Investing in Healthcare to Put a Dent in Poverty

~Written by Hussein Zandam (Contact: huzandam@gmail.com; Twitter: @zandamtique)

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Poverty and Healthcare, Two halves. Photo credit: Our Africa

Health and poverty are intricately related. Evidence suggests that there is a positive correlation between health and poverty. People with limited resources in low- and middle-income countries (LMICs) are reported to have limited access to healthcare compared to their wealthier counterparts (Wagstaff, 2002). However, other evidence has shown that health expenditure can push households into poverty (Kruk et al, 2009). Tackling either is a priority for governments to improve the welfare of people. The poor are more likely to need healthcare for many reasons including a lack of safe drinking water, a balanced diet, adequate shelter, and protection against harsh environmental conditions. Because of the increased need for healthcare, the poor incur increased spending on already limited resources, and are likely to experience catastrophic expenditure. Reducing healthcare expenditure by the poor has the potential to be a viable mechanism against deepening of poverty.

Reducing extreme poverty is a major goal of the Millennium Development Goals (MDGs) and was also considered in the formulation of the post-2015 agenda. Countries all over the world are grappling with measures to reduce income inequality and poverty. In developing countries, this is more apparent through the increase of micro credit schemes, subsidies, and social safety nets for the most vulnerable. However, evidence has shown that in spite of efforts from nations and development partners, more needs to be done to eradicate extreme poverty (Laterveer et al. 2003). Poverty and access to healthcare have been subjects of research and policy. Poverty can be viewed not only as a conception of material and income deprivation (Deaton and Zaidi, 2002) but also as the lack of opportunities for an individual to lead a life he/she values (Sen, 1999). Using this concept, empowering people to live healthy lives can be seen as an initiative to overcome poverty. However, when poverty is viewed as a deprivation of income and assets, initiatives are channeled that directly improve household expenditure; when in relation to health, initiatives that lower expenditure on health to avoid catastrophic expenditure.

The World Health Organization (WHO; 2000) has advocated for health financing measures that provide financial protection from catastrophic health expenditure. Catastrophic expenditure is a leading cause of impoverishment in many countries. Efforts to prevent catastrophic expenditure oh health have been primarily through insurance. However, in many LMICs it is not effective and/or is beyond the reach of the poor either by being too costly or by not providing adequate coverage (McIntyre, 2006). Thus, the world health report (WHO, 2010) advocated for universal public finance (UPF) as a strategy to promote universal health coverage. UPF means that governments finance interventions for people regardless of who receives it and who provides it. UPF has been in practice in many high-income countries where many necessary interventions are covered. In LMICs however, UPF is limited by targeting a set of interventions tagged as the essential health package, which means many services are excluded and require user payments at the point of care.

For example, extended cost-effectiveness analysis (EECA) was used to assess the effectiveness and reduction in financial risk afforded by a public package of interventions initiated by the government of Ethiopia (Verguet et al, 2015). The interventions examined included services for vaccination, treatment of some conditions, caesarean section surgery, and tuberculosis DOTS. Their analysis focused on UPF where there is no out-of-pocket expenditure to cover costs incurred for each of the nine interventions. They estimated the annual number of deaths averted and the annual total financial protection afforded by the reduction in out-of-pocket expenditure associated with each intervention. The results for intervention costs, health gains and financial protection varied across the interventions but it was concluded that the interventions were cost-effective and prevented cases of poverty among those at lowest income level. Such evidence can be used to convince governments to increase funding of health services with the objective of improving health status of citizens and eradicating extreme poverty among the population.

References:

Deaton, A. and Zaidi S. 2002. Guidelines for Constructing Consumption Aggregates for Welfare Analysis. World Bank. https://openknowledge.worldbank.org/handle/10986/14101. 

Kruk et al. 2009. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff. 28: 1056–66.

Laterveer et al. 2003. Pro-poor health policies in poverty reduction strategies. Health Policy Plan. 2: 138–145.

Mcintyre et al. 2006. What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc. Sci. Med. 4: 858–865.

