The Foott Memorial Lecture: ‘Tuberculosis - Past, Present and Future.’

President: Dr David Rowen FRCP

A meeting of the Southampton Medical Society was held on the 7th February 2024 to hear the Foott Memorial Lecture. The President was in the chair. A short silence was observed in memory of Mr Iain Boyd FRCOG who had died recently.

The minutes of the last meeting were approved.

            The President introduced Dr Ben Marshall FRCP PhD, Consultant and Associate Professor of Respiratory Medicine at SGH who was delivering the Foott Memorial Lecture for 2024 with the title ‘Tuberculosis - Past, Present and Future.’  He thanked the Society for the privilege of giving this lecture. He started with some personal history which led to his qualifying at St Mary’s. His PhD  was concerned with genetically engineering the BCG Vaccine to express mammalian cytokine genes.

            He said that TB has been demonstrated in Neolithic remains. This was a period when man became domesticated and cattle lived in very close proximity. TB-Bovine and TB-Mankind are very close genetically. X-rays of ancient Egyptian mummies and Pre-Colombian mummies showed evidence of TB.

            He said he recently visited the Royal College of Physicians Garden of Medicinal Plants in London. Artemisia, or wormwood, was one of the plants which was used to inhibit tuberculosis. Papaya leaves which are burned, and the smoke inhaled, contain alkaloids which inhibit TB and were used in Africa. On a recent visit to Rome he visited the garden of Keats’ House [by the Spanish Steps]. It was where Keats died of TB having contracted it as a medical student.

            Dr Marshall said that in 1848 a trial was conducted at the Brompton Hospital which showed that by giving cod liver oil to TB patients 63% improved and had less chance of death. That was in an age when 1 in 3 people contracted TB and 50% died young.

            Robert Koch proved TB was a bacterial infection and eventually won the Nobel Prize for his work on TB. Camille Guerain passed the bacillus through potatoes many times to attenuate it and the result was the BCG.

            Dr Marshall then discussed the history of various treatments. He said that most patients get through the massive drug taking required nowadays which lasts18 - 24 months.

            TB is a great mimic he said. The traditional symptoms of cough, haemoptysis, weight loss, fevers and night sweats are not necessarily how it presents as there are Latent cases as well as Active ones. Latent patients just live with it. Fifty per cent of patients nowadays will have TB at sites other than in the lungs. The point of entry is via the lung but macrophages carry the bacillus around the body to other sites. Our speaker himself developed

Tuberculous Choroidal Retinitis which he caught in London. He took 4 drugs for 12 months.

            The incidence of TB was declining in the years before the first world war which was before treatment was readily available. In 1964 there were 140 cases recorded. However in the years after 2000 the numbers took off. He now sees 20 to 30 cases a year. He discussed the concept of Latency. T cells form granulomas around the bacteria in effect locking them away. However, HIV kills T cells and so TB goes “wild” in this group of patients. There is also a high incidence in those patients with type 2 diabetes, inflammatory bowel disease,  those taking anti-TNF drugs, which disrupt the granulomas, [TNF controls the formation of granulomas] and cigarette smoking.

            Southampton now has 5 TB consultants along with specialist TB nurses and microbiologists. For any outbreaks, such as in hospital or schools, CDCs come in to screen contacts for potential cases and carriers.

            There is now a global threat from multi drug resistant TB [MDRTB] where it is necessary to resort to second line treatments which are more toxic and have to be taken for longer. In India this applies to 4% of the population and Russia and the Baltic States [Lithuania especially] and Africa have a high incidence. There are more people dying of it due to the increase in world population. Southampton has a number of MDRTB cases, and also XDRTB cases which are untreatable.

            Dr Marshall said the future will bring new vaccines and treatments. Unfortunately most TB is in developing countries which have no infrastructure to deliver these benefits.

            Questions afterwards highlighted:

                        Twin studies have shown there is a genetic link to innate resistance.

                        Many Afghan patients arriving in the UK may have TB.

