The authors share experiences of a global health partnership that worked to promote equity through a commitment to shared values and goals, engagement and communication, and mutual trust and respect. We share experiences of a global health partnership between 2 hospitals, the Ministry of Health, and a nongovernmental organization that focused on improving obstetric care at a district hospital in northwestern Madagascar.Despite having differing access to material, technical, and financial resources, the partners cultivated an environment for equity through a commitment to shared values and goals, active engagement in communication and implementing activities, and fostering of mutual respect and trust among individuals and institutions.The success of the partnership also depended on flexibility and a willingness to use technology in new ways, especially when COVID-19-related restrictions necessitated the adaptation of a simulation-based training activity on respectful emergency obstetric and neonatal health care. The types of institutions involved in global health partnerships vary widely. They may include government agencies, academic and research institutions, entire health systems, individual hospitals and clinics, businesses, nongovernmental organizations (NGOs), and others.–However, significant concerns persist about asymmetrical power dynamics in global health partnerships.In this commentary, we reflect on our experiences creating a 4-institution global health partnership with a programmatic focus on improving obstetric care at a district hospital in northwestern Madagascar. In addition to implementing effective programming on obstetric care, we consciously worked to foster equity among the partners despite our varied access to technical and financial resources. In retrospect, we identified 3 elements of our approach to partnership that supported our desire for equity: (1) commitment to shared values and goals, (2) active engagement in communicating and implementing activities, and (3) fostering of mutual trust and respect. No single path exists for effectively decolonizing global health partnerships, and to some degree, each partnership will be different. This commentary presents our lessons learned to support other global health partnerships seeking to decolonize their activities through respectful and equitable collaboration.Centre Hospitalier de Référence du District d'Ambanja (CHRD) in Madagascar is the district hospital for Ambanja district in northwestern Madagascar. It has 100 beds and approximately 1,000 deliveries per year. Access to quality obstetrical care is a major challenge throughout the country, particularly in emergency situations. Most pregnant women living in Ambanja deliver at home, so those who come to CHRD tend to be high risk or in need of emergency obstetric and intensive post-delivery care. Providing quality care for pregnant women and newborns in Ambanja district is a difficult challenge because the hospital is chronically under-resourced and understaffed. In Madagascar, district hospitals fall into a resource gap—most of the limited funding and training opportunities that exist go to either community-based primary care centers or hospitals in the capital. However, despite these challenges, the CHRD staff were committed to providing quality care to the best of their abilities, with limited supplies and equipment.For more than 8 years, CHRD maternity department staff communicated with a colleague in Switzerland and developed a relationship of trust. This obstetrician/gynecologist at Hôpitaux Universitaires de Genève (HUG) had previously spent a year working on cervical cancer and mobile health projects in Ambanja.In 2019, physicians at CHRD requested training for maternity department staff on emergency obstetric and neonatal care, and the HUG physician and her colleagues in Switzerland agreed to respond. This was the first step in building our partnership for improving emergency obstetric care in Ambanja. Extensive discussions ensued between the hospital teams. As they discussed ideas for collaboration on this topic, it became clear that their efforts would benefit significantly from additional support from other institutions. Two key institutions were approached that then became core members of the partnership: the Ministry of Health (MOH) in Madagascar and the Swiss NGO Enfants du Monde, an NGO with expertise in training providers in low-income countries on respectful maternal care. Other institutions have also made significant contributions to the partnership's work, including an Italian social enterprise, Terre Innovative, and several technical and donor agencies.As staff from the 2 hospitals discussed ways to collaborate, it became clear that their efforts would benefit significantly from additional support from other institutions.,–Through discussions, the 4 institutions agreed on a plan to conduct a simulation-based integrated training on respectful emergency obstetric and neonatal care. Simulation is a mode of instruction that uses mannequins, actors, and group role-plays to replicate clinical situations for training purposes.Implementing the training required the involvement of several staff from each partner and additional funding to support the activity. On behalf of the partnership, HUG applied for a grant of approximately 100,000 Swiss francs  from the (now closed) Swiss branch of the ESTHER Alliance for Global Health Partnerships. The partnership structure was then formalized by creating and signing a multilateral agreement that detailed each partner's roles and responsibilities. The simulation-based training on respectful emergency care for women and newborns was implemented in 2021. The training took place in a designated room at CHRD that was equipped with Internet, computers, a screen, smartphones, and other technology that enabled the Swiss partners to participate fully but remotely.This short summary glosses over many challenges. Some were typical challenges faced in any situation when organizations with different missions and goals try to work together. Others were more specific to the sudden appearance of COVID-19, which drastically affected our original plans for implementing the training.Three other major changes were required to adapt to the COVID-19 pandemic. First, because the Swiss partners could not travel to Madagascar, we added a training-of-trainers component for MOH staff. Another adaptation was conducting the training twice for 2 smaller cohorts of CHRD staff (instead of once for the full CHRD team) to limit potential COVID-19 exposures. The third major change related to the impossibility of getting certain materials used in simulations delivered to Ambanja. Workarounds included replacing high-tech mannequins with low-tech models, adding additional role-playing by the trainers, and designing training materials that could be produced in Ambanja. Each of these changes ultimately had notable benefits for the partnership. The training of trainers built national capacity and support for the use of simulation. The smaller training cohorts gave each trainee more opportunities to participate. Finally, adapting the required materials to the local context made the simulations more realistic and easier to replicate in the future.While evaluation of the impact of the training is ongoing, our early analysis of forthcoming results looks excellent (unpublished data). Among our emerging findings were: (1) the hybrid format and the course content were well-received by the CHRD participants; (2) the trainees' scores on tests of knowledge about the management of obstetric emergencies improved; and (3) most participants reported improved communication with their colleagues and patients.–Following the training, the partners reflected on this first major partnership initiative to examine whether and how it worked. The reflection involved an inductive process to identify key elements that contributed to the partnership, self-assessments of the partnership using ESTHER's “EFFECt Tool,” and a comparison of our conclusions with the results of other partnership frameworks.We concluded that our partnership has succeeded because of 3 elements: (1) a commitment to shared values and goals, (2) active engagement, and (3) mutual trust and respect. Each of these elements exists both at the institutional and individual levels .We did not consciously focus on these 3 elements at the start of the partnership, nor did we explicitly articulate a desire to contribute to the decolonization of global health. However, having identified the elements, we now actively discuss how to sustain these elements during planning conversations. We continue to explore good practices in communications, as well as for planning, implementing, and evaluating activities. In this section, we present our operating definitions of these features of the partnership.Each institution  conscientiously fulfills the commitments it makes to the partnership.The ideas, opinions, and concerns of all partnership members are taken seriously.Each institution and its individual representatives participate in good faith in collaborative and consensus-oriented decision-making.Each of the 4 partner institutions is a different type of institution working in a different context. Therefore, to collaborate effectively, each institution had to commit to shared goals and values related to the partnership's programmatic objectives and collaborative process. As a partnership, we committed to the goal of building the capacity of CHRD to provide quality maternal health care. We also created shared values to guide the strategies we used in working toward our goal. In hindsight, we identified the shared values of the partnership.The partners created shared values to guide the strategies used to achieve the goal of improving the quality of obstetric care at CHRD.Many of our partnership's operating approaches emerged organically based on the personalities of and relationships among the individuals involved. Others were articulated in the institutional agreement and other documents.A key component of our communication and decision-making processes was that all partners listened carefully, especially to opinions expressed by the CHRD team. The CHRD team had expertise on the conditions in Ambanja, so their understanding of what would be useful and applicable in that context was considered by all partners to be of paramount importance. Thus, in the discussions for planning the training, they were explicitly asked to provide their input, which was given extra weight during decision-making.Another shared value was transparency around bureaucratic and financial management.Finally, the partners shared a willingness to be flexible and experiment with new technologies and methodologies. Some approaches that now feel central to the partnership's work (such as the use of a hybrid in-person and remote training methodology) were not in our original plans. Instead, these strategies evolved as we worked closely together to implement the simulation-based training within the limitations and obstacles created by the COVID-19 pandemic. The partnership adapted implementation strategies in response to changes in the environment by updating and adding goals, testing various technologies and methods for communication, and using new tools. All partners were as committed to adaptation, change, and evolution as they were to the original goal of supporting CHRD to improve the quality of obstetric care.This element encompasses the significant investments of staff time and other resources made by each institution. Although each institution officially assigned 1 or more focal point persons to the partnership, in reality, numerous staff members were involved in the partnership's activities.One important component of active engagement was the willingness of all partners to engage in frequent and multichannel communications. Collaboration is a dynamic endeavor, particularly in a rapidly changing environment. Regular communication was required during the design, adaptation, implementation, and evaluation of the training and ad hoc activities. We used various modes of communication for these dialogues, including telephone calls, videoconferences, and chat groups. Written chat threads (on WhatsApp and the Messenger app) were especially important because they allowed all institutional representatives to follow and remain current on programmatic and administrative dialogues in real-time or asynchronously.One important component of active engagement was the willingness of all partners to engage in frequent and multichannel communications.Active engagement was especially evident at the individual level. Many individuals did significant partnership-related work outside of their regular working hours. This required high levels of motivation . Maintaining individual motivation at times was challenging and sometimes required reallocating tasks to other individuals.,The third element that contributed to success was the trust and respect shown by each institution and individual. The partnership initially emerged out of interpersonal relationships grounded in trust and respect.As the partnership grew, trust and respect continued to be earned and offered by each institution and individual. We did this by demonstrably committing to and actively engaging in the work of the partnership—that is, through the other 2 key elements. If 1 partner demonstrated engagement in the partnership's work, then other partners accorded them respect by honoring their contributions, soliciting their input, and supporting capacity development.Trusting the local knowledge of each team was also important. For us, this meant relying on CHRD to determine which training topics and modalities would work best for their staff, on the MOH to provide guidance on national standards, and on the Swiss partners for training expertise and adherence to the funder's requirements. Trusting other partners was not always easy. Each partner, at some point, had to relinquish expectations, give up control of certain tasks, and accommodate other institutions' procedures.In the absence of mutual trust and respect, a partnership is unlikely to work. Lack of trust undermines the capacity to collaborate. When partners feel distrusted, they will resist sharing concerns; when they feel disrespected, they will not share ideas. When trust and respect are withdrawn or lost, it can have huge consequences; if these ruptures are not addressed, it can lead to the end of a partnership. Thus far, our partnership has been both lucky and careful to sustain mutual trust and respect. When we consider new initiatives (and as new staff members are added to the partnership), we work to continually reinforce trust and respect through authentic and active communication and engagement.If loss of trust and respect is not addressed, it can lead to the end of a partnership.Our experience shows that the elements of successful partnership must exist at both the institutional and individual levels. Investments of time, energy, and resources are essential from both individuals and the institutions they represent. Each institution must fulfill commitments and follow through on promised investments in the partnership, including participation in collaborative decision-making. To do this, individuals within each institution must undertake the work required and receive appropriate support from their institution.The attitudes and behaviors of individuals can make or break a partnership; similarly, the values and policies of institutions must be sufficiently aligned to make collaboration equitable and effective. Trust and mutual respect are especially critical at the individual level. The collegial relationships among the founding individuals in our partnership enabled direct, realistic, and open communication, setting a precedent for the partnership's approach to decision-making. In particular, as the partnership grew, the Swiss partners' responsiveness to requests from Madagascar demonstrated respect for the Malagasy colleagues. In turn, this respect solidified the Malagasy partners' trust in the Swiss partners' commitment to equity.Change is inevitable, and our partnership is grappling with how to sustain the core elements of success as we expand, adapt to institutional changes, and respond to external circumstances. We were lucky that only a few key individuals in the partnership left their posts during the planning and implementation of the emergency obstetric care training. In each case, those who left carefully selected and oriented a replacement to take over as the partnership's focal point person.We learned from that experience that we need to develop more systematic ways to sustain the partnership through gradual and sudden changes. We have begun systematizing how we orient new participants to the partnership's goals, values, and approaches to collaboration; shift roles and responsibilities as individuals move to different positions; share the partnership's past experiences and values; remain open to input and new opportunities; and build mutual trust and respect among longstanding and new members. We are dealing with these issues as we explore expanding the partnership's work into new areas, including building capacity at CHRD to routinely test for Rh-factor and testing and treating pregnant women for HIV and other sexually transmitted infections.Building long-term collaborative relationships among institutions with similar missions but different approaches and resources can have significant positive impacts, as shown by our efforts to improve the quality of maternity care at CHRD.A strong partnership depends on 3 critical elements: clearly stated shared values and goals, active engagement, and trust and respect among partners.Partnerships exist on multiple levels, but they must especially involve both institutions and individuals in the 3 critical elements.The personal relationships and institutional structures that make a partnership work are complex and require transparency, communication, appreciation, and responsiveness.Our partnership represents a “north-south” engagement that has successfully implemented an initial project—simulation-based training—that contributes to a shared long-term goal to improve the quality of obstetric care in Ambanja. Despite the complexity of building a new partnership and in the face of complications created by the COVID-19 pandemic, we were able to achieve this goal through our commitment to shared values, active engagement, and mutual trust and respect. The organic evolution of this partnership may not be easily replicated by others, but we offer 4 overarching lessons we have learned from our experience.We hope that these lessons are useful for others working to build equitable global health partnerships, decolonize global health, and contribute to improving health outcomes globally.


Opioid overdose deaths have increased in Sweden and other developed countries in recent decades, despite increased treatment efforts and harm-reduction interventions. Further knowledge in this field is needed if this trend is to be reversed. Previous research suggests that mental health and patterns of prescription of opioids and other prescription drugs are associated with increased opioid-related mortality. The present study therefore aimed to investigate what drugs were prescribed during the last six months of life to individuals with a history of illicit substance use who died with opioids present in their blood, the relationship between drugs prescribed and drugs found in blood at time of death, and if prescription of specific drugs was temporally associated with death.This was a retrospective, register-based observational study that utilized data from the National Board of Forensic Medicine, the Prescribed Drug Registry, regional health care services, and municipal social services. We used conditional logistic regression to find temporal associations between the prescription and dispensing of drugs and time of death.Prescription and dispensing of alprazolam and diazepam were temporally associated with death. The most frequently dispensed drugs were zopiclone, pregabalin, methylphenidate, diazepam and oxycodone. Methadone, alprazolam, and buprenorphine were the drugs most often found in the blood. Opioids and tranquilizers in combination were found in a vast majority of deaths, and prescription data suggested that the use of these drugs was illicit in a majority of cases.Prescription of certain drugs, especially alprazolam and diazepam, should be made with great caution to patients with a history of illicit substance use or concurrent use of opioids. Drug-related deaths, with opioids involved in a large majority of cases, are an increasing problem in developed countries, sometimes referred to as an opioid crisis or epidemic. According to a recent report from the OECD (The Organization for Economic Co-operation and Development), the average number of drug-related deaths per capita in OECD countries increased by 20% between 2011 and 2016. The highest rate of drug-related deaths in 2016 among the OECD countries were observed in the US, Canada, Estonia, Sweden and Norway, in that order . In SwedThe mental health of patients is likely to affect opioid prescribing. In the US, patients with a mental disorder are prescribed more opioids than patients without a mental disorder when controlling for multiple factors such as the cause and severity of pain . Other sIn addition to opioids, other prescription drugs used in combination with opioids increase the risk of opioid-related death. In particular, the use of benzodiazepines (BZD), but also the use of z-drugs  and pregabalin, is widespread among opioid-addicted individuals, often involved in opioid deaths, and seems to be associated with increased mortality in combination with opioids both when prescribed and used illicitly –26. An ADespite extensive treatment efforts and increasing harm-reduction interventions, opioid-related deaths have increased in Sweden over time . The NatWhat drugs were prescribed during the last six months of life to individuals with a history of illicit drug use who had opioids present in their blood at the time of death?What drugs were found in the blood at the time of death?To what degree were the drugs found in the blood at the time of death prescribed?Were any drugs or drug classes associated with prescription during the last month of life in this population?This was a retrospective, register-based observational study that utilized data from The National Board of Forensic Medicine (NBFM) and The Prescribed Drug Register (PDR). The study was approved by the Regional Ethics Committee in Lund, Sweden . As the study involved only deceased subjects, no informed consent procedure was carried out.Every year, a little over 90,000 people die in Sweden . Of thesThis study utilized a cohort selected for previous studies on opioid-related mortality ,38. The To identify cases where opioids were present in the body at the time of death, forensic reports at The National Board of Forensic Medicine (NBFM) in Lund, Sweden, were inspected manually. The first selection included all deaths that had occurred in Skåne where the person was also registered as living in Skåne in the national population registry. Approximately 1000 forensic autopsies are performed at NBFM in Lund each year. This includes all deaths in Skåne as well as deaths in one neighbouring small county and the southern parts of two additional counties. Opioids were present in 503 out of the roughly 4,000 cases during the above-mentioned time periods. The forensic reports were read to determine if there was a patient history of illicit substance use. A person was considered to have a history of illicit drug use if the report from the forensic autopsy or the police report included in the NBFM journals mentioned use of one or more narcotic substances, if the autopsy report mentioned needle marks, or if illegal drugs  were found at the forensic chemical analysis. In cases where such a history was found, additional information was collected from NBFM and The Prescribed Drug Register (PDR), see data sources below. Information was also collected from health care, municipal social services and the Prison and Probation Service, but these data are not used in the present study. We refer to a previously published article for detailed descriptions of these authorities and for background information .The cause of death was determined using information stated in