fong continues to explore the boundaries between the medical profession and other industries for valuable lessons that might be of use to us all. The second programme recounts the ups and downs of NASA’s Jet Propulsion Laboratory.

The story begins in the early 1990’s, when NASA was in a very different place from the glory days of the Apollo era. Still dealing with the fall-out from the Challenger accident and other problems with its unmanned missions, the agency’s budget was significantly cut back. Its new administrator, Daniel Goldin, was forced to adopt a very different and riskier approach to space exploration, one that was in many ways anathema to the NASA’s engineers and scientists: it was dubbed: Faster, Better, Cheaper.

But as we’ll hear, this approach came at a price and would lead to nearly a decade of failures as the cost-cutting took its toll. Kevin talks to NASA experts, including Robert Manning, chief engineer of arguably, the most ambitious and successful of all their planetary missions, Mars Science Laboratory, which landed the Curiosity rover on the surface of the red planet in 2012. How did they overcome repeated failures to achieve this remarkable success? And what can that experience teach us about delivering better healthcare?

In a new four-part series for BBC World Service and The Open University, broadcaster and medic Dr Kevin Fong explores what healthcare can learn from other organisations that succeed and fail. In this programme, Kevin joins a helicopter air ambulance crew in the United States and discovers how the combination of commercial pressures and de-regulation have resulted in helicopter EMS becoming one of the most dangerous occupations in the country. According the National Transport Safety Board, the body charged with investigating aircraft safety, over a twenty year period, they have averaged one accident every 40 days in the United States. Kevin hears from medical crew, pilots, regulators and survivors, to discover what needs to change in order to reduce accidents and improve safety for the hundreds of thousands of patients transported by helicopter air ambulances each year.

Photo by Heath Holden/Getty Images

Dr Margarita Holmes is one of the best-known advisers on sex and relationships in the Philippines, drawing on her extensive clinical experience as a psychologist. In this programme she talks to people with HIV/Aids about the ethical and personal dilemmas they face. In a series of intimate and searching conversations, she hears their stories about confronting taboos, choosing who to tell and when, and how they maintain relationships while carrying the virus. In a country where the Catholic Church’s teachings on homosexuality are highly influential, Dr Holmes explores the often-hidden realities of living with HIV.

(Photo: A couple embracing and a ribbon forming the symbol for HIV/Aids. Credit: Shutterstock)

Dr Peter Mugyenyi runs one of Africa’s largest HIV medical research institutes, the Joint Clinical Research Centre in Kampala, which he helped to found in the early years of Uganda’s AIDS epidemic. Uganda was the first African country in which AIDS was identified.

Peter explains the realities of HIV treatment in Ugandan clinics today, a decade after effective drugs against the virus started to become more widely available in African countries. Life prospects for hundreds of thousands of Ugandans are much better than they were. Yet an estimated 40% of adults with HIV are not receiving any treatment.

The proportion of untreated infected children is even higher. In conversations with Ugandans who are living with HIV, fellow medics and health workers, activists and government representatives, Peter Mugyenyi explores the successes, failures and challenges in getting the best possible treatment to every Ugandan who needs it. That ambition is also a vital part of preventing the continuing transmission of the virus in African countries.

(Photo: Dr Peter Mugyenyi and staff at Butolo Anti-retroviral Therapy Clinic, Uganda. Credit: Andrew Luck-Baker)

Former UK Health Secretary Norman Fowler continues his investigation into what works and what does not when it comes to reducing the rate of HIV/Aids. He travels first to Russia where the infection rate is still rising, mainly among drug addicts. He finds tough drug abstinence programmes in place rather than needle exchanges and the use of methadone, policies which have been applied effectively elsewhere. And, he hears testimony of the stigma and suffering endured by Russian homosexuals.

He journeys on to Sydney in Australia, where he finds some of the most effective public health programmes in place – including the decriminalisation and regulation of sex work.

(Photo: A Russian boy holds banner reading Stop Aids. Credit: Denis Sinyakov/AFP/Getty Images)

Former UK Health Secretary Lord Fowler focuses on his own experience. When the virus hit Britain, and despite opposition from then Prime Minister Margaret Thatcher, he pushed through a major public information programme.

Now, 30 years later, Lord Fowler travels across the globe to examine a set of simple but effective policies which can keep people safe and healthy - and to inquire why they still meet fierce resistance in some parts of the world.

