Defeating Tuberculosis: A Possibility?

~Written by Sarah Khalid Khan (Contact: sk_scarab@yahoo.com)

Disease has always played a part in reforming community and geographical distribution of people through the ages. The bubonic plague, the Spanish flu, cholera and tuberculosis (TB), are some of the illnesses that have altered human history. Interestingly, TB has been glorified in literature more than others. The characters, Mimi in La boheme, Fantine in Les Miserables and Satine in Moulin Rouge all met with a similar fate at the hands of this disease.

According to the Global Tuberculosis Report 2015, the year 2015 is considered a turning point for TB as the global community progressed from Millennium Development Goals (MDGs) to Sustainable Development Goals (SDGs). TB mortality has decreased by 47% since 1990. Between 1990 and 2014, as a result of correct and timely diagnosis, 43 million lives were saved. We have made progress by moving from the “Stop TB Strategy” to the “End TB Strategy”. According to the latter, the targets for 2030 are to reduce the number of TB deaths by 90% and incidence by 80% (1).

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Source: TBAlert.org

These statistics give us hope for a world without TB. But, having worked in a tertiary hospital in a low middle-income country, I have my doubts. Although the statistics reported by the World Health Organization (WHO) are the best available at the moment, these are estimates with very wide confidence intervals and may not provide a precise idea of the current situation in low and low middle income countries (LIC and LMICs).

In the surgical ward where I worked, one-third of the abdominal procedures were for perforation due to abdominal TB. To my knowledge, patient records were maintained through an electronic health system on the hospital server. Hard copies of the records were kept in nurses’ offices or junior doctors; duty rooms. These were put in storage, usually available for 4 to 5 years. The conditions of the storage area were extremely shabby and damp, where paper records could hardly survive. Electronic records, however, were said to be available in perpetuity. No one knew if these records were ever shared with the WHO to help with estimates. Popular opinion was that if the world knew the actual incidence and prevalence of diseases like TB in countries like ours it would be an embarrassment. Regardless, it is essential to have as accurate as possible estimates to converge efforts towards a TB free world.

Despite the best intentions and apparently achievable goals, the situation remains grim. According to the WHO, TB still imposes a great burden on the world. In 2014, 9.6 million new cases of TB were diagnosed while 1.5 million people died as a result of TB (2). Despite the history of this disease, research for newer TB drugs has been limited (3). In 2012, a new drug for multidrug resistant TB was introduced after a drought of 50 years (4). In addition, though BCG vaccines are part of immunization programs in countries where the disease is endemic, the current vaccine was developed in 1921 and is not entirely effective (5). A systemic review and meta-analysis that included articles from 1950 to 2013 reported 19% efficacy against TB in vaccinated children compared to non-vaccinated children (6). Although current research is encouraging there are questions of affordability of newer drugs for low resource countries where TB is more prevalent. Furthermore, five percent of the global burden of TB is due to multidrug resistant strains (7). The research required for averting these cases poses additional problems of affordability, availability and accessibility in LICs and LMICs.

Children present another area of grave concern. It is estimated that 550,000 children are infected with TB each year. The condition is frequently overlooked in children, often due to delayed and inefficient diagnosis (8). Adoption of the latest recommended diagnostic tools by the WHO is a challenge in itself because accessibility, affordability and availability again come into play in LICs and LMICs. Since TB flourishes in poor living conditions, the current global refugee and migrant situation has increased concerns about TB exposure, infection and transmission (9).

It is time that LICs and LMICs focus on establishing the true burden of major diseases like TB, and work towards adopting recommended diagnostic tools and treatment for all forms of TB. Unless the state actors and international community work together, the policies and aid provided will continue to fall short and the target to end TB will remain out of reach.