the report from the forensic autopsy. Cases were categorized as “opioid overdose deaths” if the cause of death was unintentional opioid overdose, intentional opioid overdose (suicide) or intoxication with opioids with unknown intent. All other causes of death were categorized as “non-opioid overdose deaths”. Unclear cases were discussed with a forensic pathologist and associate professor at NBFM in Lund. The vast majority of cases were intoxications with several substances.Data were collected from NBFM and PDR and the data sources were linked using the personal identification number, which is unique to each Swedish citizen. The data from NBFM include personal identification number, sex, age, registered address in population registry, place of death, and cause of death for each subject. The toxicological data include the prevalence and concentration of prescription drugs, alcohol, and illegal drugs. Information about all prescribed drugs for each individual in their last six months of life was obtained from PDR, which is a nationwide database containing information on all prescribed drugs dispensed at Swedish pharmacies since July 1, 2005. The data from PDR include date of prescription, date of dispensing, Anatomical Therapeutic Chemical classification system (ATC) code, trade name, package size and dosage forms for each time that a prescription drug was dispensed. Drugs that were prescribed but not dispensed, and drugs that the individual received directly without a prescription (e.g. during in-patient care), are not in the registry and therefore not included in our study. Information about ongoing OST was retrieved from searches in health care journals, as patients in OST often receive their medication at the OST clinics without necessarily having a prescription in PDR for methadone or buprenorphine.Information from NBFM, health care, municipal social services and the Prison and Probation Service was linked together in a SPSS file by L.A. Information about drug prescriptions was merged with this file. All data management and statistical analysis regarding drug prescriptions was performed by author J.W. SPSS version 25 was used for data management and analysis. Conditional logistic regression was applied to calculate if the prescription of certain drugs increased the odds of death during the same month. This was done by determining whether each individual had at least one prescription for a given drug during each of the last six months of their life, creating a binary variable for prescription of each drug of interest per month (see below). The last month in life becomes the case and the five previous months become the control for each individual. By using conditional logistic regression and conditioning the analysis on each individual, each individual becomes his or her own control as in a case-crossover design. The same procedure was used to analyze the dispensing of the same drugs. Since there is no pre-set command for conditional logistic regression in SPSS, the analysis was run using the pre-set command for Cox-regression in the survival package in SPSS, but with the time variable set to one for all cases and controls.To find the frequency of prescribed drugs and the relationship between drugs prescribed during the last six months of life and drugs found in blood at time of death, information from the forensic examination and chemical analysis was merged with data from PDR. For each prescription two variables were created: one representing the difference between date of death and date of prescription, and one representing the difference between date of death and date of dispensing in months. Two separate files were created: one containing all individual prescriptions issued during the last six months of life, and one containing all individual prescriptions dispensed during the last six months of life. This was done to account for drugs prescribed more than six months prior to death but dispensed within six months of the date of death. The total number of dispensed prescriptions for each drug during the last six months was acquired through the descriptive statistics package, but no calculations were made in this regard. All ATC codes were then, using a pre-set function in SPSS, given a number in a new variable based on alphabetical and numerical order of ATC codes occurring in our material. The number of months between prescription and death for each individual prescription was then multiplied by 1000 and added to the number replacing the ATC code. This produced a new variable containing information about both the number of months between prescription and time of death and the specific substance for each individual prescription. Rearranging the file so that all prescriptions to the same individual were on the same row  then made it possible for SPSS to count prescriptions of specific drugs issued during each of the last six months of life for each individual. The resulting variables were then converted into binary format, and the same procedure was repeated for drugs dispensed during the last six months of life. These resulting variables were then used to perform the conditional logistic regression described above.The same principle used to determine if a drug was prescribed during each of the six months prior to death was also used to determine if each individual had a certain drug prescribed at least once during the last six months of life. If a person had at least one prescription of a substance found in blood at the time of death during the last six months of life, this substance was considered to possibly have been prescribed. Conversely, a drug found in blood at the time of death in individuals who did not have a single prescription of this substance during the last six months the substance was considered likely to be illicit, with the exception of the OST drugs methadone and buprenorphine. These drugs were considered likely to be illicit if the person, according to patient files, did not have ongoing OST at the time of death.A selection of drugs and drug classes was made for analysis in the conditional logistic regression, as it was neither possible nor desirable to analyze every substance that occurs in the material. As mentioned in the introduction, psychiatric comorbidities and the prescription of opioids, BZD, z-drugs and pregabalin are associated with increased opioid-related mortality. Therefore, opioids, BZD, pregabalin, z-drugs, antipsychotics, stimulants, and antidepressants were included in the analysis. All drugs as one group, all drugs that affect the nervous system as one group, and all somatic drugs as one group were analyzed to control for general patterns not unique to a certain substance.The study population consisted of 235 individuals, 186 male and 49 females, between the ages of 18 and 64, where one or more of the opioids heroin, methadone, buprenorphine, fentanyl, oxycodone, or morphine were detected in forensic toxicological screenings. The mean age at the time of death was 38 years. In 82% of the cases, opioid overdose was the underlying cause of death. Of these, the opioids that caused the most overdose deaths were, in falling order, were methadone (44%), heroin (21%), buprenorphine (16%), fentanyl (15%), oxycodone (4%), and morphine (1%). In 18% of all cases in the cohort, the above-mentioned opioids were present in the blood, but opioid intoxication was not the main cause of death . In the latter group, morphine and methadone were the most prevalent opioids, each accounting for approximately one third. In the vast majority of the 235 cases, other drugs besides the opioids mentioned above were also detected at the autopsy. Sixteen percent had ongoing OST at the time of death.The five most frequently dispensed drugs in this population during the last six months of life were, in falling order, zopiclone (457 dispensed prescriptions), pregabalin (230), methylphenidate (219), diazepam (183), and oxycodone (154). The five drugs that were prescribed to the largest number of individuals during the last six months of life were, in falling order, zopiclone , mirtazapine (38), paracetamol (38), alimemazine (35), and pregabalin (34). Zopiclone alone accounted for 10.3% of all dispensed prescriptions and was prescribed in 30% of cases. Opioids, not including OST drugs, were prescribed to 51 individuals. Fifty-three individuals (23%) had no dispensed prescriptions during their last six months of life. In the group that had dispensed at least one drug during the last six months of life, the number of dispensed prescriptions ranged from 1 to 281. The first quartile was 5, the median was 11, and the third quartile was 29. See More than one opioid was present in the blood at time of death in 23% of opioid overdose deaths, but only in 2% of deaths from other causes. The number of substances, including metabolites, found in the blood at time of death ranged from 1 to 17, with a mean of 6. At least one BZD was present in the blood at time of death in 72% of opioid overdose deaths and in 71% of deaths from other causes. BZD, z-drugs, or pregabalin was present in 83% and 76% of cases respectively.The five most prevalent drugs in blood at time of death were methadone , alprazolam (101), buprenorphine (59), clonazepam (57), and pregabalin (54). Alcohol was present in blood at time of death in 90 cases. To avoid including cases where alcohol was produced post mortem we used a cut-off at a blood alcohol concentration of > 0.5 ‰, which led to 40 cases where alcohol above this concentration was found . The fivA majority of prescription drugs found in the subjects’ blood at the time of death were not prescribed to these individuals during the last six months of life. In the 57 cases where clonazepam or metabolites of clonazepam were found in the blood at the time of death, only two had a dispensed prescription for clonazepam during the last six months of life. Thus, the fraction of clonazepam use that is likely to be illicit is 97%. The five prescription drugs that had the highest fraction of use that is likely to be illicit were clonazepam (97%), codeine (90%), fentanyl (90%), buprenorphine (83%), and morphine (83%). Cases where heroin was present have not been included in the morphine group. The five drugs most frequently found in the blood at time of death with no prescription filled during the last six months of life were alprazolam (83), methadone (81), clonazepam (55), buprenorphine 49), and codeine (43). See Tables 9, and coThe case-crossover analysis for drugs prescribed and dispensed for each month in the last six months of life found statistically significantly increased odds of death within the same month for prescription of alprazolam  and diazepam , as well as for dispensing of alprazolam  and diazepam . No other drugs or drug classes demonstrated a significant temporal association with death. See Tables We have found that the drugs most prescribed during the last six months of life to subjects with a history of illicit substance use who die with at least one opioid present in their blood are analgesics, tranquilizers, antidepressants, antipsychotics and stimulants, suggesting high rates of polydrug use and psychiatric comorbidity. It is worth noting that the five most dispensed drugs in this population all have potential for misuse, especially in populations with a previous history of addiction ,21,41–45The drug class most often found in blood in our material, aside from opioids where presence was an inclusion criteria, was benzodiazepines. While most benzodiazepines and opioids are available as prescription drugs, few individuals with these drugs in their blood at time of death had filled a single prescription for them during the last six months of life. Methadone and buprenorphine, both OST drugs used in Sweden, caused a majority of opioid overdose deaths, with methadone causing the largest number of deaths in our study. A large majority had used these drugs illicitly, as only one in six received OST at the time of death. This is consistent with previous findings ,40. The The present study found a temporal association between death and the prescription and dispensing of alprazolam and diazepam. Alprazolam and diazepam were frequently found in blood at the time of death where alprazolam was relatively