Photo: Aids Activists Rally In Front Of White House (Credit: Chip Somodevilla / Getty Images)

Tony Fauci looks back at the scientific breakthroughs that have transformed HIV/Aids from a death sentence to a disease that can now be treated and prevented. Having watched in horror as his patients quickly died from the disease in the US in the early 1980s, as director of the National Institute of Allergy and Infectious Diseases, he has dedicated his career to fighting it.

He talks to the Aids activists who pressurised the US government and Dr Fauci himself to find the drugs they so desperately needed and the scientists whose extraordinary discoveries lie at the heart of the global fight against the disease. And while that fight continues, Dr Fauci believes a recent breakthrough could one day herald an Aids-free generation.

Archive clip from How to Survive a Plague, courtesy of Dartmouth Films & Public Square Films.

(Picture: Human Immunodeficiency Virus. Credit: Science Photo Library)

In Japan hundreds of thousands of young people withdraw from society for years or even decades.

They are known as hikikomori and Claudia Hammond travels to Tokyo to discover more about this mysterious condition and why it is so prevalent in Japan.

If you have a mental health problem, where you live in the world makes a big difference to the care you receive. In many lower and middle income countries, three-quarters of people with mental health problems don’t have access to mainstream mental health services. Even in wealthier, developed countries, the figure is close to 50%.

Claudia Hammond investigates some of the alternatives that occupy this ‘treatment gap’.

Psychiatrist Dr Monique Mutheru is one of just 25 psychiatrists in Kenya. In the absence of services to meet the mental health needs of Kenyans, traditional healers and witchdoctors play a crucial role in diagnosing and treating them. Claudia examines a programme which brings health workers and traditional healers together. It provides training for traditional healers to refer their severely ill patients to the clinic and avoid harmful practices that some healers carry out, such as lobotomy and bloodletting.

Even in developed countries like the United Kingdom, where mental health services are freely available, some people with mental health problems feel that the treatments do not help. The Hearing Voices Network provides support to ‘voice hearers’, through support groups, helping them to manage and engage with the voices that trouble them.

July 22, 2011 has been described as the day Norway cried. After detonating a car bomb in Oslo, killing eight and injuring many more, Anders Breivik took a ferry to the island of Utoya. There, dressed as a policeman, he began a murderous spree, hunting down and indiscriminately shooting young people on the island who were attending a youth camp. Seventy seven people were killed in total, many of them teenagers, and hundreds injured.

This was the worst mass murder in Norwegian post-war history and the whole country was in shock. But Norway used this national tragedy to pioneer new ways of caring for their citizens. Claudia Hammond reports on the ground-breaking new ways Norway has been road testing to deliver psychological and mental health support to those who survived, and to those who lost relatives and friends.

Solitary confinement is a form of torture that undermines identity and mental health. In “The Truth About Mental Health - Four Walls” Claudia Hammond talks to ex political prisoners about their experiences and how they dealt with living in such inhumane conditions. Advice too from Professor Craig Heaney who works with prisoners in Supermax prisons in the United States of America and psychiatrist Professor David Alexander who has worked with many hostages.

It's a common misconception that children, unlike adults, are so resilient that they can bounce back from the emotional and psychological impact of war and conflict. The evidence contradicts this and world experts in the field warn that, while some children do recover fully from exposure to the horrors of war, others experience long-term mental health problems.

As the war and fighting in Syria continues to claim more lives and destroy many others, Claudia Hammond reports from Jordan on how this latest conflict is exposing yet another generation to the traumatic impact of violence, killing and loss. She investigates what actually helps to alleviate the suffering of these children and prevent a life-time of recurring emotional distress.

From the Al Zatari refugee camp in the north of Jordan she hears about the scale of the challenge facing international organisations like Save the Children. And she meets a group of Syrian mental health professionals from the Arab Foundation for Care of Victims of War and Torture who, as refugees themselves, are running a mass outreach programme, developed by some of the world's leaders in child trauma at the Children and War Foundation, to teach as many Syrian children as possible, psychological techniques and coping strategies.

From time to time we all find ourselves in some kind of emotional turmoil. But when do everyday anxieties or unusual thoughts tip over into a mental health problem? And who decides what’s normal, and whether a treatment that works in one country will work elsewhere? Last October in a village outside of Bangalore, Keshava was dramatically rescued from ten years of being bricked into a room, in his own home. As police knocked down the walls, the young man in his thirties emerged, dishevelled and naked. He’d been locked in a tiny room, without doors or daylight, and was fed through a window. Keshava had become increasingly unwell in his twenties. Unable to cope with his increasingly violent outbursts, or get him the help he needed, his family gradually walled him in. Stories of mental illness like this are happening all around the world, and in this opening programme Claudia Hammond explores how mental illnesses are treated in different parts of the world. Do we all experience similar conditions and respond to the same treatments? Or are our beliefs about our minds so tightly bound to the culture in which we live, that local solutions provide the best chance of recovery? Claudia visits Cultural Psychiatrist, Dr Micol Ascoli, at Newham’s Centre for Mental Health, who believes that service users’ own cultural interpretations of mental illness are crucial to their recovery.