                        Fifty percent of far eastern nurses test positive for TB.

                        BCG can be a very effective treatment for MDRTB cases in about 50% of patients.

                        If medical students are travelling abroad for more than 6 weeks they should have a baseline test before they go and repeat it on return.

                        Bill Gates funds TB research and treatment generously.

The President then thanked Ben for such a stimulating and enthralling lecture.

There being no other business the meeting was closed.

Foott Memorial Bursary Winners

President: Dr David Rowen FRCP

A meeting of the Southampton Medical Society was held on the 6th December 2023. The President was in the chair. The minutes of the last meeting were approved.

The President introduced our speakers, the Foott Memorial Bursary winners.

Dr Lottie Mercer who spent elective that focused on rare diseases and the genetics of them.

She said there are more than 7000 rare diseases which have been defined.  In the UK there are three and a half million people who have one. The time to final diagnosis is 5.6 years with multiple incorrect diagnoses en route. Interestingly 81% present in childhood and 80% have a gastric origin. She spent the first half of her elective in the genetic lab in Southampton and the second part at Great Ormond Street Hospital in their genetic clinics. The main points she derived were a. diagnosis of these conditions, b. risk assessment and genetic counselling, c. trying to predict the import of the diagnosis for that patient - and for potential offspring,

and d. the difficulties of transition to adult clinical services for these children when they reach 16 to18 years.

She described her experience from this elective and how it has convinced her she would like to pursue a career in genetics and rare diseases. She thanked the Society for their generous bursary.

Dr Feroza Ahmad: She was interested to see how care in Southeast Asia compared to that in the NHS. She arranged to spend half her elective in Bali and half in Malaysia. In Bali the biggest difference between them and the UK is the amount of education pertaining to medical matters. In their medical education classes at school, which had around 14 children, the children were taught about health care which included general matters such as hand washing and how germs are spread. The really important illnesses in Bali are mosquito born diseases and HIV and they were taught how protect themselves form these illnesses.

In Malaysia she attended the Queen Elizabeth Hospital to study dermatology. She is very interested in dermatology and is considering a career in the subject. She found the consultations to be very relaxed and consultants would happily see 2 patients at the same time. She considered that confidentiality isn’t very important there.

She found the experience very educational and considered that the differences between the NHS and what she found in SE Asia were more cultural than clinical. She thanked the Society for the bursary

 And lastly  Dr Yanika Johnson who decided to spend her whole elective in Jersey as she was born there. She was interested in anaesthetics and ICU care. She said there is one hospital for the whole island which has 200 beds and 7 ICU beds.

There is no formal specialist training in Jersey so she found that the consultants had much more time for her. They were very willing to teach at length and she found that this intense approach was very educational and confirmed her decision to become an anaesthetist.

She also said that there is GP training in Jersey. A consultation with a GP would £50 to £60! She thanked the Society for the bursary.
Our speakers in the end had to present their talks online as there was a train strike on the day of the meeting.

The President thanked them all for their reports and the meeting was closed.

Four Decades in Clinical Academia here in Southampton - a wonderful journey

A meeting of the Southampton Medical Society was held on the 1st November 2023. This meeting was held at lunchtime.

The President was in the chair. The minutes of the last meeting were approved.

The President introduced our speaker, Prof. Cyrus Cooper who spoke to the title “Four Decades in Clinical Academia here in Southampton - a wonderful journey”.

