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.

The Environmental Cost that Living in this World Puts on Our Health

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

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Source: Environmental Health, World Health Organization (WHO)

As revolting as it sounds, there are places in the world where the chances of consuming one’s neighbours’ faeces are quite high if one is not vigilant regarding sanitation and hygiene. That being the condition of many areas in low and lower-middle income countries does not mean that high and higher-middle income countries are exempt from any environmental conditions that are harmful to health.

But, what is environment health? The World Health Organization (WHO) defines the term as, “All the physical, chemical, and biological factors external to a person, and all the related factors impacting behaviours”. It, however, excludes genetics and the social and cultural environment.

In low-income settings, concerns for environmental health may arise in the context of sanitation and hygiene, as well as indoor and outdoor pollution. In high-income countries, many chronic diseases like diabetes and cardiovascular disease, are associated with sedentary lifestyles. While these might be attributed to behaviour, one must consider that such behaviours can arise from changes in the environment. Over 80% of communicable and non-communicable diseases can be attributed to environmental hazards.  Overall, conservative estimates indicate that about one quarter of the total global burden of disease is owing to this cause (WHO, 2011). Furthermore, the biggest killers of children under 5 years are all environmental-related diseases, including diarrhoea, respiratory infections, and malaria.

Other diseases of concern are helminthic infections, trachoma (a bacterial eye infection), Chagas disease, leishmaniosis, onchocerciasis, and dengue fever. All of which are associated with impoverished conditions and can be mitigated by improving sanitation, hygiene, and housing. Although conflicts and natural disasters might be catastrophic for any country, struggling economies tend to suffer more because disasters worsen the poor conditions which directly affect sanitation and hygiene practices, creating conducive conditions for various infectious diseases, and ultimately feeding into the vicious cycle of poverty.

Many interventions are underway to address these conditions, including Water, Sanitation and Hygiene (WASH) initiatives, Integrated Vector Management, Programme on Household Air Pollution, International Programme on Chemical Safety, Health and Environment Linkages Initiative, and Intersun Programme for the effects of UV radiation. The acknowledgement of the effects of the environment has grown. One of the Millennium Development Goals (MDGs) was, “To ensure environmental sustainability.” The Sustainable Development Goals (SDGs) are more extensive and thorough in placing focus on the environment. Goal 1 is to end poverty, goal 6 is to make provision of clean water and sanitation possible, and goal 13 is to stop climatic change resulting in floods and drought (United Nations, 2014).

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The Sustainable Development Goals. Source: United Nations System Staff College

It is encouraging to see steps being taken to control environmental hazards; however, the journey to measuring and eradicating such conditions still remains a challenge, which will hopefully be overcome through future endeavours.

References:

United Nations (2014). Sustainable Development Goals. doi:10.1017/CBO9781107415324.004

World Health Organization (2011). WHO Public Health & Environment Global Strategy Overview

Coups and Contrecoups

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

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Source: Federation Internationale de l'Automobile

Back while I was doing my house job, what most people would call a clinical internship, I worked for six months in the surgical ward of a government hospital in Lahore. Working in the surgical emergency meant witnessing, receiving, and managing patients with surgical injuries, ranging from minor wounds, to firearm injuries (FAI) and road traffic accidents (RTAs) besides other conditions requiring a clinical diagnosis. Indeed studies indicate that most of the cases presented in the emergency department are due to RTAs (Khalid et al., 2015).

Some of the worst cases I remember seeing were RTAs. Most of these patients ended up in neurosurgery as a consequence of head trauma. If one were to take a tour of the neurosurgery ward and go through case files or talk to the attendants, one would discover that most of the cases have a history of RTA. If you were on call and were awakened during the night by women crying, you would speculate that it is probably a life lost on the neurosurgery floor. Patients often stayed in the ward for long periods with an uncertain prognosis.