References:

1. World Health Organization. Global Tuberculosis Report 2015. 2015.

2. World Health Organization. Research for Tuberculosis Elimination. 2014.

3. Frick M. 2014. Report on Tuberculosis Research Funding Trends, 2005-2013. [Internet]. Treatment Action Group. 2015. Available from: http://www.treatmentactiongroup.org/sites/tagone.drupalgardens.com/files/tbrd2012 final.pdf

4. Médecins Sans Frontières, International Union Against Tuberculosis and Lung Disease. DR-TB Drugs Under the Microscope. Sources and prices for drug-resistant tuberculosis medicines. 2nd edition. 2013.

5. World Health Organization. Tuberculosis vaccine development [Internet]. World Health Organization; 2015 [cited 2016 Mar 19]. Available from: http://www.who.int/immunization/research/development/tuberculosis/en/

6. A Roy et al. Effect of BCG vaccination against Mycobacterium tuberculosis infection in children: systemic review and meta-analysis.  BMJ 2014; 349:g4643

7. World Health Organization. Multidrug Resistant Tuberculosis (MDR-TB). 2015.

8. World Health Organization. Combating Tuberculosis in Children. 2015.

9. World Health Organization. Tuberculosis prevention and care for migrants. 2014.

Health Promotion: An Effective Approach to Achieve the Sustainable Development Goals

~Written by Karen Hicks, Senior Health Promotion Strategist & Lecturer, New Zealand (Contact: karen_ahicks@hotmail.com)

In September 2015 the United Nations adopted seventeen sustainable development goals (SDGs) (Figure 1) as part of the 2030 Agenda for Sustainable Development; which aims to end poverty, fight inequality, injustice, and tackle climate change. These SDGs are acknowledged as going beyond the previous Millennium Development Goals (MDGs) as they aim to address, ‘The root cause of poverty and a universal need for development that will work for all people’ (United Nations, 2015).

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Figure 1. Sustainable Development Goals. Source: http://wfto.com/sites/default/files/field/image/2015-07-21-SDGs.png

Each of the SDGs relate to health and wellbeing with aims, approaches and principles that are concomitant to the discipline of health promotion; a discipline that acknowledges the complexity of health and is based on the principles of human rights, equity and empowerment (Williams, 2011). Consequently, such principles imply that health promotion is an effective approach toward achieving the SDGs. This approach is supported by the global framework and described in “The Ottawa Charter for Health Promotion” (WHO, 1986) (Figure 2) which identifies five key action areas: building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills and reorientating health services through advocacy, enabling mediation for effective practice.

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Figure 2. The Ottawa Charter for Health Promotion Logo. Source: http://www.who.int/healthpromotion/conferences/previous/en/hpr_logo.jpg 

An example of a collaborative initiative that illustrates health promotion as defined in the Ottawa Charter is the International Network of Health Promoting Hospitals & Health Services (HPH). The initiative works to reorient health care towards an active promotion of health for patients, staff, and communities. Further detail on the approach can be accessed on the HPH website.  

The principles and actions illustrated alongside the interdisciplinary approach of health promotion that empowers people and communities (Health Promotion Forum of New Zealand, 2014) and focuses on equity and the broader determinants of health (Davies, 2013) is acknowledged by the World Health Organisation, “Health promotion programmes based on principles of engagement and empowerment offer real benefits. These include: creating better conditions for health, improving health literacy, supporting independent living and making the healthier choice the easier choice” (WHO, 2013 p 16).  The value associated with the approach clarifies how health promotion can effectively contribute to achieving the seventeen SDGs where the SDGs can guide the delivery of effective health promotion to improve health, wellbeing and personal development throughout the global community.

References:

Clinical Health Promotion Centre. The International Network of Health Promoting Hospitals & Services.  http://www.hphnet.org/ Accessed 22/1/2016. Bispebjerg University Hospital Denmark.

Davies, J.K. 2013. Health Promotion: a Unique Discipline? Health Promotion Forum of New Zealand.

Health Promotion Forum of New Zealand. 2014. http://www.hauora.co.nz/defining-health-promotion.html#sthash.5sStc8VF.dpuf.