Prof Cooper started by telling us that he started in Southampton with a ‘house job’ and has been here ever since. He graduated from the University of Cambridge and St Bartholomew’s Hospital, London in 1980, and in 1985 took up an SHO position at the Southampton General Hospital.  He became interested in rheumatology and joined the MRC Environmental Unit, first under Professor Sir Donald Acheson and later Professor David Barker, and became interested in osteoporosis. In1990, he won an MRC Travelling Fellowship to the Mayo Clinic, USA, where he continued his research into osteoporosis. He returned to the UK in 1992 to take up a position as Senior Lecturer in Rheumatology and MRC Senior Clinical Scientist. He was promoted to the Foundation Chair in Rheumatology at the University of Southampton in 1997 while continuing as an MRC Senior Clinical Scientist at the MRC Environmental Epidemiology Unit. In 2003, he was appointed Director of the MRC Epidemiology Resource Centre, University of Southampton. In 2010, this was reconfigured as the MRC Lifecourse Epidemiology Unit and funding was extended to 2015. Professor Cooper leads an internationally competitive programme of research into the epidemiology of musculoskeletal disorders. He is particularly interested in the strategic future of osteoarthritis and osteoporosis.

Prof Cooper outlined the history of these conditions starting with Hippocrates in 400BC.  He discussed the diagnosis and prevention of these conditions in view of the burden they place on society. He said that there were developmental origins to osteoporosis and a low bone density is found in children of mothers with low vitamin D levels. Vitamin D supplements during pregnancy are important, especially during winter, and improvements in childhood bone density have been demonstrated as a result. He has been the leader of large randomised controlled trials of calcium and vitamin D supplementation as preventative strategies against hip fracture in the elderly.

 He finished his talk saying that in 2021 the MRC Lifecourse Epidemiology Unit funding was made secure until 2026.

The President then thanked Professor Cooper for his fascinating biography and his helpfulness to the local medical community as well. There was prolonged applause from a grateful audience.

Bias, Prognosis and Interventions

A meeting of the Southampton Medical Society was held on the 4th October 2023.

The President was in the chair. The minutes of the last meeting were approved.

The President introduced our speaker, Dr Iain Macintosh, consultant anaesthetist in PICU Southampton University Hospital, who spoke to the title ‘Bias, Prognosis and Interventions’. He asked, why study the process of decision making in science, when it is something we do all the time? It is algorithm driven. But medical decision making is full of shortcuts exposing the possibility of confirmation bias. He discussed Gerd Gigerenzer’s work on Ecological Rationality and explored with “illness scripts” how people can be good decision makers by using simple heuristics but there is always a risk of bad decisions.  At birth, Dr Mackintosh said, the gestational age of an infant is 100% important but as it gets older it becomes less so. He had created a questionnaire of 26 scenarios relating to the management of infants from 23 weeks to 30 months in PICUs and asked how using ecological rationality and heuristics might affect the clinical outcomes. He sent the questionnaire out to 278 PICU consultants and received 74 replies with a variety of responses which he discussed.

Dr Mackintosh then invited comments from the audience. A discussion ensued covering a variety of clinical situations including the role of AI.

The President thanked Dr Macintosh for such a stimulating evening.

Training health workers in Nepal

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Nigel Dickson FRCGP

A meeting of the Southampton Medical Society was held on the 5th April 2023.

The President was in the chair. The minutes of the last meeting were approved.

The President introduced our speaker, Dr Oliver Ross, Consultant in Paediatric Anaesthesia and Paediatric Intensive Care who spoke on Nepal and of his experiences in visiting and training Nepali healthcare workers over 15 years with the Nick Simons Institute.

Nepal is a country of 30 million people. There are areas of half a million people with no proper healthcare. The Nick Simons Institute was set up to support district hospitals which are the forgotten branch of health care in Nepal. There is also a significant need for rural GPs in the country areas.

Dr Ross showed a film of a mother being transported from a rural area to have a Caesarian Section for obstructed labour. She is on a stretcher which is being manhandled across mountain tracks  with steep ascents and descents on uneven stony ground. A perilous journey. The film ended with a picture taken outside a mission hospital of a group of healthy looking mothers. But this hospital was not able to provide obstetric surgery.

