What if you're in a hospital in India or China.

And I don't mean to pick on those two countries specifically

but once you get out of the high income countries to low and middle income
countries does the
pattern look the same or are there broad differences?
I would say there are a couple of places in which they
are substantial differences.
Notably the risk of adverse drug events is a bit lower.
It's lower?
Yes and that's in large part because fewer medications
are used in developing transitional countries.
Because many of the most dangerous medications are actually quite expensive and
then infections
are more common.
So if you think about it from an overall profile of patient safety,
it sounds like what you're saying is your risk of having an adverse event,
having something bad happen in the hospital, probably no different in a lower
middle income
country but maybe a little less likely to have a medication
problem, adverse drug event, but maybe a little more likely to have infection.
Exactly and the risk of most complications is probably somewhat higher.
The chance that it could be prevented is also a bit higher.
The other broad category that we don't have on this list
is birth related injuries.
And those are extremely important, especially in developing countries.
One of the things that happens in developing countries
is that birth rates are very high so it's something that happens a lot and yet the
resources
that we have to deal with things are somewhat more limited.
And both fetal and maternal mortality rates and injury rates
are substantially higher in developing countries.
So this is not just about the fact that when women come into the hospital or a
birthing
center that they might have the normal complications
of childbirth but you're saying that in the process of care
delivery, there may be new things introduced that can
cause problems.
That's part of it.
And part of it too is that women often come later to birthing centers.
They come after they're suffering a complication.
I'm going to take a step back and say here we are.
We've identified a set of adverse events, injuries
that happen due to medical care.
We've talked about it for high income countries, we've talk about it for low and
middle income
countries.
Let's say we put all of this together.
From a population health point of view is this a small deal,
is this a big deal?
If you put it all together, it's actually a really big deal.
If you look at causes of death, it's a little uncertain
what the exact numbers are but in developed countries,
this probably comes in right after cardiac issues and cancer.
It's probably the third leading cause of death.
So it's really a serious issue.
And there's some work that we've done together, supported
by the WHO, that tried to quantify disability adjusted life years lost,
how many years of life are lost.
We found that about 23 million disability adjusted life years
are lost around the globe from just these kinds of events.
Exactly and there were other things that we couldn't include
and we made very conservative estimates, I would say, throughout as to how big the
magnitude
of harm was.
Let's take a minute and just identify what were things
that you think are clinically important that we weren't able to get to?
Right, so among those were counterfeit drugs, unsafe injections.
Unsafe injections.
And the other big one we already mentioned which is the birth
related injuries.
So this is very helpful and the main reason we couldn't get at this
is really data issues.
Exactly.
For example, for counterfeit drugs, some estimates are that up to half
of all the medications in developing countries are not truly what they're supposed
to be.
The exact proportion is uncertain, the benefit that people would have gotten if
they were
the real thing is also not clear.
But it's pretty clear that it's a big issue.
When we talked about adverse drug events, we were talking about giving legitimate
drugs
but having problems from that.
Here, the issue is even if you give the right treatment,
there may be in some instances, as much as half of the medications,
may not have the exact substance and dosage that it's claimed to have.
Exactly.
And then around unsafe injections, for example, in some parts of the world
it's routine to give a lot of injections.
That's been a longstanding practice, for example, in India
and it was quite common to reuse needles, which obviously carries
with it the risk of HIV transmission as well as hepatitis B and C.