United Nations. 2015. http://www.un.org/sustainabledevelopment.

Williams, C. 2011. Health promotion, human rights and equity. Keeping up to date. Health Promotion Forum of New Zealand.

World Health Organisation. 1986. The Ottawa Charter for Health Promotion. WHO.

WHO (2013) Health 2020: a European policy framework and strategy for the 21st century Copenhagen, World Health Organisation.

Highlighting Childhood Disability: DiaBlog with Priyam Global

~Written by Jasmine L. Hamilton (Contact: lajuaniehamilton@gmail.com; Twitter: @jasminogen) with Michaela Cisney (Twitter: @priyamglobal)

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A mother supports her son during a therapy session in Hope Special School, Chennai, India.

Disability affects an estimated 1 billion persons worldwide (1). An estimated third are children, the majority of whom (>80%) live in low and middle income countries (LMICs) (1-2). Children affected by disability and their families face significant challenges, including social isolation and stigma, high risk of poverty and violence, minimal resources and programming, and inadequate services, to name a few (1-2). Further, although the convention on the rights of the Child (CRC) and the Convention on the Rights of Persons with Disabilities (CRPD) (3-4) state that children with disabilities are entitled to the rights of all children and should be provided access to health care, education and protection from violence, abuse and neglect, the current challenges faced by children with disabilities demonstrate failures in translating these values at policy, national and international levels (5-6). The millennium development goals (MDGs) for example, excluded disability from its agenda, a major oversight with dire consequences on children worldwide. For example, a recent report by Human Rights Watch revealed that in South Africa, the second largest economy in Africa, over 500,000 disabled children are unable to access primary education, an issue thought to be a prevalent problem in LMICs (1,5-6). The World Health Organization, UNICEF, and others have repeatedly outlined the shortage of research, policy, or action on behalf of children affected by disabilities in developing countries.

Fortunately, recent developments at the policy level indicate movement towards a more equitable approach for addressing disability. Most importantly, the inclusion of targets toward improving access to education and employment for disabled persons in the sustainable development goals (SDGs), stands to profoundly affect the way disability is perceived worldwide, with a significant possibility of increased access to healthcare, education, and other services available to children affected by disability.

These developments are bringing optimism and a surge of hope to organizations and volunteers that have been working tirelessly to bring about positive change in this area. I recently spoke with the director and co-founder of Priyam Global (http://www.priyamglobal.org/#who-we-are) a new NGO working to improve quality of life, opportunity, and global perception of value for the world’s poorest children who have disabilities, in an effort to outline major challenges and steps that can be taken towards creating a more equitable world for children affected by disability. What follows are her comments on some of the challenges and hopes that she has for Pryiam Global and the children with disabilities in Chennai, India who inspire her work.

Q1: What does Priyam stand for, when was it founded and what is your vision for the organization?

Michaela Cisney: Priyam is a word meaning ‘love’ that is shared among the Tamil, Hindi, and Sanskrit languages. The name was selected through a collaborative process with the children’s home we partner with in Chennai and reflects what is essential to the success of our work: a simple, abiding love for all of humanity, but especially for its children. I co-founded Priyam in July 2014, with the vision of bringing childhood disability to the heart of global health by creatively and attractively reframing the ways we look at children, ability, and value.

Q2: How many disabled children are you currently reaching and what assistance do you provide?

Michaela Cisney: Our collaborative work with a special education school and a children’s home currently reaches about 200 children affected by disability in India. We’ve been able to support and increase special nutrition initiatives to combat India’s severe child malnutrition rates, cost-share the expenses of additional therapists, provide start-up funding to selected families for self-employment opportunities, train and place national and foreign volunteers, and—importantly—take a critical role in increasing awareness and understanding of childhood disability as an urgent and relevant global maternal and child health issue.

Q3: What is your biggest challenge working in the area of CD?