Sen, A. (1999). Development as Freedom, Oxford University Press, Oxford, 1999.

Verguet et al. (2015): Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. Lancet Glob Health 2015; 3: e288–96.

Wagstaff, A. 2002. Poverty and health sector inequalities.Bull. World Health Organ. 80: 97–105.

WHO (2000). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2000.

WHO (2010). World Health Report. Health systems: improving performance. Geneva: World Health Organization, 2010.

Examining How Women are Influenced by Inaccessibility to Clean Water

~ Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Since 1990, 2-3 billion people have gained access to improved drinking water sources, however, much is yet to be done, as billions still do not have access to safe drinking water (Dora, et al., 2015). This has led to several negative health consequences among many communities, as one-third of deaths are linked to the intake of contaminated water in low-resourced countries (West & Hirsch, 2013). Women are often responsible for housework such as cooking, cleaning and maintaining good hygiene. They are also mainly responsible for the care of children and the sick. As all of these tasks require the use of water, women in low-resourced countries are disproportionately affected by the inaccessibility to safe water.

Risks Associated with Water Collection

In 71 percent of households in sub-Saharan Africa women are responsible for collecting water (West & Hirsch, 2013).  As a result, in places such as the mountainous areas of Eastern Africa, women use up to 27 percent of their caloric intake to get water (West & Hirsch, 2013). Sometimes, they must travel a long distance, often several times in one day. This can lead to physical strain, especially among the elderly. This strain can be exacerbated by extreme heat or with heavy pumps at well sites. Water collection can also be dangerous in remote locations where there is increased risk of rape or other forms of violence.

Impacts on Women as Caretakers, and the Terminally Ill

With a high prevalence of HIV and AIDS in these regions, there has also been an increase in care needed for the terminally ill, and once again, it is the responsibility of the woman to provide the needed care (West & Hirsch, 2013). This involves emotional support, but also other aspects such as bathing and toileting. Providing this type of assistance can become more difficult when there is little accessibility to clean water. Furthermore, caregivers also have an increased chance of developing physical pain and infections because of the risks they are exposed to. Increasing accessibility to clean water will not only improve the outcomes of HIV treatment, but it will also reduce the burden of care on women. As a result, this can improve the quality of life for both groups (Figure 1).

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Figure 1: How improved water and sanitation influences the health of those with HIV/AIDS, and caretakers (West & Hirsch, 2013).

Overall, inaccessibility to clean water increases the emotional distress on women and reduces the level of care they are able to provide to those around them. When mothers have poor health status they are unable to provide the adequate resources needed for the well being of their children, which can lead to growth stunts (Requejo, et al., 2015).

Like any other public health issue, this one is complex. Many factors must be examined to determine how improvements can be made to increase the availability of safe water, while also empowering women. For example, while women have to travel long distances in order to get clean water, this also gives them a chance to socialize with other women and spend some time away from the home. Thus, what can be done to preserve this time for social interaction, while minimizing the health risks?  In order to answer this and similar questions, governments and NGOs must critically analyze social systems, specifically gender norms, health systems and physical infrastructure in low-resourced countries.

References:

Dora, C., Haines, A., Balbus, J., Fletcher, E., Adair-Rohani, H., Alabaster, G., et al. (2015). Indicators linking health and sustainability in the post-2015 development agenda. The Lancet , 385 (9965), 380-391.

Requejo, J. H., Bryce, J., Barros, J. A., Berman, P., Bhutta, P., Bhutta, Z., et al. (2015). Countdown to 2015 and beyond: Fulfilling the health agenda for women and children. The Lancet , 385 (9966), 466-476.

West, B. S., & Hirsch, J. S. (2013). HIV and H2O: Tracing the connections between gender, water and HIV. AIDS Behaviour , 17 (5), 1675-1682.  