Caesarian Section is the commonest operation in the under 40s in Nepal. Obstructed labour with death in utero causes a significant maternal mortality. There is a delay due to failure to recognise that help is needed. Part of the problem is lack of personal money as everything has to be paid for. But there is another delay due to the difficulty  of transporting cases to a surgical unit as demonstrated in the film. There is a 2 hour slot between help being needed and surgery after which there is a steep curve in maternal mortality rates. It takes on average 15 hours to transport the mother to a unit across the mountains. Dr Ross was glad to say that maternal mortality is falling in Nepal. However there is a concomitant rise in the suicide rate amongst women - women who might have formerly died in childbirth. Women do all the work in Nepal. In general there is a correlation between a lack of education of young women and maternal mortality.

But improvements are afoot. GP postgraduate training now involves teaching them to do Caesarian Sections. Programmes are being developed to teach health assistants in specialist areas of treatment. Teaching assistants to do essential surgery is important. The Global Surgery Commission recommends that 80% of the population of an area should have access to surgery [5000/100,000 population].

The Simons Institute is trying to aid this process. It works with 12 hospitals. They have a programme  developing Paediatric Clinical Standards with which our speaker is involved along with other paediatric specialists from the UK. They have been concentrating on teaching triage and specialised paediatric care to young doctors. However it is difficult to get changes and to persuade young doctors to serve in rural areas.There is a growth of private hospitals in better off areas with the result that there are 50 paediatricians offering private treatment per 150,000 population as opposed to 5 for the general population.

The President thanked the speaker saying it was an excellent talk to end the season.

https://www.nsi.edu.np/

and

The CMO Sir Chris Whitty on the future of global health

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Nigel Dickson FRCGP

A meeting of the Southampton Medical Society was held on the 1st March 2023.

The President was in the chair. The minutes of the last meeting were approved.

The President introduced our speaker, Prof. Sir Chris Whitty, Chief Medical Officer for England, whose lecture was entitled ‘Where is Health Going?’.

Sir Chris said we need to take the long view of health. In the short term it can look grim. But this was always so and for the last 3 years, due to the pandemic, especially so. The indicators we need to follow are mortality and disability.

Consider children under 5 years. In the last century, before the second world war, childhood mortality was very high. In the last 20 years childhood mortality has decreased enormously. The Far East has shown the most rapid improvement of all. Malaria mortality has reduced 50% in the last 70 years. Immunisation programmes have been preventing infections and improvements in water has played a part too. In the last 10 years respiratory deaths have reduced, and neonatal mortality has reduced as well.

The physical health of children over 5 years old has improved so much that they have a low probability of dying and the majority will live a long life. In most countries of the world there has been an improvement in life expectancy. For non communicable diseases, such as cancers, deaths under 50 years are rare. Even breast cancer is reducing. The exception is in mental health where there is a gap in our ability to do something about it. Covid made this worse.

For the over 50s things have got much better. Cancer deaths peaked in the 1950s since when there has been a steady decline. A 75% drop since 1975 is largely due to the reduction in cigarette smoking. There has been a decline in CVA mortality as well. This has been driven by the use of antihypertensives by primary care and the use of stents, surgery and thrombolytics in the hospital setting. There has been, he said, a series of incremental improvements resulting in a general decline in the mortality from most major cancers which is very positive.

However there are headwinds. Obesity is the big challenge. It starts in early childhood and is strongly linked with deprivation. Deprivation correlates to smoking, obesity and poor working conditions. It became worse during the Covid epidemic.

An ageing population produces new problems. When better off people retire they tend to do so to the country. Their children are left in the big towns and cities for work and are not able to support their parents if needed. Who is going to support them?

The incidence of dementia in men is half that in women and presents a care problem. The mortality in 80 year olds is improving whereas in 90 year olds it remains constant. However people in their 80s are getting multiple diseases and the medical profession cannot cope with this.

In conclusion he said that life expectancy has increased and the health of the population is improving at a remarkable pace.

The President thanked Sir Chris for a fascinating lecture and that it was a great honour for us to have such a high profile visitor. Sir Chris in response thanked the Society for their hospitality.

There being no other business the meeting was closed.