more prevalent in overdose deaths and diazepam was relatively more prevalent in non-overdose deaths. Alprazolam is regarded to be a drug with high misuse potential and more severe withdrawal symptoms compared to other BZD . In all The large proportion of individuals in our material who had alprazolam or diazepam in their blood at the time of death but did not have a prescription for these drugs during the last six months of life suggests that obtaining these drugs through means other than a prescription is relatively easy. However, our study also found that prescription and dispensing of these drugs was temporally associated with death. This finding can be interpreted in two ways. Firstly, the prescription of alprazolam and diazepam could indicate a worsening of mental health shortly before death, which could be independently associated with an increased risk of overdose and death. Secondly, it could be interpreted as an indication that these drugs are dangerous and have a direct effect on mortality. Some support for both of these interpretations can be found –19,55,56Among strengths of the present study, it can be noted that our study population included all deaths in a geographically defined area that met our criteria. Since the NBFM files were reviewed manually, selection was likely more accurate than if a search function had been used. In addition, the PDR lists all drugs dispensed at Swedish pharmacies since 2005. Taken together this means that the data presented in this study are likely to be very accurate.The present study also has limitations. The study is a retrospective observational study, and therefore the results cannot be interpreted as causal relationships. The statistical analysis used in the study considers prescriptions of different drugs in a binary fashion and does not take absolute dose or changes in dose into account. If a patient was prescribed a medication throughout the period studied but the dose was altered, our statistical model is not fit to notice this. Therefore it is possible that prescription patterns may affect opioid-related mortality in ways that cannot be captured by this study. Additionally, opioids were only analyzed as a group and not individually, so it is possible that the prescription of certain opioids is temporally associated with death. Our study population is in the smaller range since each drug is prescribed to relatively few patients. A similar analysis on a larger population would produce narrower confidence intervals and allow analysis on subgroups, such as cause of death.Also, the study here was based on patients included because of autopsy detection of a number of classical opioids occurring in many of the drug-related fatalities seen in the present setting. In recent years, a large number of novel opioid and non-opioid (in particular the latter) compounds have arisen in the illicit drug market ,58. The In addition, it also should be borne in mind that the present study was conducted prior to the COVID-19 pandemic, and it cannot be excluded that prescription patterns and mortality from licit and illicit drugs may have been altered due to the extensive changes in society during the pandemic. Authors have called for attention to the use of addictive substances in that situation . On the The classification of drugs in blood at the time of death as prescribed or not is based on the presence of a filled prescription for the drug within the last six months of life, making it a conservative approach. Therefore, estimates of the proportion of prescription drugs with potential for misuse found in blood at the time of death that were used illicitly should be interpreted as possibly low in relation to actual numbers.The widespread prescription of BZD, pregabalin and z-drugs in our study on individuals with a history of illicit substance use who died with at least one opioid present in their blood is cause for concern. These drugs were involved in most opioid overdose deaths in our material and have previously been linked to increased opioid overdose mortality when used in combination with opioids –11,13,20


The number of human rabies cases caused by pet dogs in Guangzhou has been decreasing after years of comprehensive interventions. Consequently, attacks by stray dogs become a major issue in rabies control.To share our experience of successfully dealing with rabies to provide some inspiration for prevention and control in countries and regions affected by it.A multidisciplinary One Health response was initiated to control this outbreak. Rabies virus was detected by PCR in the brain tissue of the associated stray dog. The sequences were aligned with reference sequences downloaded from GenBank using ClustalX. The maximum likelihood method implemented in MEGA 5.0 software package was used in a phylogenetic analysis of the aligned sequences.Twelve patients with exposure to the stray dog were identified in the field investigation. Rabies vaccines and immunoglobulin were administered to all patients within 48 h. After 1 year of follow‐up, no exposed patients showed symptoms. Maximum likelihood analysis of the nucleotide sequences obtained from the PCR products indicated that the rabies virus in the dog was closely related to isolates from neighbouring provinces of Guangdong as well as those from surrounding countries of China.Multidisciplinary One Health intervention is effective not only in the control of rabies but also in rapid emergency responses to attacks by rabid stray dogs. In July 2017, 12 residents  were bitten by the same rabid stray dog. With the One Health strategy action, no one occurred rabies after 1 year of follow‐up. To share our experience of successfully dealing with rabies to provide some inspiration for prevention and control in countries and regions affected by it. Twelve exposed cases, two staff members who euthanised stray dogs, and two sample collectors were all vaccinated with the rabies vaccine and immunoglobulin at the rabies outpatient clinic. The time of vaccination was recorded by the clinic.The diagnostic criteria for rabies were based on the WS 281–2008 standard issued by the Ministry of Health, China: a history of epidemiological exposure and manic  manifestations; the diagnosis is considered confirmed if samples are antigen‐positive or nucleic acid‐positive for the rabies virus or if rabies viruses can be isolated . The N and G genes of rabies virus were amplified by reverse‐transcription PCR of RNA extracted from the brain tissues of the stray dog  were immunised immunisation. Rabies immunoglobulin and vaccine were administered to all exposed cases, and their rabies neutralising antibody levels assessed. Propaganda on rabies prevention was distributed throughout the entire district, and the public was educated about how to respond to bitten or scratched by animals, including advice on visiting rabies outpatient clinics after potential exposure.The investigation identified the rabid dog as a stray dog. In the afternoon of 18 July, the first exposed case was attacked, followed by 6 people who were consecutively bitten by the same dog. In the morning of 19 July, another 5 people were attacked. On 20 July, the rabid dog was captured and euthanised  present to the hospitals, they are required by the network policy to receive close attention, with the intention to identify the causes. Furthermore, the cases should be properly handled and treated to prevent the occurrence of serious public health incidents. The rabies surveillance and management system involves multiple public health and safety sectors and agencies and is based on the One Health strategy. The previous human‐oriented prevention and control strategy has been transformed into a human‐ and animal‐specific prevention and control system involving promotion of dog vaccinations, control of stray dogs, removal of infection sources and post‐exposure vaccination and antiserum treatment of patients, and public education. After years of practice and improvement and formal implementation, there have been no reported cases of human rabies in Guangzhou during the past 2 years, which has demonstrated the effectiveness of this control measure. Among them, the extensive educational activities on rabies prevention and control is a prerequisite for the successful outcome in this event; through organised events in elementary and middle schools, community committees, advertisements in television and network media, educational leaflets, and World Rabies Day, Guangzhou has educated the public regarding the seriousness of rabies, major transmission routes, the importance of preventive vaccination and immunoglobulin administration immediately after exposure, and the role of regular vaccination of pet dogs.4.2There are tens of thousands of stray dogs in Guangzhou today, most of which are abandoned. Although there are more than a dozen civilian animal shelters and rescue stations, because of the large number of stray dogs, this is still a drop in the bucket. In 2013, the Guangzhou Municipal Public Security Bureau established the Guangzhou Dog Shelter and Inspection Office to receive, inspect, and process abandoned, stray, detained, and confiscated dogs, with a focus on advocating civilised, scientific dog‐keeping and animal protection. In terms of reducing the number of stray dogs, the effects have been minimal. In many countries with rabies epidemics, stray dogs are a major public health hazard. Several countries, including India, have implemented the Animal Birth Control (ABC) program, which has achieved good outcomes by vaccinating and sterilising stray dogs to control their numbers and rabies .https://publons.com/publon/10.1002/vms3.986.The peer review history for this article is available at


In the Second World War, there was a flowering of the battlefield surgery pioneered in the Spanish Civil War. There were small, mobile surgical units in all the theatres of the War, working close behind the fighting and deployed flexibly according to the nature of the conflict. With equipment transported by truck, jeep or mule, they operated in tents, bunkers and requisitioned buildings and carried out abdominal, thoracic, head and neck, and limb surgery. Their role was to save life and to ensure that wounded soldiers were stable for casualty evacuation back down the line to a base hospital. There is a handful of memoirs by British doctors who worked in these units and they make enthralling reading. Casualty evacuation by air replaced the use of mobile surgical units in later wars, throwing into doubt their future relevance in the management of battle wounds. But recent re-evaluations by military planners suggest that their mobility still gives them a place, so the wartime memoirs may have more value than simply as war stories. Surgeon in the Jungle War, published in 1979, decades after the Second World War ended in 1945 and when there had been plenty of opportunity for ‘adequate records’ to be written. In the Royal Army Medical Corps (RAMC) Baty commanded the Seventh Indian Mobile Surgical Unit (7 IMSU) from May 1943 during the campaign against the Japanese in the Arakan region on the coast of Burma. My father, Harry Walker, was an anaesthetist who joined a different unit, 5 IMSU, in May 1944 and supported the troops at Kohima and Imphal in Assam, through central Burma to Rangoon, and on to Singapore at the Japanese surrender in 1945. His unit then treated Javanese civilians injured in the Indonesian revolution and he returned to England in 1946. I am currently working on a reconstruction of his wartime experience.‘In the various military histories of the war in South-East Asia, the intimate details of the fighting are adequately recorded but no more than passing mention is made of the part played by the Medical Services, in particular, the Mobile Surgical Units.’ The quotation is from John Baty's The reason may have been an assumption that MSUs would be superfluous in future conflicts when improved air evacuation would move wounded men rapidly to well-equipped surgical hospitals away from the front. Indeed, rapid casualty evacuation by helicopter was a feature of the Korean War (1950–1953) and Vietnam War (1964–1975) as portrayed in Richard Hooker's 1968 novel, Robert Altman's film M*A*S*H, and the spin-off television series.35 ‘Richard Hooker’ is the pen-name for the collaborating authors Richard Hornberger, a former US Army surgeon, and W C Heinz.It is perhaps surprising that there was no post-war evaluation of mobile surgical units (MSUs), given that they were one of several important changes to the organisation of medical services for casualty evacuation that were introduced on the recommendation of the wartime Hartgill committee in 1941.ad hoc forward surgical teams and Patillo concluded that the MSU had ‘re-emerged on the modern battlefield.’But, in his 1993 thesis, Patillo studied the 1940s Burma campaign experience in order to explore ‘problems with rapid deployment and ground mobility’ of American mobile hospitals in the 1980s and 1990s. During the American invasion of Grenada in 1983 the field hospital that was deployed proved to be less mobile than was required and, in the first Gulf War of 1990–1991, the large numbers of nursing staff and beds of American field hospitals ‘adversely affected mobility.’ Many medical units created  The authors of a 2020 paper comment that ‘truly austere circumstances’, with little opportunity for air evacuation, prevail in many conflicts today, as in the Second World War. These conditions are also replicated in natural disasters and well-prepared forward military surgical teams, with standardised equipment and procedures, are vital. There is current interest in how these teams should be organised and, for example, Chinese military doctors in 2018 reviewed the literature on their composition and work. Memoirs by doctors from a war many decades ago may therefore be relevant for today’s military medical planners.The issue of how modern armies should provide forward surgical capability remains moot. A 2015 article from the Canadian Armed Forces emphasises the role of ‘damage-control surgery’ in special operations in ‘austere environments with fewer personnel and a smaller logistical footprint than conventional operations.’ writes succinctly in his memoir, is not a vehicle. ‘Rather, it’s a small mobile field hospital with a staff of about 50 operating just behind the front line […] Each of the three Brigades in a Division has its field ambulance.’ Base hospitals were large general hospitals with up to 1000 or more beds and a full complement of support services, housed in tents, huts and available buildings. For example, 21 British General Hospital, where my father served when he was first in India, started life in France for the first few months of 1940, was evacuated from Dunkirk when the Germans invaded, then spent the next two years in Leeds, Sussex and Perthshire before moving to India in June 1942. In India, the hospital moved from Secunderabad to Trimulgherry, Jhansi, Dinapore and Calcutta before disbanding in Madras in 1946.Along with the MSU, this article mentions two other kinds of mobile unit which carried out surgery in the Second World War: the field ambulance and the mobile hospital. A field ambulance, as DonaldsonThe MSU is generally accepted to have had its definitive origins in the Spanish Civil War of 1936–1939. In the previous major European conflict, the First World War, the aim of casualty evacuation was not to take the surgeon to the casualty but to remove the injured from the battlefield to a hospital out of range of artillery fire. Because most of the fighting fronts were essentially static and air warfare was in its infancy, large hospitals could be set up in tents or buildings in a safe environment several miles from the fighting, to which casualties could be evacuated by ambulance train or horse- or motor-ambulance. Although several MSUs were equipped they were set up too late in the war to be deployed to any effect. This unit was deployed in 1917 during cavalry operations in Beersheba and elsewhere. It used a ‘surgical operating car’ to carry personnel and equipment and to provide electrical power. Quoting the Official History of the First World War, Wade observed that, ‘the equipment required […] was not necessarily either bulky or elaborate, and […] surgeons could co-operate advantageously with the various field ambulances [which] welcomed the arrangement by which they were relieved of the onerous responsibilities of carrying out the surgical treatment of those patients who required serious and prolonged operative treatment.’However, the potential of MSUs was clear even in the First World War. For example, the work of an Australian ‘advanced operating unit’ in Palestine was described in a 1940 essay by Wade.status quo. Two elements became important: the mobile field hospital (or ‘field ambulance’) and the MSU . The MSU consisted of two or three doctors and around 10 or 12 support staff, including nursing orderlies, in self-sufficient units which could run two operating tables. This surgical capability could be deployed flexibly to field hospitals as the military situation dictated.The Spanish Civil War was more mobile than the First World War and the extensive use of aerial bombing by the Nationalists and their allies, the Nazi regime in Germany, meant that all medical units were now vulnerable and aggregations of transport or casualties could become targets. Traditional military hospitals, with their large amounts of equipment and personnel, were cumbersome and slow to move. The familiar saying that war forces innovation proved correct in this setting. One paper has pointed out that at the onset of the Civil War most Spanish military doctors defected to the Nationalists, leaving Spanish civilians and young foreigners as the doctors working with the Republicans. They had a pressing need to improvise and no commitment to the Principles and Practice of War Surgery and Jolly’s Field Surgery in Total War. Both stressed that the patient's outcome was greatly improved by minimising the elapsed time between wounding and surgery. This allowed prompt resuscitation including blood transfusion, wound debridement which reduced the risk of infection, immobilisation of fractures, and life-saving procedures such as tracheotomy or the ligation of blood vessels. The aim was to save life and improve the casualty's chances of surviving evacuation to a well-equipped base hospital where definitive surgery could be carried out at leisure.Two surgeons who worked in the Spanish Civil War published influential books: Trueta's Principles and Practice of War Surgery in 1943. In it, he emphasised five points for the treatment of limb wounds: prompt surgical treatment, cleaning the wound, excision of devitalised tissue, drainage, and plaster immobilisation.16Josep Trueta  was a Catalan orthopaedic surgeon who was Professor of Surgery in Barcelona during the Spanish Civil War and dealt with thousands of combatant and civilian casualties. He left Spain at the Nationalist victory in 1939 for Oxford, moving back to Catalonia on his retirement. He was a pivotal figure in developments in war medicine, participating in the early penicillin trials, for example. But his major wartime contributions were his studies on war surgery, published as a pamphlet in Catalan in 1939 and later developed into Field Surgery in Total War, published in 1940. A recent biographical study published in this journal emphasises Jolly's contributions in the areas of triage, the treatment of abdominal wounds, and wound closure techniques, as well as his advocacy of Trueta's plaster technique for limb wounds. He proposed an organisational concept called the ‘Three Point Forward System’ with triage as far forward as practicable, which shunted the injured either to No. 1 hospitals close to the front or to No. 2 hospitals further back, prior to onward movement to evacuation hospitals. He concluded that ‘the reduction of the time-lag for the gravely wounded necessitates a reorganisation throughout the system.’Douglas Jolly (1904–1983) was a surgeon from New Zealand who, while studying in London, joined a volunteer unit in 1936 and travelled to Spain where he formed a MSU on the Republican side. On the outbreak of the Second World War, he wrote  But the retreat to Dunkirk during the German Blitzkrieg in 1940 demonstrated that medical units were insufficiently mobile; some casualty clearing stations were over-run by the Germans and most lost much of their heavy and bulky equipment. Richard Doll's articles in the BMJ give a young doctor's eye view of the chaos of the retreat. And, in his 1985 Doctor at Dunkirk, Ian Samuel, a general practitioner with surgical training, describes the pressures of being out of contact with specialist surgical expertise and adapting a farm kitchen as an operating theatre. ‘I managed to do surgery with quite inadequate surgical instruments,’ he wrote, but he had to abandon many casualties during the retreat and describes giving an overdose of intravenous morphine to ‘impossible’ cases before leaving them behind.When the Second World War began, the British Army's casualty evacuation system was still based on the largely static warfare of the First World War. Hamilton Bailey published the first volume of his Surgery of Modern Warfare in July 1941 and the War Office's Hartgill Committee codified the lessons in December 1941.21 The mobile tank warfare in the Western Desert in North Africa in 1940–1943 showed the need for surgical teams with light logistical demands which could function close to the fighting and move between larger medical units ‘in an ever-changing pattern depending on the tactical situation.’ Furthermore, few British casualties could be evacuated by air until the end of 1942, necessitating treating the wounded close to the front. By early 1943, the principles of battlefield surgery were widely accepted and in January 1944 the War Office published a short manual for doctors, A Field Surgery Pocket Book, and distributed it throughout the year, including to doctors in prisoner-of-war camps. A revised edition appeared in 1950 in response to the Cold War, including the Korean War, and to the Malayan Emergency and other violent independence struggles in the former British Empire.24British doctors learned quickly from the Spanish Civil War surgeons. Lectures were delivered.MSUs were not the only type of mobile unit in the Second World War. Field transfusion units, for example, were often co-located with MSUs, and malaria forward treatment units allowed men to recover and return to their units without the delay that was inevitable with evacuation to a base hospital.Defeat into Victory. Other senior officers wrote accounts from the perspective of lower levels of command, notably the leaders of the ‘Chindit’ columns, which penetrated behind Japanese lines: John Masters, Bernard Fergusson,28 and Michael Calvert. The novelist George Macdonald Fraser wrote an important memoir from the viewpoint of an ordinary soldier, Quartered Safe Out Here.As John Baty pointed out, the Second World War generated much literature, mainly focussed on strategy and combat. General William ‘Uncle Bill’ Slim published a classic general's memoir from the Burma campaign in 1956 in  In a post-war evaluation for the Office of Medical History of the US Army Medical Department, the senior medical officer to the Chindits, William Officer, wrote that communication between fighting officers and medical officers was poor. ‘The habit of looking upon the doctor as a Fifth Columnist likely to blab the merest piece of confidential information which is vouchsafed him, is still all too prevalent.’ The memoirs from MSUs confirm this impression and present the units as reacting to events, rather than having a role in planning. But this distance from strategic responsibility, coupled with their clinical autonomy, appeared to energise some doctors and at times the memoirs have a conspicuously buccaneering tone.These memoirs rarely refer in any detail to medical units, which tend to be taken for granted by their soldier authors. Harrison, in his history of British military medicine in the Second World War, comments that good commanders like Slim recognised the importance of the medical services in maintaining fighting strength and the men’s morale but, for some, they were a disagreeable burden. General Orde Wingate, the instigator of the Chindit forces, for example, insisted that ‘Every man with my force must be a fighting man.’ He wanted ‘no passengers nor Geneva Convention people.’All Spirits, describes an itinerant pre-war life as a ship's surgeon, film unit doctor, and medical officer in colonial outposts, before taking a casualty officer job in the London Blitz. But ‘the pay of even a lieutenant RAMC […] was a princely sum compared with my thirty shillings weekly.’ He joined the 224 Parachute Field Ambulance and volunteered for the glider attack on Pegasus Bridge near Caen as part of the D-Day landings in June 1944. In the last few weeks before the German surrender, he was seconded to the Special Air Service, operating ahead of the main body of troops and seeing Belsen, the link-up with the Russians, and the streams of displaced persons on German roads.Life in the front line suited the more adventurous doctor. John Vaughan, for example, in his 1988 A Field Surgery Pocket Book sets out the expectations for MSUs at the time. It starts by reminding the reader that casualties can be grouped as: requiring resuscitation before any surgery or evacuation, requiring immediate operation and holding until fit to move, and fit for evacuation. Units could be deployed ‘as far forward as practicable’ to deal with soldiers needing immediate surgery, or further back in order to operate at greater leisure on evacuated casualties as well as on any local wounded. ‘The wounded may start to arrive late in the evening,’ the manual informs its readers, meaning that attention to the generator and the lighting is vital. It warns that each operation takes, on average, an hour, wounds are frequently multiple, and a surgical team cannot deal effectively with more than 12–16 such cases in 24 hours, even in ideal circumstances. It lays great emphasis on triage and on rapid decision-making, which ‘saves time and more cases will be dealt with and unnecessary or hopeless operations will be avoided. […] Keep fit and get as much rest as possible. Stamina will be severely tested during times of stress. […] Do not waste energy by operating on patients who should be evacuated. Indeed, it may be less hazardous to evacuate a wounded man than to operate.’ This emphasis on standardisation and simplification was quite different from the variations in individual practice that a civilian surgeon expected at the time. Pocket Book's suggested layout for an operating tent.Most of the injuries the units dealt with were caused by mortar bombs or shell fragments, with machine gun and rifle bullets causing most of the remainder. The most frequent injuries seen were limb wounds, but others, though less common, were often life-threatening and the first priorities for immediate surgery were abdominal wounds, including of the perineum and buttocks, open chest wounds, and severe maxillo-facial and other head wounds, including burns and complicated eye wounds. The units dealt with open limb fractures and complicated soft tissue injuries requiring amputation. The interval after wounding was almost always longer than was usual in emergency surgical practice in civilian life, and sometimes much longer because of enemy action. If evacuation from the fighting had been delayed by days, or even weeks, then patients would arrive with infected wounds, gas gangrene, maggot infestation, or tetanus. In the Burma campaign, the patient's general condition could be compromised further by malaria, vitamin deficiency or dysentery.Another major difference from civilian practice was the lack of continuity of care. If time and the state of the conflict permitted, the unit might retain a few patients in order to complete their treatment but usually the forward surgeon was only the first in a chain of surgeons back to the base hospital. The primary role of the MSU was to make the patient and his wound safe to travel and as soon as the patient was fit to be moved he was evacuated down the line. The teams were expected to clean wounds of any accessible foreign bodies, debride devitalised tissue, control bleeding by tying off any damaged larger blood vessels, and incise fascial compartments to relieve tension. With rare exceptions, they should not ‘waste time’ searching for foreign bodies, inserting drains, or suturing. Sulphonamide powders and, later, topical penicillin were routinely dusted into the wound. The wound was left open, protected with vaseline gauze, covered with sterile cotton wool and bandaged. Limb wounds were splinted, usually by plastering. Clear and accurate record-keeping was emphasised, so that surgeons in base hospitals understood what the MSU had done.The manual assumed (though this varied in practice) one surgeon, one anaesthetist, two operating room assistants and seven general duty orderlies who undertook the preparation of patients, plastering, overseeing the generator, ensuring a supply of water, laundry, and equipment sterilising. The units carried portable operating tables and beds and enough equipment, linen and dressings for one hundred cases but ‘the surgeon should be prepared to work […] if necessary without gloves.’ It was soon appreciated that in order to be effective they needed to control their own transport. The units were often paired so that surgical teams could spell each other. The host  was responsible for additional nursing, feeding patients, and casualty transport. It also undertook the general administration of the MSU, its pay, rations and discipline, and maintained its contact with headquarters. BMJ and Lancet, as well as the Journal of the RAMC, published articles to inform and educate their readership about technical medical topics relating to the war.In surveying the Second World War literature by doctors, the first thing to note is that an older generation of doctors wrote many articles and chapters to inform their juniors of their insights they had gained in the First World War and even the Boer wars. The Spanish Civil War experience gave up-to-date advice to the new Army surgeon or anaesthetist. Throughout the conflict, the  The various Official Histories were slowly published, including the volumes of the Medical History of the Second World War, concluded in 1968 by The Principal Medical Lessons of the Second World War. But, as the military historian John Keegan pointed out in his influential 1976 The Face of Battle, historians compiling official histories may achieve ‘the remarkable feat of writing an exhaustive account of one of the world’s greatest tragedies without the display of any emotion at all.’ He contrasted the dryness of some military history with the immediacy of war fiction and advocated a cautious use of memoir, directing historians to investigate contemporaneous letters and journals, leave the archive, visit battlefields, and talk to soldiers. Some exploration of emotions was essential.After the War, the medical journals published ‘lessons learned’ articles, such as Wigglesworth's account of casualty evacuation. in her analysis of memoirs by Second World War veterans, has pointed out that publication was constrained by paper rationing and, more importantly, by censorship. From 1942 to 1945, the British government banned the publication of service reminiscences. There were a few exceptions but they were heavily censored. Until the mid-1950s serving officers, or veterans who had been involved in wartime intelligence work, were required to submit their manuscripts for a security review.A handful of more personal memoirs trickled out during or soon after the war ended. Houghton,Burma Surgeon by the American missionary doctor Gordon Seagrave. Seagrave created a mission hospital in the China–Burma borderlands in the 1920s. He joined the US Army Medical Corps during the Japanese invasion of Burma in 1942, forming a MSU which accompanied the American General ‘Vinegar Joe’ Stilwell, commanding Chinese forces, on his retreat to India. Seagrave's book fitted well with the contemporaneous American political and military strategy to support China. He returned to Burma after the War and published several books which raised his hospital's profile and funds for mission activity.Perhaps the first memoir of mobile surgery in the Second World War was the 1944  The author had varied postings after joining the Army, which included surgery in the Western Desert and in a casualty clearing station in Italy. It is structured like a novel, moving from the English Channel before Dunkirk round the Mediterranean and European battlefields to finish with the author in the Channel again, looking at the white cliffs of Dover while talking about his return to civilian life. It incorporates well-written dialogue and descriptions of landscape and operating teams. It is an excellent advertisement for the military surgical life and attracted a Foreword by the Director-General of the Army Medical Services which comments that it ‘is the authentic stuff.’ Although not avoiding difficulties and danger, it is a notably constructive and upbeat account which supports the Foreword's assertions that the medical service in the war was ‘a happy, confident brotherhood’ and that ‘to see an advanced operating centre or casualty clearing station at work during a battle […] gives an unforgettable impression of teamwork at its best.’The first British medical memoir including descriptions of mobile battlefield surgery (and one of the best) that my search discovered was published in 1948 anonymously by ‘J A R.’ Unlike J A R he was a professional soldier, joining up in 1938 and after the War serving in Korea and in a UK military hospital. As a houseman, his chief had told him he would ‘get all the surgery you want’ in the Army because a war was coming, together with a socialist government and ‘you will be better off in a service that you have joined of your own free will.’ Like J A R, Watts worked in mobile units in the Western Desert, Italy and Germany. Like my father, he was part of the British force in Java which attempted to suppress the Indonesian revolution immediately after the Japanese surrender. His account has many practical descriptions and well-argued conclusions about battlefield surgery but written from the perspective of a conservative soldier at the end of Empire. Unlike the books by civilians, his account is peppered with anecdotes from the Mess and whimsical descriptions of the troops and civilians which are of their time but which, to today's ears, sound patronising.John Watts published his memoir in 1955.Soldier Surgeon in Malaya is a battered paperback, its strident black and yellow cover dominated by the face of a brutal Japanese prison guard. The cover shouts in red capital letters that it is a ‘true and realistic story of a Japanese prisoner of war camp’ but it is not one of the almost voyeuristic accounts of cruelty and deprivation that were published at the time. Instead, it describes mobile surgery during a retreat, as the Japanese made their stunning advances in 1941 and 1942.My copy of Thomas Hamilton's 1958  the same authors' article on blood transfusion in this journal, Aidan MacCarthy's 1979 A Doctor's War, and Glusman's story of four American doctors captured by the Japanese in the Philippines.The accounts of surgery by doctors who were taken prisoner form a special case of wartime medical life-writing which this article does not consider. These books are not so much about the experience of surgery in mobile warfare but of medicine practised under extremely adverse conditions with grossly inadequate resources. They form a sub-section to the large sub-genre of prisoner-of-war memoirs. Some examples are the biography of Bill Frankland by Watkins, who did not serve close to the front line in the Second World War, though their accounts provide detail about base hospitals. Some aspects of life in a malaria forward treatment unit in the Burma campaign, as described by Charles Evans, were similar to life in an MSU.This article also excludes memoirs by nurses, such as Angela Bolton, Over the same period, he married and started a family.But much personal experience remained unpublished. Most of the doctors returning from the War were civilians, temporarily recruited to the armed services. For many, life was too busy for writing memoirs. Some returned to pick up roles they had left and there was a government scheme to integrate young doctors back to civilian practice via supernumerary posts. When my