The Role of the Built Environment in Reducing the Incidence of Type 2 Diabetes

~Written by Joann Varickanickal (Contact: joann.varickanickal@gmail.com)

Diabetes is a chronic disease that affects many people worldwide. Type 1 diabetes is an autoimmune deficiency that often develops in childhood and impacts about 10 percent of those with the disease (Canadian Diabetes Association, 2009). However, type 2 diabetes develops later in life, is influenced by environmental and lifestyle factors, and is prevalent among nearly 90 percent of those with diabetes.  While Type 2 diabetes used to be considered a “disease of the West”, it has now spread to more countries; thus, more efforts need to be made to reduce the incidence of this disease. As healthy diets and regular physical activity are key components to reducing the prevalence of type 2 diabetes, the built environment needs to be taken into consideration. The built environment includes all of the aspects of an environment created by humans, such as neighborhoods and cities, and consequently plays an important role in ensuring that people can access healthy food, and increase physical activity.

The Importance of Community Gardens

The accessibility of healthy foods can increase with the implementation of community gardens. Preliminary studies reveal several benefits of community gardens, including the associated increased intake of produce. One study examined the benefits of community gardens in South-East Toronto, concluding that those who participated in the maintenance of the garden increased their intake of vegetables and fruits and bought fewer produce from grocery stores (Wakefield, Yeudall, Taron, Reynolds, & Skinner, 2007). While these community gardens were established by non-governmental organizations, city planning officials still have a large role to play, as they could ensure that there is land in urban areas specifically designated for community gardens.   

Gardens could also be incorporated into schoolyards. One example of this was in California where the “Garden in Every School” program was implemented, and vegetables and fruits were grown on school property.  The kids helped to maintain the garden and this promoted healthy eating and an overall increase in the local food supply (San Mateo County Food System Alliance, 2010; Dannenberg, Frumkin, & Jackson, 2011).

The Role of Active Transportation

Encouraging physical activity is also a key component in reducing diabetes prevalence and this can be done through changes in the built environment by encouraging active transportaiton. This would involve increasing the walkability of communities through the implementation of pedestrian infrastructure, such as sidewalks and safe crossings, to ensure that these places are easily accessible.  

Encouraging “Smart Growth” would also be important. This concept was developed in the 1990s by initiatives that were being implemented by various organizations, including the American Planning Association (Dannenberg et al., 2011). “Smart Growth” policies encourage the preservation of open space, and making communities more walkable. This could be done through the implementation of mixed-land use development, which would ensure that employment, schools and shops were within close proximity and walking became one of the main methods of transportation.

Another key component of Smart Growth is developing a variety of transportation methods through the implementation of Transit-Oriented Development, which also became prominent in the 1990’s. This would be another way to encourage physical activity and reduce reliance on cars. Implementing bike lanes also encourages biking as a means of transportation. In Portland, Oregon there was an increase in biking after several miles of bike lanes were added, as a quadrupling in bikeway miles resulted in a quadrupling of bicycle bridge traffic (refer to Figure 1).

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Figure 1: An increase in bikeway miles in Portland, Oregon was led to an increase in bicycle traffic (Dannenberg et al., 2011).

There are other factors to consider when examining type 2 diabetes, such as biological factors among certain ethnic groups, and the difficulties associated with trying to make behavioural changes. However, by making sustainable changes to the built environment to increase accessibility to healthy foods and encourage active transportation, government officials and non-governmental organizations can begin to greatly reduce the prevalence of type 2 diabetes.  

References:

Canadian Diabetes Association. (2009). An economic tsunami of the cost of diabetes in Canada. Retrieved March 28, 2015, from http://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/economic-tsunami-cost-of-diabetes-in-canada-english.pdf 

Dannenberg, A. L., Frumkin, H., & Jackson, R. J. (2011). Making Healthy Places: Designing and Building for Health, Well-Being, and Sustainability. Washington: Island Press.

Hu, F. B. (2011). Globalization of Diabetes: The role of diet, lifestyle, and genes. Diabetes Care , 34 (6), 1249-1257.

San Mateo County Food System Alliance. (2010). A Garden in Every School. Retrieved March 25, 2015, from Ag Innovations Network: http://aginnovations.org/images/uploads/call-to-action_GBL_final.pdf 

Wakefield, S., Yeudall, F., Taron, C., Reynolds, J., & Skinner, A. (2007). Growing urban health: Community gardening in South-East Toronto. Health Promotion Internationl , 22 (2), 92-101.