Changing the World Feet First

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Nigel Dickson FRCGP

The Southampton Medical Society met to hear the Foott Memorial Lecture on the 1st of February 2023 . The President was in the chair. The lecture was delivered by Professor Clifford Shearman OBE BSc FRCS MS., Emeritus Professor of Vascular Surgery, University of Southampton.  The President introduced Prof. Shearman who spoke to the title “Changing the World - Feet First”

Professor Shearman said that diabetic foot complications had been an interest for all his clinical life. He described the six steps of change with regard to the diabetic foot.

Phase 1. Recognition that there is a problem.

The commonest complication of diabetes is foot ulcers. There is an individual lifetime risk of 25% and up to 5% of diabetics will be having treatment at any one time. These patients are 24 times more likely to end up having an amputation than the general population. Forty five per cent of these ulcers will heal in one year and twenty-five percent will never heal.

Every 30 seconds a diabetic somewhere in the world has an amputation The outcome after amputation is poor. Only 1/3rd of the amputees will become fit again. But, he said, 85% of amputations could be avoided with rapid and correct treatment. In the UK there are more than 200 amputations a week and of these 45% will be for diabetic complications.

Phase 2. Enthusiasm.

Determination to attack the problem through education and research. Diabetes UK produces literature for diabetic patients on how and when to seek help, and other advice on diabetes. There is now public health information available, from a variety of sources, which is a result of research.

Phase 3. Research.

A great deal of research has been done.  It was observed that diabetics with foot ulcers commonly had diabetic neuropathy with reduced sensation and a lack of muscular strength due to a myopathy. They commonly had ischaemia and a lack of collaterals. There tended to be a rapid progression of pathology after ulceration started. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, surgical debridement and drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularisation should be undertaken in those with significant arterial disease. The research showed that treatment needed to be commenced within 3 days to prevent the ulcers becoming established with inevitable complications. Time is Tissue he said.

Phase 4. Implementation.

It is not all gloom. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries. Finland put in place a national programme of public awareness very early on. As a result the number of amputations fell. Unfortunately there has never been a national programme in the UK. However Southampton and a few other hospitals around the country set up a foot protection protocol in the first decade of this century. This included an algorithm for the treatment of foot ulcers. Revascularisation was performed where needed. Amputation rates fell in the partaking hospitals. The result of this research programme in financial terms, which cost only £150,000, produced enormous savings for the NHS compared with standard treatment  As a result eventually National Guidelines were issued.

Phase 5. Persistence. Unfortunately due to decreased funding the whole system has shrunk away since 2015. Diabetics are 6 times more likely to lose a leg now.

The National Diabetes Foot Care Audit in 2017 reported significant variability and deficiencies of care throughout England and Wales, with emphasis on change in the structure of healthcare provision and commissioning, improvement of patient education and availability of healthcare access. They found:

Only 82% of diabetics have diabetic footcare

Only 71% of clinics could see the patient quickly

46% of new ulcers would have to wait to be seen for more than 2 weeks.

Political pressure is needed he said.

Phase 6. Litigation. The NHS paid out £2.75 billion in 2021. It has a liability of £8.82 billion. It costs the service £8 billion annually.

The claims for clinical negligence are numerous. These include delays in referral, failure to expedite treatment, lack of coordination and lack of multidisciplinary care.

In consequence GIRFT [Get It Right First Time] was set up by the government in 2017. GIRFT liaises with NHS England regional teams to support putting recommendations into local practice.

Professor Shearman said teamwork is essential for best practice in diabetic footcare.

The President thanked Professor Shearman for his lecture on such an important subject. It was extremely interesting. He said that Southampton was very lucky to have had Professor Shearman as their surgeon.

There being no other business the meeting was closed.