father, for example, qualified in Edinburgh in 1942 he had already been a houseman for six months in the wartime accelerated registration scheme. He went into the RAMC on registering and a year later was an anaesthetist in Burma. After returning to the UK in 1946, he was an anaesthetist in a military hospital, worked in general practice to familiarise himself with civilian medicine, and returned to Edinburgh for advanced training before taking up his consultant anaesthetist post in the National Health Service, inaugurated in 1948. (One can hope that a university today would respond differently to a former student's extreme and unique experience.)Many wartime letters, diaries and contemporaneous case notes were packed away, stored in lofts and cupboards, and surfaced only much later. For example, my father's friend George Blair was a prisoner of the Japanese in Taiwan, an ordeal that affected him profoundly and contributed to his premature retirement. Although he wrote up an account of treating vitamin deficiency from the case notes he had kept, his university felt that the manuscript contained insufficiently rigorous analysis for acceptance as a thesis and the case notes, with his wartime letters, became publicly accessible only when his family deposited his papers in the Wellcome Library after he died.These archived personal papers throw light in unexpected corners. Women doctors like Molly Newhouse, for example, were recruited into the RAMC but not allowed to work in the front line. There are, therefore, no women surgeons amongst the memoirists considered here. But Newhouse's unusual perspective provides sceptical insights on induction into the Army and on life in a base hospital in India and is also in the Wellcome Library. has observed that the Falklands War of 1982 ‘re-ignited cultural memories’ of the Second World War  and that when the various 50th anniversaries came round in the late 1980s and 1990s, publishers were ‘inundated’ with manuscripts by veterans. She has pointed out that memoirs written after the event are composed and published in a social and cultural context that has developed post-war and in which the war has acquired a particular narrative. She also observed that memoirists are self-selected.More memoirs started to appear as the doctors who had worked in MSUs approached retirement age from the 1970s onwards. HoughtonThe Black Scalpel, published in 1968. Already a senior surgeon when he joined the RAMC, Parker became bored with life in a military hospital, took courses in parachuting, small arms and unarmed combat, and applied for a post in a MSU. In the 24th Forward Surgical Unit in North Africa and Italy, he had ‘absolutely magnificent’ equipment and ‘the most brilliant anaesthetist with whom I have ever been privileged to work.’ After a period of illness with jaundice he was approached by a colonel in the Special Operations Executive and parachuted into occupied France, improvising hospitals in a school and a barn with the help of medical students and operating without an anaesthetist. At times he functioned as the leader of a Resistance band, armed with a Colt revolver, combat knife and Tommy gun, and he was later decorated by the French government.While acknowledging Houghton's comments, the medical accounts nevertheless provide a picture of battlefield surgery. The first of these later memoirs that my search discovered was Geoffrey Parker's  1979 Surgeon in the Jungle War was based on operation logbooks and contemporaneous diaries. He describes his medical colleagues: an anaesthetist who acted as second in command (‘we were very much in each other's pockets’) and a Sikh junior doctor who assisted at operations and spoke many dialects, an invaluable skill in the multi-national, multi-lingual 14th Army. His British corporal ran the operating theatre, equipment and supplies. There were Indian and British nursing orderlies and an Indian driver, dhobi and sweeper. The mobility and autonomy of his unit give an entrepreneurial flavour to some of Baty's stories. They improvise equipment repairs using bamboo; his corporal ‘liberates’ equipment from the various field ambulances to which they are attached; they prefer to attach themselves to Indian units because their cooks prepare the best food. Baty confronts the commander of a casualty clearing station who wants to over-rule him and writes to New Delhi suggesting improvements in vehicles, equipment and tents. And, overall, the book is full of lively anecdotes about life and surgery. His book also contains sketches of his temporary operating theatres in jungle bashas and photographs of his team which, unfortunately, cannot be included in this article because of the Journal's space constraints.Baty's biography of the much-decorated doctor Martin Herford in 1995 and Lambourn's record of his father's life in 2006. After volunteering in 1940 for the Finnish Aid Bureau, whose leaders turned out to be ‘chancers and crooks,’ Martin Herford was briefly in the Royal Air Force before transferring to the RAMC because ‘the conditions under which the MOs and their orderlies worked were as perilous as those endured by the troops.’ His biography illustrates the importance of the competent organisation of surgical services, as much as surgery itself. In Greece and Yugoslavia, he organised casualty evacuation by train, travelling to Crete and Egypt before joining the campaigns in the Western Desert, and then Sicily and Italy. He commanded a field ambulance in the D-Day landings and was taken prisoner while ferrying supplies to the wounded at Arnhem. He set up a prison hospital for British casualties before escaping and returning to his unit.As the doctors who had served in the Second World War aged, biographies, rather than memoirs, appeared, such as Hall’sSurgeon at War was published posthumously as late as 2015, edited by his daughter, but the primary memoir on which it is based dates back to a private publication in 1979. A former surgical registrar and ship's surgeon, Aylett was part of the retreat to Dunkirk and then of the desert war in North Africa before commanding the 14th Field Surgical Unit as part of the D-Day landings, and then in Germany and Denmark. His daughter summarises thus:In the midst of the worst carnage, surgeons would be operating for seventeen-hour stretches, followed by time in the wards, for days on end, making hundreds of quick decisions without the benefit of diagnostic aids. Then, three hours to pack up, a few hours sleep, a journey through devastation, three hours in which to set up, and it would all start again.As the children of these battlefield surgeons themselves age, Aylett's first-person account of the work of the MSUs may well be among the last to be published.Stanley Aylett's While accounts by surgeons who served in MSUs are themselves rare, my search has failed to find any memoirs by anaesthetists. Nor have I identified any published by non-commissioned officers, the medical orderlies who worked in these units.The War Office and accredited news organisations sent photographers to the Second World War fronts. Among their images of casualties in regimental aid posts or rehabilitation in the base hospitals are a few photographs of MSUs. Some wartime photographs have not been digitised, and hence their images do not appear in online searches, so it is possible that there are more photographs of battlefield surgery in the various image collections. In the publicly accessible collections, I have not been able to identify any photographs from MSUs in the Far East, although there are a few casualty evacuation. The only photograph I possess of my father in his operating tent in Burma is from March 1945. He wrote on the back ‘Note operating light made from a Jap “Zero” wing. Cpl. Markwick in picture, also clock from a Burmese house. Were shelled here. Damage – one scraped back from jumping into a trench!’ Camera film and photographic paper were scarce in the War and this is a small print whose content is confusing unless you know what you are looking for. Many other similar photographs of wartime operating theatres must have been discarded by their inheritors in favour of portraits and other more comprehensible images.Do No Harm exemplifies. The observers of conflict write compelling literature, such as the Vietnam War photographer Michael Herr'sDispatches, or Contact Wounds by Jonathan Kaplan, a surgeon who has worked for disaster relief organisations. Battlefield surgery, likewise, has a heroic, intrepid character that lends itself well to life-writing, both memoir and biography. The best of the Second World War medical memoirs are as readable as good fiction and offer as many empathetic insights into the human condition.Memoirs by surgeons are popular, as the success of Henry Marsh'sRespice, Prospice , could also be applied to the memoirs I describe in this article. Memoirs by the participants in war are important primary historical documents, along with their journals and letters. They may be subjective and individual, but they also offer rich, granular detail which more conventional histories cannot match. As the military historian John Keegan wrote, allowing combatants ‘to speak for themselves’ is ‘not merely a permissible but, when and where possible, an essential ingredient of battle narrative and battle analysis.’ In the same way, the medical memoirs explored in this article add detail to the official medical histories and are an essential ingredient in the history of the work of these units in the Second World War.These memoirs also add to our understanding of the evolution of military surgery. After the War, multi-volume official medical histories were published by the governments of the United Kingdom, Canada, Australia, New Zealand, and India. The motto for their concluding volume,


Video streaming service delivery is a challenging task for mobile network operators. Knowing which services clients are using could help ensure a specific quality of service and manage the users’ experience. Additionally, mobile network operators could apply throttle, traffic prioritization, or differentiated pricing. However, due to the growth of encrypted Internet traffic, it has become difficult for network operators to recognize the type of service used by their clients. In this article, we propose and evaluate a method for recognizing video streams solely based on the shape of the bitstream on a cellular network communication channel. To classify bitstreams, we used a convolutional neural network that was trained on a dataset of download and upload bitstreams collected by the authors. We demonstrate that our proposed method achieves an accuracy of over 90% in recognizing video streams from real-world mobile network traffic data. Mobile data traffic is increasing at a steady rate of 42% annually, with video traffic making up 69% of all mobile data traffic . The incPoor QoE can lead to customer dissatisfaction, complaints, and churn. This especially applies to video stream stalling, which is considered the most frustrating form of QoE degradation . AcademiTherefore, current and future mobile networks should be able to recognize the services used by customers and predict current and future demands for such service delivery. On the MNO side, the recognition of services and QoE guarantees are problematic due to heterogeneous data sources, varying time granularity of collected data, massive data amounts, and stochastic user behavior. Additionally, the increasing use of end-to-end encryption  for InteWe propose a new method for recognizing mobile video traffic based solely on the shape of bitstreams, rather than more complex methods involving the inspection of TCP/IP packets and session flows.We train the CNN using our own collected dataset of real mobile network users.We evaluate our proposed method and demonstrate that it achieves comparable performance to other methods, even when using simpler datasets.Considering the difficulties of video stream delivery for mobile networks and the limitations of recognizing such a service from the MNO perspective, we propose a method of recognition of mobile video traffic based only on downlink and uplink bitstream. This study continues our previous work  on the aIn mobile 4G and 5G networks, a wireless