Sustaining the Fight against Malaria

~ Written by Randall Kramer, PhD, M.E. (Professor of Environmental Economics and Global Health, Duke University) & Leonard Mboera, PhD, MSc (Chief Scientist, Tanzania National Institute for Medical Research)

*Also published on the Duke Global Health Institute Website 

On World Malaria Day, April 25, there’s much to celebrate and acknowledge when it comes to the fight against malaria. Over the past 15 years, we’ve seen a huge ramp-up of international funding, and the latest statistics show impressive progress—a 46% decrease in malaria infections among children in sub-Saharan Africa and an estimated 4.3 million deaths averted globally over time.

One of the most effective malaria control measures has been the free distribution of several hundred million insecticide-treated mosquito nets that protect people from mosquitoes while sleeping. In 2004, only 3% of at-risk people in sub-Saharan Africa had an insecticide-treated mosquito net available to them, compared to 49% in 2014 after an international campaign.

The U.S. government is among the major funders of malaria control, and it’s one of the few international assistance programs that has garnered bipartisan support through the Bush and Obama terms. But despite the upsurge in spending and the laudable success of these programs, malaria remains one of the leading causes of death in poorer and tropical parts of the world.

The need for continued support is critical; it’s estimated that eliminating malaria as a major global disease threat would require double the current $3 billion invested annually in malaria control. But in the face of so many other pressing needs, why should we continue to invest in malaria?

In the last year, nearly 200 million people suffered from malaria, and its death toll—more than 500,000—was 50 times greater than that of the widely publicized outbreak of Ebola in West Africa. And malaria takes a particularly devastating toll on the young. More than 80% of the deaths from malaria are in children under five, and those who manage to survive the illness often suffer lasting effects on development, school performance and lifetime earnings.

Because malaria is such a resilient killer, we can expect to see these malaria losses continue and potentially rise in the absence of continued financial support. In fact, with temperatures steadily increasing throughout the world as a result of global warming, malaria-transmitting mosquitoes have begun to take residence in new regions, raising the specter of malaria spreading far beyond its current boundaries.

In addition to the physical suffering malaria causes, the disease stunts national economic progress.

Studies by Columbia University economist Jeffrey Sachs suggest that, if not for malaria keeping children out of school and agricultural workers out of the fields, the rate of economic development in sub-Saharan Africa would have been much higher in the past few decades.

And lastly, we can’t underestimate the goodwill generated by our investments in mosquito nets and other malaria-defeating approaches in recipient countries. As one community member told our research team in rural Tanzania, “Mosquito nets have been a great help to us. The day when mosquito nets were distributed, people were very happy, because many people in our community could not afford to buy the mosquito nets.”

The malaria parasite, a resilient and opportunistic pest, has successfully co-inhabited with humans for thousands of years, and it continues to adapt and evolve, damaging populations and economies across the globe. We now have the knowledge, technology and health systems to significantly reduce its devastating human impacts. But putting these assets into action will require renewed political will and financial commitment from rich and poor countries around the globe—including the U.S.

Keeping the Spotlight on Neglected Tropical Diseases (NTDS)

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

Neglected tropical diseases (NTDs) are a group of diseases with different causative pathogens that largely affect poor and marginalized populations in low-resource settings and have profound, intergenerational effects on human health and socioeconomic development. The WHO has prioritized 17 NTDs that are endemic in 149 countries, of which some such as dengue, Chagas disease, and leishmaniasis are epidemic-prone.

NTDs can impede physical and cognitive development, prevent children from pursuing education, frequently contribute to maternal and child morbidity and mortality, and are a cause of physical disabilities and stigma that can make it difficult to earn a livelihood. Largely eliminated in developed, high-resource countries and frequently neglected in favor of better-known global public-health issues, these preventable and relatively inexpensive to treat diseases put at peril the lives of more than a billion people worldwide, including half a billion children. Several reasons have been postulated to explain the neglect of these diseases; an underestimation of their contribution to mortality due to the asymptomatism and lengthy incubation period that is characteristic of many of the diseases, a greater focus on HIV, malaria and TB because of their higher mortality, and a lack of interest in developing (non-profitable) treatments by pharmaceutical companies.