Refugee Health Alldance Tijuana Mexico

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Nigel Dickson FRCGP

A meeting of the Southampton Medical Society was held on the 16th of January 2023 . The President was in the chair. The minutes of the last meeting were approved. The President introduced the speaker, Dr Josh Gray, who was one of the Foott Memorial Grant winners who spoke about his experiences on his elective. Dr Gray spent his elective with the Refugee Health Alliance Clinic in Tijuana, Mexico. He said the town is one of the most dangerous in Mexico due to the drug gangs. It is also a centre for refugees. They come mainly from Haiti, about 80%, and 20% from other countries of Central America. The Haitians make a punishing journey via northern Brazil and travelling north through Central America. They are severely abused all the way. Many who come to the clinic have been refused entry to the US at the border or deported from the US. In general the citizens of Mexico accept the refugees though.

The refugees are in very poor health; unvaccinated, undernourished and suffering many diseases. They consist of families, lone children, pregnant women and all are homeless.

The Refugee Health Alliance was formed in 2018 in response to this medical crisis. They have a team of 2 salaried doctors of registrar level of experience, 2 medical students, 2 translators and a team of midwives. The resources are very limited and so the number of blood tests and imaging investigations are severely limited. The doctors rely on traditional history taking and examination! Josh said his clinical acumen improved enormously from this experience and that he became such a much better doctor.

He described a day in his life there. Every morning there was a massive queue of women, children and men waiting. He would only manage to see about 10 patients a day. The consultations were all in Spanish [in which he is only moderately fluent]  as very little English is spoken. He was well supervised. He saw severe motor cycle accident cases, “jungle” bites, Leishmaniasis, a case of dextrocardia, a case of leiomyosarcoma and numerous ill homeless children. The refugees often want a medical certificate stating they need treatment in the USA as this can be a mode of entry there.

The experience has been a profound benefit for his doctoring skills. Being a junior doctor in the National Health Service, during this last 6 months, is ‘mindless’ in comparison.

He has every intention of returning to Mexico to help them out again.

He thanked the Society for his grant and said he would not have been able to make the journey without it.

The President thanked Josh very much for his interesting presentation.

The meeting was then closed due to technological failure.

https://www.refugeehealthalliance.org

Medicine in Antiquity

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Alan Roberts FRCP

A meeting of the Society was held on December 7th 2022. The President was in the chair.

The minutes of the last meeting were approved. The President then introduced the speaker for the evening Dr Keith Liddell who spoke to the title Medicine, Disease and Doctors in Antiquity.

Dr Liddell started his survey of over 5000 years of medicine in antiquity with a photo of mummified bodies from 4000 years BC found in China. He visited the site and subsequent gene analysis showed that they were Celts and not Chinese. The Chinese government  regarded this as a sensitive finding. Dr Liddell said that there were skin changes on the bodies of fungal infection and also that they had nits.

Hippocrates said that a physician must know what went before. Winston Churchill said that the longer you look back the longer you can look forward.

Therefore it was important to study the ancient past. Humanity has always suffered from diseases which are similar to those of today. They also had treatments.

Studying the bodies revealed interesting things such as sacrificed Inca children had their skulls smashed in, or that the Neanderthal man’s body found in the alps had an arrow that had punctured his lung. A toothless man found in Georgia was believed to be 1,700,000 years old.

But bodies are not always available. In which case, he said, study the bones. A Neanderthal skeleton showed signs of a surgical amputation 50,000 years ago. The ancient Egyptians after performing trephination of the skull, a procedure which was performed in all civilisations, sealed the wound with a copper patch. Diseases or wounds affecting the joints and bones reveal so much about the lives of the ancients.

If no body or bones could be studied then look at their Art. Ancient art has revealed many diseases such as a case of Sturge Weber syndrome from 2nd C AD or a severe case of Leishmaniasis. Cave drawings show hunting accidents and erotic scenes. Sculptures reveal fertility practices.

Finally study the writings. The Edwin Smith papyrus from 176BC is a comprehensive manual on surgery for military wounds. The Berlin Papyrus describes urine tests for pregnancy. The Chester Beattie Papyrus has a treatment for anal itch. The Ebers Papyrus describes treating ulcers with honey.