For a loved one to die is devastating enough. But to lose those closest to us in war or conflict, and not to know where they are or how they died, compounds the grief and hugely complicates the grieving process. Families can not mourn fully, because they are unable to lay their loved ones to rest. Claudia Hammond reports from Bosnia Herzegovina, where thousands of people have missing relatives, and from Cyprus, where hundreds of Greek and Turkish Cypriot families have been waiting 40 and 50 years, for the bodies of their missing to be found. In Cyprus, there is a renewed push by Greek and Turkish Cypriots to find the hundreds still missing after inter-communal fighting in 1963 and 1964, and Turkish forces’ intervention on the island in 1974 following a military coup.

The UN-backed Committee on Missing Persons (CMP) in Cyprus is trying to increase its funding to speed up the process of identifying burial sites, exhuming bodies and identifying the missing before the lives of the waiting relatives themselves come to an end. The CMP has turned for help to the International Commission on Missing Persons (ICMP) in Bosnia Herzegovina, the world’s largest specialist DNA laboratory. Exhumed remains are sent to Sarajevo for DNA profiling and the results matched with genetic information collected from the families of the missing.

Following the war in the former Yugoslavia, the ICMP has helped to identify almost three quarters of the 40,000 people missing after that conflict, and they now share this expertise around the world.

The CMP in Cyprus has its own investigators, searching for potential gravesites, as well as scores of forensic anthropologists, painstakingly exhuming remains from mass graves, but the investigative journalist, Sevgul Uludag, is recognised across both communities as key to the process.

For 12 years, Sevgul has worked on a completely voluntary basis, to find the missing. She carries two mobile phones, for Turkish and Greek Cypriots to contact her, in confidence, and she tells Claudia about the death threats she has received to try to stop her work.

Claudia also hears from 69-year-old Maria Georgiadis, who lost her whole family - her mother, her father, her sister and her brother in 1974. None of their bodies have ever been recovered. And from Veli Beidoghlou and his sisters, Sifa and Muge, who were finally able to lay their father to rest after waiting 44 years for his body to be found and returned to them for burial.

Producer: Fiona Hill

Picture Credit: Committee on Missing Persons, Cyprus

Huge advances in technology now mean people can be kept alive longer, blurring the boundary between life and death. This intensifies the dilemmas for doctors, patients and their families. Different cultures and religions have reacted in a variety of ways - from preserving life at all costs, to euthanasia, with many countries sitting somewhere in between. Claudia visits Jerusalem in Israel to explore how the religions there, shaped over many centuries, have adapted to medical advances at the end of life. She discovers how Ariel Sharon’s final years, ventilated to keep him alive, illustrate the pivotal role religion plays.

Jewish law forbids any act which could hasten a person’s death. So, unlike many countries around the world, Israeli law prohibits the withdrawal of life support, such as a ventilator, from patients who are dying. But the law also prevents ventilators from being withdrawn from patients who are not dying, who have been saved by modern medicine yet depend on a ventilator to breathe.

With unique access, Claudia visits Herzog hospital on the outskirts of Jerusalem, where patients lie in beds, kept alive on ventilators. Many are unconscious but some are aware of their surroundings. She hears from the families of patients, some who have been there for many years. It is only lawful to turn a ventilator off in Israel when a patient is confirmed dead. Yet fierce religious debate continues about how death should be actually defined. While ‘brain stem death’ criteria are usually used, there are sections of the ultra-orthodox Jewish community who argue that the final heart beat is the critical moment, with huge implications for end of life care.

(Photo credit: By kind permission of Herzog Hospital)

The truth about mortality is that, when it comes to global figures, it is not known what people die of because more than half of the deaths in the world are not registered. Yet all public health programmes rely on mortality data to decide where to put resources. A lack of accurate data can mean that funding allocation is distorted. Even when data is collected, the cause of death can be incorrect and cultural factors can affect the way the forms are filled in. This is not a new problem as Claudia discovers when she meets the Royal Society’s head of Library and Archive, Keith Moore, she hears that in the 16th Century causes of death included grief, fright and even wind. BBC Urdu Correspondent, Suhail Haleem reports from India on the attempts there to create a comprehensive register for the first time. The Million Deaths Study, which began in 1998, is monitoring nearly 14 million people in 2.4 million nationally-representative households in India. Any deaths that occur in these households during this period will be assigned a probable cause. Researchers carry out a 'verbal autopsy'. This is where researchers visit families who have lost a loved one and ask them about the symptoms to try to ascertain what they really died from. The study has generated some interesting and controversial results that have important implications for healthcare in India.