channel is the last mile of data, video streaming, and voice service delivery. In the wireless channel, the achievable throughput and delay fluctuate rapidly due to HAS adjusts video quality parameters to match the current network conditions . HAS necIn 4G LTE and 5G New Radio (NR) networks, the individual user’s bandwidth depends on the current cell load or the physical resource blocks (PRBs) available in the time-frequency grid  and the Such a situation is shown in The HAS has a periodic requirement to download video chunks, followed by idle periods during which the video chunks are played. If the base stations were aware of the amount of data in each chunk and the download period, the base station scheduler could periodically reserve the required time-frequency resources for this particular user. Therefore, recognition of the video service from the LTE/NR base station side could help to prevent video stalling and avoid QoE degradation for the user.End-to-end (E2E) data transmission is an interaction between the application on the UE side and the server or Content Delivery Network (CDN) on the other side. Typically, CDNs are owned by third-party OTT service providers and not by MNOs. Data delivery is handled using IP stack protocols . From a mobile network point of view, it is treated as payload data and is delivered with the best effort, independently of the service used by the client. However, MNOs could benefit from knowing what type of services their clients use. The MNO could then prioritize, block, throttle, or apply different pricing models for specific traffic classes. Techniques such as port-based or deep packet inspection (DPI) were previously commonly employed to identify the type of service or application. However, their accuracy has decreased due to the growing proportion of encrypted traffic . Since 2Previous studies related to our work propose using TCP/IP packet header or packet interarrival time information to recognize services and applications ,13,14. HThe remainder of the paper is divided into four sections. The collected dataset and the CNN model used for classification are described in In this section, we describe the method for differentiating video streams from other applications used on mobile networks based on bitstream shape only. We train a CNN for this task on the dataset collected by the authors. The dataset is composed of bitstreams from popular Android applications including Facebook, the browser Chrome, YouTube, and others.The dataset assembled for this study is composed of 3257 h of 1 s granular time series data from real users of the mobile network. Acquiring data from actual users, rather than using synthetic bot-generated data, provides a more precise representation compared with other research ,21. The The next step is to construct a dataset to train the neural network. To preserve valuable information, we divide the collected data into windows of 60, 300, and 600 s, with overlaps of 59, 299, and 599 s, respectively. We assign a label to every data window indicating the name of the application running on the smartphone at that time. We discard windows that contain multiple applications.The windowing data augmentation technique produced a massive quantity of training samples, including over 9 million samples that are 60 s long, over 5 million samples that are 300 s long, and over 3 million samples that are 600 s long. From this amount of data, we can select a balanced number of samples representing each application.To gain insight into the usage patterns of the collected data, we analyze it in terms of duration of use and statistical properties. We present the applications with the longest usage duration in We select and visualize a few random examples of the most used applications. In By analyzing random samples, we can infer that different applications have unique bitstream forms. For example, the Chrome, Facebook, and 9GAG apps show periods of high data transfer and intervals of minimal network activity. We can infer that these patterns correspond to periods when the user is actively engaging with the app and downloading content, and when they are viewing or reading previously downloaded content. The HAS pattern is clearly observable in the YouTube application, as video segments are both downloaded and played. The emailing application Outlook uses both downloading and uploading simultaneously, to receive and send emails. The last example is the Messenger app. It displays a pattern of constant download and upload during voice or video calls.x axis for a more accurate visualization.Random examples do not represent all of the cases and are used to visually understand possible time series shapes generated by different applications. To make comparisons across a large number of data samples, we need to use statistical features of the data. For this reason, we use the library of time series feature generation  to generWe can see that there is a partial overlap between the means and standard deviations of the samples. On average, video has a higher mean bitrate and a higher standard deviation within the sample. Additionally, YouTube has multiple peaks, which are probably due to video streams of different resolutions.An additional interesting point is the fundamental frequency of video bitstream samples. Although the selected statistical features (mean and standard deviation) show distinctions between video and other services, further differences can be drawn by considering time series shapes.Convolutional networks are neural networks that employ convolution in at least one of their layers, rather than using general matrix multiplication . CNNs arThe CNN uses a vector of one or two rows as its input, which represents downloaded-only or downloaded and uploaded bytes, and consists of 60, 300, or 600 numerical values. The input vector undergoes convolution, followed by batch normalization . NonlineThe preparation of the dataset incurs a high memory requirement, and the model training demands GPU resources. We use the Google Cloud Platform to deliver high-performance and flexible computing resources.In this section, we describe our testing methods, evaluation metrics, and the results of testing for video stream recognition from the bitstream shape only.The video stream recognition model is trained by separating samples of 60, 300, and 600 s into two categories: video and the rest. The video category is composed only of samples from the YouTube app, even though the HAS service can be used inside the Internet browser or other applications. For any sample sequence length, we select 100,000 samples to represent video and 100,000 samples from all other applications. Selecting an equal number of samples from each category helps avoid training with imbalanced data. The model is trained and evaluated using different sequence lengths, looking only at downlink bytes, next downlink, and uplink in 1D sequence (uplink sequence added at the end of downlink) and 2D sequence (uplink and downlink fed simultaneously).To evaluate the performance of the classification, we use several evaluation metrics. First, we calculate the accuracy using Equation . Then, wP is defined as the number of true positives R is defined as the number of true positives Accuracy is calculated as the number of correct classification predictions divided by the total number of predictions. Precision Furthermore, we calculate the misclassification rate for each of the most used applications according to Equation . The misUsing the misclassification rate for each of the most used applications, we verify not only how many times the video is correctly or incorrectly recognized, but also which applications confuse our model.The model is evaluated using input sequences with identical duration to those of the training data, but with completely new and unseen samples. Samples are chosen at random from the gathered dataset in equal proportions from the video and the rest of the applications. The classification accuracy achieved by the trained CNN model in classifying 60, 300, and 600 s sequences is shown in The precision and recall in distinguishing between the video stream and other applications, using the CNN to classify 60, 300, and 600 s sequences, are shown in To add more robustness to the evaluation and increase proximity to the real mobile network usage scenario, we evaluate our model against the new data in the same proportions as collected. The number of samples from each application and their misclassification rates are presented in In this section, we present the results of a comparison of the proposed method with other techniques that aim to identify the class of services or specific applications that transfer data over the network. The comparison is based on various criteria, such as the purpose of classification or recognition, the algorithm type, the method of dataset collection or generation, and the complexity of data preprocessing and required networking domain knowledge. Finally, the performance of the methods is compared in terms of accuracy, precision, and recall, and the results are presented in It is worth noting that other related works use datasets that contain more information, including data from inside Internet Protocols such as source port, destination port, number of bytes in a packet payload, TCP window size, interarrival time, and packet direction. In contrast, our proposed method only evaluates the shape of bitstreams generated by different services on a second-level granularity, without inspecting the content of packets. If the aim is not only to recognize encrypted video streaming but also to guarantee QoS/QoE from the mobile network base station side, then data availability must be considered. The scheduler of LTE and NR nodes is implemented in lower layers, such as MAC, which are not aware of TCP/IP packet content and treat it as payload only. Therefore, we believe that proposing a method of identifying video streaming services based solely on the shape of the generated bitstream would enable us to use simple and accessible data without raising privacy concerns.The proposed method simplifies network traffic classification by eliminating the need for TCP/IP packet parsing and session flow construction. Furthermore, the proposed method does not necessitate knowledge of the TCP/IP protocol stack and its implementation in actual network nodes. The comparison shows that despite the use of simple bitstream input data, the proposed method is still comparable with the other methods in terms of accuracy, precision, and recall.Based on the evaluation results presented in Based on the misclassification rate results of the 300 s input sequences shown in The results obtained show that distinguishing between video streaming and other types of applications is feasible, but the dataset collection should be improved to avoid times when the application with the video streaming capability is in use, but no video is being streamed.With the increasing use of encrypted traffic and VPNs, it is becoming difficult to determine the applications and services that customers use on mobile networks. However, recognizing the service being used is crucial to ensure specific QoE requirements. Furthermore, identifying and categorizing mobile data traffic based on service or application can help prioritize specific types of traffic, implement dynamic pricing, or block MNOs.In this study, we investigate the feasibility of identifying video streaming services solely based on the shape of the generated bitstream. MNOs can collect bitstream data at all times without violating privacy concerns. Furthermore, the use of a convolutional neural network (CNN) model does not require data preprocessing or extensive knowledge of data transfer protocols.The findings of this study indicate that the CNN has the ability to distinguish between video streams and other types of data streams produced by various applications. The high demand for video streaming suggests a requirement for future work that aims not only to recognize encrypted video streaming, but also to guarantee QoS/QoE. Knowing that a client is engaged in video streaming and being aware of the parameters of the HAS service can aid in optimizing resource scheduling at the mobile network base station.