Dr Liddell also described some of his worldwide visits to archeological sites. It was a talk rich in examples.

The President thanked Dr Liddell for his fascinating and learned talk.

A Penguin in the clinic - remote healthcare in the Falklands

SOUTHAMPTON MEDICAL SOCIETY

President: Dr Nigel Dickson FRCGP

A meeting of the Southampton Medical Society was held on the 2nd of November 2022.In the President’s absence the previous President was in the chair. The minutes of the last meeting were approved.

He introduced the speaker, Dr Matthew Dryden who spoke to the title “A penguin in the clinic - remote public health care for the Falkland Islands with occasional visits to check on the fauna as well”. He said the Falklands are so isolated that historically infections were only introduced from people on ships. In times gone by whalers brought in measles and diphtheria but in modern times cruise ships bring in Norovirus or HIV. During the early days of the Covid pandemic the islands closed their borders and cruise ships were excluded. There was a small outbreak amongst army personnel but it didn’t reach the population because the army cases were isolated promptly. In April 2022 the borders were opened and a wave of cases followed. However the population had all been vaccinated and no-one was hospitalised.

The Falklands consist of two main islands and numerous small ones. Our speaker had visited most of them over the years. They team with wildlife. Port Stanley is quaint, like a 1950s village on a Scottish island. It has two memorials of note; one to the WW1 battle of the Falkland Islands and another in memory of the 20,000 whales killed in the past. There are two mountains, Mts.Tumbledown and Kent. The final battle of the 1982 Falklands war was on Mt Tumbledown.

Stanley Sound has picturesque wrecks but there are still mines on the beaches there, and elsewhere, that were laid by the Argentinians during the Falklands war in 1982. Neither penguins nor sheep, which roam freely, set off the mines. Elsewhere the mines are being removed gradually by Zimbabweans. The British army is based in the Mount Pleasant Barracks near Port Stanley. Most travel on the islands is by plane.

The population is 3,000 and 75% live in Port Stanley.  The islanders make most of their money out of fishing which is tightly managed. There is a new 28 bed hospital which is staffed by 3 GPs and a visiting surgeon. Trauma represents a large part of the work with frequent RTAs, due to the extremely large drainage ditches alongside the roads, fishing accidents and even wounds from elephant seal bites. Major trauma and obstetric problems have to be flown out to Chile or Uruguay or Southampton General Hospital. The list of medical problems is large: Elderly care, mental health, alcohol, diabetes, TB, hydatid disease are all endemic. Introduced infections are of concern too such as  HIV, STDs, MRSA, ESBLs, Norovirus, Covid and the possibility of Zika virus and Ebola being brought in.

X-rays are available in the new hospital not only for humans but for egg bound penguins, injured dogs, a land mine to see if the detonator is still present and even fish.

Dr Dryden’s role covers advice for treatment, food and water standards, infection control policy, antibiotic formulary and policy, immunisation and microbiology services.

He is concerned to try and break the links of hydatid disease. Dog tapeworms are frequent as the dogs eat sheep offal lying around and humans stroke the dogs. Somehow the links have to be broken. Port health is another of his responsibilities with which come a variety of problems. In 2012 a diplomatic incident was caused when a cruise ship carrying 3000 passengers coming from Argentina arrived with a large outbreak of Norovirus. It was decided not to let the passengers ashore which was taken as a snub by the Argentinian government. Then a naval ship with a case of TB arrived and it had to be decided whether to let the crew ashore or not. The MOD insisted they did due to the crew having served a long period at sea. There were 27 close contacts and 250 BCGs were done and everyone had to fill in a questionnaire. Five cases of persistent cough were discovered which had to be X-rayed.

Dr Dryden finished with a gallery of wildlife photos which highlighted the very rich natural environment in the Falklands.

The President then thanked Dr Dryden for his excellent talk.

There being no other business the meeting was closed.