Michaela Cisney: As a connector organization and catalyst, the greatest challenge we face is general low awareness in high-income countries of childhood disability realities, contexts, and opportunities for change in developing countries. Disability makes people uncomfortable, reflecting a great need for disability issues to be framed as secondary to universal values that resonate with all of us: a child’s beautiful personality, a toddler’s wellbeing and ability to thrive, a mother’s love bound by her inability to provide for her children in extreme poverty. Disability is somehow seen as “other” to these issues and so it’s a challenge to gently dismantle prejudices many of us are not even aware we hold, to then attractively frame CD in positive contexts of change and growth while also portraying urgent realities in a balanced way.

Q4: What is your greatest hope for Priyam Global and the children in Chennai that you currently work with?

Michaela Cisney: My greatest hope is that every child, in Chennai and beyond, would see the full and beautiful realization of her rights and dreams: a family that loves her without limits, a body and mind that are cared for and well, and the opportunities to explore her interests and thrive using her strengths.

To learn more about the work of Priyam Global visit www.priyamglobal.org For information on the global plan to address the challenges faced by persons with disabilities visit: http://www.un.org/disabilities/default.asp?id=1618

About Michaela Cisney

Michaela earned a Master’s in Public Health in Behavioral, Social and Community Health from Indiana University, focusing on maternal and child health, and nutrition and disease interactions. Before launching Priyam Global, she worked with Timmy Global Health to develop culturally-relevant monitoring and evaluation plans for a WASH program in rural Ecuador. In addition to her role as Executive Director for Priyam Global, Michaela works as a consultant for World Vision International (WVI), where she helps WVI communicate critical impact of community health worker programming globally for marketing and advocacy. She has also worked with WVI to design and launch a global training on individual/household health behavioral counseling (ttC). Follow her on Twitter: @priyamglobal

References:

1. www.un.org/disabilities/documents/review_of_disability_and_the_mdgs.pdf
2. http://www.who.int/disabilities/media/news/2012/13_09/en/
3. Convention on the Rights of the Child. New York: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx
4. Convention on the Rights of Persons with Disabilities: http://www.un.org/disabilities/convention/conventionfull.shtml
5. https://www.hrw.org/sites/default/files/report_pdf/southafrica0815_4up_0.pdf
6. http://www.theguardian.com/global-development/2015/aug/18/disabled-children-poorer-countries-out-of-primary-education-south-africa-human-rights-watch-report

Global Health Insights from the 2015 Gates Annual Letter

-Written by Adenike Onagoruwa, PhD (Contact: adenike.onagoruwa@gmail.com)

For the seventh consecutive year, Bill and Melinda Gates have released an annual letter, discussing the Gates Foundation’s activities and sharing progress on the fight against poverty and disease. An organization headed by two of the world’s most powerful philanthropists, the Gates Foundation funds global health, development and advocacy efforts aimed at reducing poverty and eradicating preventable diseases that disproportionately affect the developing world population.

Through its grant-making and operational activities; the Foundation has, especially in the past decade, set the health agenda for aid organizations, research institutes and even governments around the world. It is therefore quite important to pay attention to the insights, priorities and goals outlined by these primary players in the global health and development arena. With the upcoming expiration of the Millennium Development Goals (MDGs), this year’s letter evinces the momentousness of 2015.

Released at the start of the year, the 2015 Gates Annual Letter titled “Our Big Bet for the Future” makes ambitious predictions regarding the next 15 years. The big bet is this: “The lives of people in poor countries will improve faster in the next 15 years than at any other time in history. And their lives will improve more than anyone else's.” Acknowledging the absurdity of this bet in the face of seemingly worsening world problems (they do add a caveat that a handful of the worst-off countries will continue to struggle); the two give these reasons why they think there has never been a better time to accelerate progress, resulting in longer lives and better health:

●     “There will be unprecedented opportunities to get an education, eat nutritious food, and benefit from mobile banking.”