Tiny babies are, from birth, active learners. They don’t wait for the world to come to them. Claudia Hammond explores the very latest research about what influences the developing mind of the new born infant.

Dr Caspar Addyman from the Babylab at Birkbeck, University of London, describes the biggest ever internet survey of babies’ laughter, which concludes that babies really do get the joke.

Professor Celeste Kidd and researchers from the University of Rochester in the US reveal that just like the fairytale, Goldilocks, babies will focus their attention on things that are “just right”. As Goldilocks chose the porridge, the chair and the bed that suited her perfectly, the inquisitive infant will choose exactly the right level of stimulation and interest - too complicated, and they look away, too simple and they lose interest.

During the first year of life, the development of both the brain and the rest of the nervous system is hugely affected by babies’ nourishment - a sobering fact when you consider that 165 million children are undernourished, according to Unicef. This shortage of the right nutrients can have lifelong effects and Dr Sophie Moore from the UK’s Medical Research Council’s International Nutrition Group reports form The Gambia, from the MRC field station in Keneba. Sophie and Dr Sarah Lloyd Fox from the Centre for Brain and Cognitive Development at Birkbeck describe the work being done to find early warning systems to raise the alarm before poor nutrition causes stunting and affects brain development.

And, one of the world’s leading authorities on infant communication, emeritus professor of Child Psychology and Psychobiology at the University of Edinburgh, Colwyn Trevarthen, talks to Claudia about the importance of talking to babies, and the musicality in those communications.

Picture: Baby laughing, Credit: BBC

The first 24 hours are the most crucial in their survival for the 15 million premature babies born every year. And the stark truth is that survival depends on where in the world a baby is born.

Professor Joy Lawn is in the studio with Claudia and Suhail Haleem reports from Goa, where simple measures are producing dramatic results. And, we hear from professor Neil Marlow about the study which has followed babies born at less than 26 weeks for 19 years, to find out the long term effects on the lives of very premature babies.

(Photo: A baby holds an adult's finger, Credit: Simon Fraser/Science Photo Library)

Claudia Hammond exposes a hidden problem which occurs before life has even begun. Nosiphiwo was ostracised by her husband’s family in South Africa after years of trying, in vain, for a baby. Stories like Nosiphiwo’s, of social stigma and even physical abuse and destitution, are common in low-income countries, where most of the millions of infertile women in the world reside. While programmes tackle the causes of infertility, such as preventing and treating sexually transmitted infections, calls to provide affordable fertility services have been overlooked by agencies which tend to focus on the problem of over population.

Claudia visits Tygerberg Hospital in Cape Town where infertility treatment is being offered at a fraction of the cost of private clinics. Programme Director, Dr Matsaseng, is pioneering differing ways to keep costs down, from using cheaper medications in smaller amounts, to taking on the jobs of several staff himself, texting and supporting patients through each stage of their cycle to co-ordinate their treatments.

The next step is to find a way to take low-cost infertility treatment to rural areas. But this requires a laboratory. The Walking Egg Project, a shoe-box sized portable laboratory for performing IVF, could provide the answer. By the start of 2014, sixteen babies had been born using the system and the team in South Africa now hope to trial it at the hospital.

A one-off special panel discussion on one of the world’s most complex and devastating food issues: diabetes. Presenter Anu Anand is joined by a panel of experts, food industry players and campaigners as they respond live to questions brought up by the documentaries and beyond. On social media, phone, email and live on-air, anyone can be part of the virtual audience for this interactive panel programme. From the role of fast food companies and the controversial sugar tax, to everyday advice on how to cope with the condition, the show will tackle a broad spectrum of diabetes-related issues and questions.