With urbanization of an exploding population and motorization, the world has also witnessed an increase in RTAs (Atubi, 2012). In Pakistan, the number of motor vehicles on the roads is high and the implementation of traffic rules is low. Road safety is not a prevalent concept and in some places it appears to be completely non-existent. Road injuries rank 9th among the top Disability Adjusted Life Years (DALYs) per 100,000 in Pakistan. Since men are the primary bread-winners, the proportion of male to female casualties is disproportionate; more males suffer disability and death than females (Abdul & Tehreem, 2012). Therefore disability, hospital bills, death and funeral expenses often leave families in bankruptcy.

The situation of road traffic injuries is not very hopeful worldwide either. According to WHO 1.25 million people lose their lives as a result of road injuries and most of these casualties are in low and middle-income countries. Sufficient to say that road traffic injuries are a rather neglected area of global health. Recently there have been efforts to rectify this oversight as RTAs have now been identified as a major cause of death and disability besides communicable and non-communicable diseases. The Sustainable Development Goals (SDGs) presented in September 2015 show an advance towards recognition of the dilemma of RTAs and aims to decrease the number of deaths by 2020 (Cossio et al., 2015). Steps will hopefully be taken towards creating policies that make roads and vehicles safer for people across the world. One can hope that these policies will ultimately rub off in low and middle-income countries where the most lives are lost due to RTAs.

References:

Abdul, M. K., & Tehreem, A. (2012). Causes of Road Accidents in Pakistan. J. Asian Dev. Stud, 1(1), 22–29. Retrieved from ISSN 2304-375X

Atubi, A. (2012). Determinants of Road Traffic Accident Occurrences in Lagos State : Some Lessons for Nigeria. International Journal of Humanities and Social Science, 2(6), 252–259

Cossio, M. L. T., Giesen, L. F., Araya, G., Pérez-Cotapos, M. L. S., VERGARA, R. L., Manca, M., … Héritier, F. (2015). Global Status Report on Road Safety 2015. World Health Organization (Vol. XXXIII). doi:10.1007/s13398-014-0173-7.2

Khalid, S., Bhatti, A. A., & Burhanulhuq. (2015). Audit of surgical emergency at Lahore General Hospital. Journal of Ayub Medical College, Abbottabad : JAMC, 27(1), 74–7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26182742

Access to Toilets: Not as Common as You Might Think

~Written by Theresa Majeski (Contact: theresa.majeski@gmail.com; Twitter: @theresamajeski)

There are over seven billion people on the planet and 2.4 billion of them do not have access to proper sanitation. Almost one billion people still defecate in the open. The risk of disease and malnutrition increases with poor sanitation, especially for women and children. This year’s World Toilet Day on November 19 highlights the impact of poor sanitation on malnutrition.

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Figure 1 : World Toilet Day poster, 2015. http://www.worldtoiletday.info/wp-content/uploads/2015/10/wtd-artist-poster-724x1024.jpg

Every day, over 1,000 children die from preventable water and sanitation related diarrheal diseases. Half of all cases of under-nutrition associated with diarrheal or intestinal worm infections are directly due to inadequate water, sanitation, and hygiene. Stunting and wasting, which cause irreversible physical and cognitive damage, have been linked to poor (water, sanitation and hygiene (WASH) conditions. In 2014, almost 1 in 4 children under five years of age suffered from stunting globally. 58% of all cases of diarrheal disease are directly related to inadequate water, sanitation, and hygiene.

Access to proper sanitation, hygiene, and potable water is so important that it was included in the 2000 Millennium Development Goals (MDG). Since 1990 an additional 2.1 billion people have started using basic toilets, and today around 68% of people have access to proper sanitation. However, the final MDGs Assessment report shows that the world has fallen short of the MDG goal by 700 million people. This means that there is still work to be done, which is why access to sanitation and clean water is Goal 6 of the Sustainable Development Goals.

There are many innovations occurring in the WASH area. One example is a project by Give Water that promotes child health by developing child-sized latrines and teaching children about proper sanitation and hygiene practices in school. This ensures that proper WASH practices start from a young age. The WASH Impact Network website provides a lot of information about additional innovative WASH projects. 

Access to proper sanitation and clean water is a human right. While progress is being made towards this goal, there is still work to be done. World Toilet Day highlights the continued effort to provide proper sanitation facilities to every person on the planet.