●     “These breakthroughs will be driven by innovation in technology — ranging from new vaccines and hardier crops to much cheaper smartphones and tablets — and by innovations that help deliver those things to more people.”

The key global health breakthrough they foresee happening by 2030 is that “Child deaths will go down, and more diseases will be wiped out”. Here’s how:

Cutting the number of children who die before age 5 in half again. The percentage of under-five deaths worldwide has been cut in half (1 in 10 children in 1990 to 1 in 20 today). 1 in 40 children by 2030 can be achieved by

●     scaling proven, existing interventions for saving newborn lives such as: immediate and exclusive breastfeeding for the first six months; delivering injectable antibiotics immediately a baby appears ill; basic training for resuscitating a struggling-to-breathe newborn with a hand-pumped oxygen mask; immediately drying and warming the newborn after delivery through skin-to-skin contact; and topical application of chlorhexidine to the umbilical cord for prevention of sepsis specific mortality.

●     Comprehensive immunization - almost all countries will include vaccines for diarrhea and pneumonia, two of the biggest killers of children, in their programs.

●     Improved hygiene and sanitation to reduce disease spread - through simple hand-washing and innovative toilets specially designed for the poor.

●     Leveraging on the work that has been done to strengthen country-level health systems in many poor countries.

Reducing the number of women who die in childbirth by two thirds. The number of mothers dying will go down by:

●     Increasing the number of women that give birth in healthcare facilities instead of at home.

●     Making sure that caregivers at healthcare facilities are well-supplied and well-trained.

●     Improving access to contraceptives and to information about pregnancy spacing.

Wiping polio and three other diseases off the face of the earth. Polio, elephantiasis, river blindness, and blinding trachoma can be eradicated by 2030 through:

●     Free medicines made possible by continuing donations from pharmaceutical companies.

●     Strategic delivery of these medicines aided by advances in geographic information systems for disease surveillance.

Finding the secret to the destruction of malaria. While the two are not optimistic about the elimination of malaria by 2030, they believe that all the tools for its complete eradication will be available by then. By 2030, based on early versions of these tools currently in development, it is anticipated that:

●     There will be a vaccine that will prevent the transmittal of the malaria parasite from infected persons to the mosquitoes that bite them, thus halting the spread of the disease.

●     There will be a single-dose cure that will completely clear the parasite from infected persons.

●     There will be a diagnostic test that can provide immediate results on infection status.

Forcing HIV to a tipping point. Alongside efforts to develop a vaccine or cure for HIV, HIV will be forced to a tipping point globally when:

●     The number of people beginning anti-retroviral treatment in sub-Saharan Africa surpasses the number of newly infected people.

●     The high HIV transmission rate in sub-Saharan Africa is arrested, leading to a worldwide reduction in HIV cases.                 

Progress towards these health breakthroughs will be complemented by parallel progress in agriculture (innovations to increase yield and improve nutrition content in order to increase earnings and reduce malnutrition); education (the creation of better technology to revolutionize learning, make online education easily accessible and reduce the gender literacy gap); and banking (increased access to mobile banking that gives the poor more control over their finances, makes transactions more efficient, less time consuming and makes it easier to borrow and save).

What does this letter mean to the health and development community? Well, as one of the biggest funders, the letter provides a projection of what we can expect to see in global health programming in the years to come. For instance, there will be an emphasis on scientific and technological discoveries aimed at reducing maternal and child mortality. Organizations working to develop vaccines as well as rapid, low-cost diagnostic tests and medical devices will receive priority funding. Just as the MDGs have been used as a framework for driving actions and policies in development, the goals outlined in the 2015 Gates Letter will certainly have impacts on programs and policies in many developing countries, as well as on the funding directions of other donor agencies.