Mexicans are the world’s biggest consumers of fizzy drinks, many argue that Mexicans are quite simply addicted to them. They are part of daily life. But Mexico’s government says it is fighting back, and not long ago introduced the first-ever sugary drinks tax imposed at a national level. Katy Watson speaks to the ministers who proposed it, the companies who opposed it and the Mexicans who are dying of diabetes, and in some cases still enjoying their favourite sweetened drinks. In a country known for its violence, diabetes is actually a bigger killer than Mexico’s drugs industry, and the disease comes at a huge financial cost to the country. Katy travels to the Yucatan, one of the poorest areas of Mexico, where the branding of Coca-Cola is on every street corner. She meets families whose relatives have died of diabetes yet refuse to give up daily soft drinks. We meet the children who are members of a growing club of early-onset diabetes 2 and speak to the doctors trying to tackle a problem that they say will get worse before it gets better. Consumer groups think Mexico is the new battle ground for drinks companies but they want more to be done. Industry leaders say tax is not the way – education is what is needed instead. And we travel to the US, the home of the multinational fizzy drinks industry, where consumers and policymakers are split – Berkeley in California has imposed a sugar tax of its own, the first ever in the US, and sees Mexico as an inspiration. Yet in Washington, industry insiders and lobbyists tell Katy that the pro-regulation camp are going to lose their battle, as ultimately big business will keep giving the consumer what they want.

(Photo: A traditional Mexican breakfast)

Smitha Mundasad visits the Bronx in New York City, one of North America’s poorest and most diverse boroughs. Type 2 diabetes is now so common here that people say every family is touched by the disease. Hispanics, blacks and other ethnic minorities suffer particularly high rates and even young children are developing the disease. Researchers here are working with patients to better understand how type-2 diabetes develops and how to combat it. Smitha discovers that the high blood sugar we associate with this disease is just a symbol of an exceedingly complex process. Excess fat in the body triggers a chain of events, involving a range of different organ systems, which make the body less able to respond to the hormone insulin. Insulin usually controls the blood sugar level, so when the body can’t respond to it properly sugar levels rise. Medication & lifestyle changes early on in the disease are both critical. Numerous medications have been developed targeting different parts of the disease process, but research is ongoing to establish the optimal timing and combination. Here in the Bronx, many people don’t even know they have the disease and some struggle to take medication or make the lifestyle changes. So ethnic minorities suffer higher rates of complications, such as blindness, amputation, kidney failure, heart attack and stroke. Branded a ‘food desert’ due to the lack of opportunity to access fresh produce, strategies are underway to help people make the necessary lifestyle changes, to help treat and prevent diabetes.

Image: Presenter Smitha Mundasad in the Bronx, New York City. Credit: BBC

The tiny, idyllic Pacific islands which make up the Kingdom of Tonga are setting for an unlikely and acute health crisis. With around 90% of Tongans overweight or obese, and with rates of diabetes in adults approaching 40%, Tongans have seen health deteriorate and life expectancy fall. Katy Watson explores the relationship between size and status in deeply religious Tonga, and hears how a decades-old policy of importation has led to the abandonment of the traditional Tongan diet in favour of foods which many blame for soaring rates of type 2 diabetes.

Tonga was almost untouched by diabetes two generations ago but a diabetes specialist at the local hospital tells Katy how she is “drowning” from her workload. Katy also speaks to a visionary Church Minister who preaches healthy eating. He says it’s up to the church to transform the health of the Kingdom, and that people here are now dying from too much, rather than too little.

Katy hears from the Health Minister, who thinks charging for healthcare could be the solution. Katy also speaks to those fighting to restrict imports of the infamous “mutton flaps” - cheap high fat offcuts of meat that some feel are unfairly dumped on the Pacific Islands without a thought for peoples’ health.

Type 2 diabetes is taking on epidemic proportions around the world, and South Asia is at its epicentre.

Presenter Anu Anand travels to Sri Lanka where one in ten adults have type 2 diabetes, and another one in ten have early signs of the disease - so called ‘pre-diabetes’. That’s four million people on this tiny island nation alone.

Palm-fringed beaches lined with stalls selling fresh tropical fruits and sea food are not hard to find here. So why are so many people, in both urban and rural areas, being ravaged by a disease we more commonly associate with Western lifestyles?

Anu asks why rates are so high in South Asia and explores how Sri Lankans are seeking to diagnose, treat and prevent a disease which is ravaging not only adults, but children too.

A big problem with type 2 diabetes is that it is silent. At least half of those with the disease don’t even know they’ve got it, until it has wrecked the body’s blood vessels, causing anything from heart attacks and strokes, to blindness and kidney failure. Life-threatening limb infections requiring amputation are also common.

Such complications of the disease are now overwhelming Sri Lanka’s health service.

The picture is equally stark in India, where Anu lives. Many of her family members have already developed type 2 diabetes. She asks whether she is likely to develop the disease and is alarmed by what she discovers.

Image: Anu Anand, BBC Copyright