The master plan of the Gates touches on several vital issues that are central to health and development and is sensitive to the gender applications and implications of proposed activities. It galvanizes public engagement with the introduction of a “Global Citizens” program that invites and provides a platform for “global citizens” to “lend their voice, urging governments, companies, and nonprofits to make these issues a priority”. Certainly, their big bet can only be attained by building collaborations within existing structures and breaking down walls between nonprofit sectors. Monetary and R&D investments by the private sector coupled with international political support will be paramount for achieving any progress. Political will and better bureaucracy at the country level is a huge determinant of success. However, it is noted that the letter does not focus much, if at all, on the development of structures that sustain interventions such as legal, policy, financial and governmental environments. The focus is rather on straightforward solutions that can be achieved while bypassing these systems and institutions.

All-in-all, the letter provides a credible, multi-sectoral agenda and it is hoped that the Post-2015 Sustainable Development Goals will be as practical as the 2015 Gates Annual Letter in providing achievable goals for improving global health in the next 15 years.

References:

Bill and Melinda Gates. 2015 Gates Annual letter. www.gatesnotes.com/2015-annual-letter

Global Health and Post-2015 Agenda: Making a Case for Vulnerable Populations

~Written by Hussain Zandam, Health Systems and Policy Researcher (Contact: huzandam@gmail.com) 

The health-related Millennium Development Goals (MDGs) has made relative progress in improving access to essential healthcare. The next step, as suggested by many professionals in the development arena, is to consolidate on the gains and address the existing wide gap in quality healthcare among populations, especially in LMICs.  This can be tackled by addressing the challenges faced by a range of vulnerable populations. Vulnerable groups are defined as social groups who experience limited resources and consequent high relative risk for morbidity and premature mortality. The group is represented by different categories of people including; women, children, elderly people, ethnic minorities, displaced people, people suffering from illnesses, people with disabilities and others. Together, these groups makes up a very significant population. For example, according to World Bank’s report on disability, PWDs makes up about 20% of world population equivalent to over billion people.

There is ample evidence confirming that access to effective health care is a major problem in the developing world. Many millions of people suffer and die from conditions for which there exist effective interventions. Vulnerable populations make up majority of these people. While some challenges are similar across different vulnerable people, others are specific to a particular vulnerable group. Selected factors to categorize groups should reflect specific subgroups of the population - such as poor rural women, or members of an ethnic minority - that require particular awareness due to their underlying social characteristics, which afford them less opportunity to be healthy than their more privileged counterparts. As a group, they also tend to be the least healthy and most probably have the most to benefit from health care. The fact that those most in need make least use of health care is widely considered inequitable.

Insufficient resources, inappropriate allocation, and inadequate quality are major impediments to the delivery of effective health care that reaches this group. The access problem cannot be solved without tackling each of these deficiencies. Even with limited resources, services should aim for equity, emphasizing the individual and their dignity rather than their merits, economic circumstances or ethnicity. Equitable access has been defined as ‘‘care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographical location and socio-economic status.  Adequate access is also linked to timeliness and the quality of services.

According to Organization for Economic Cooperation and Development/World Health Organization (OECD/WHO) DAC guidelines, the development of equitable financing through increasing pre-payment and risk pooling is one of four priorities for the development of a pro- poor health system delivering quality, accessible health services to the poor. The extension of health insurance cover is a long-term goal. At low levels of development, a more feasible policy is to maintain reliance on out-of-pocket payments but to grant exemptions to groups, principally the poor, for which price is a major deterrent to use. Policy initiatives can accelerate the process, however it is important for health policies to include not only commitments to core concepts of human rights ‘for all’, but also whether for vulnerable groups in a way which takes account of their ‘vulnerabilities’.

A general strategy can be defined at the global level, while policy measures should be heterogeneous, varying with the local conditions in which they are implemented. Finally, as nations and the entire world accept more and more responsibility for the health of human beings, the discussion on ‘‘universal health coverage’’ as the successor to health-related millennium development goals, global health should have a strong focus on the health of the poor and vulnerable.