Progress has been made in recent times in combating these diseases and several international measures have been taken. Resolution WHA66.12 adopted at the sixty-sixth World Health Assembly in May 2013 highlighted strategies necessary to accelerate the work to overcome the global impact of neglected tropical diseases. Previously in January 2012 at the “London Declaration”, representatives of governments, pharmaceutical companies and donor organizations convened to make commitments to control or eliminate at least 10 of these diseases by 2020. They proposed a public-private collaboration to ensure the supply of necessary drugs, improve drug access, advance R&D, provide endemic countries with funding and to continue identifying remaining gaps.

So far, the coalition has made progress with delivering on their promises:

Pharmaceutical Companies - In 2013, drug companies met 100% of drug requests, donating more than 1billion treatments. On the R&D front, clinical trials for some NTDs have been started. In addition, several drug companies have enabled access to their compound libraries.

Governments - Compared to 37 in 2011, 55 countries requested drug donations at the end of 2012. Also, over 70 countries have developed national NTD plans. Within a year of the Declaration, Oman went from endemic trachoma to elimination and by 2014, Colombia eliminated onchocerciasis.

Donors - NTDs have become more visible on the development and aid agenda, especially with the £245 million earmarked in 2012 by DFID for NTD programs. Other donors have since followed suit.

However, despite these strides, challenges remain as treatments are not reaching everyone in need. Although 700 million people received mass drug administration (MDA) for one or more NTDs in 2012, only 36% of people in need worldwide received all the drugs they needed. There’s also the anticipated challenge of environmental and climate change on NTDs; with dengue being identified as a disease of the future due to increased urbanization and changes in temperature, rainfall and humidity.

The spotlight needs to remain on NTDs and their contributions to ill-health and poverty for efforts to be sustained. 

To sustain these efforts, greater advocacy has to be made for integrating NTD control into other community and even national level programming, without losing them in the crowd. Some anthelminthic drugs for preventive chemotherapy are on the WHO Model List of Essential Medicines and their distribution has been effective and economical. However, to succeed at NTD elimination, we have to look beyond mass drug administration to the removal of the primary risk factors for NTDs (poverty and exposure) by ensuring access to clean water and basic sanitation, improving vector control, integrating NTDs into poverty reduction schemes and vice versa, and building stronger, equitable health systems in endemic areas. There needs to be a consensus as to how to ensure this. At present, it seems there is a gap between elimination objectives and how to incorporate them into other health and development initiatives such as water and sanitation, nutrition and education programs. It has long been established that helminth parasite infection contributes to anemia and malnutrition in children. The presence of other protozoan, bacterial and viral diseases also contribute to school absenteeism. Guinea worm disease (dracunculiasis) can be recurrent when there is no access to safe drinking water.

There is also a need to maintain a surveillance and information system for NTDs in light of increasing migration and displacements. Another way to ensure that the spotlight is kept on NTDs is research that provides evidence of interactions and co-infections with other diseases. For example, epidemiological studies from sub-Saharan Africa have shown that genital infection with Schistosoma haematobium may increase the risk for HIV infection in young women (Mbah et al, 2013). Understanding that neglected diseases can make the “big three” diseases (malaria, HIV and tuberculosis) more deadly and can undermine the gains that have been made in health, nutrition and education is important (Hotez et al, 2006).

Erroneous overstating of the progress made in controlling and eliminating NTDs can have a detrimental effect on funding and public perceptions of their importance. Thus, there is a need for increased synergy between stakeholders. Achievements in polio eradication do not equal achievements in human African trypanosomiasis eradication. While some NTDs can be managed with specific drugs, some such as dengue do not have a specific drug. Therefore, while keeping the spotlight on NTDs collectively, it is important to emphasize their diversity and to also keep in mind the subgroup of NTDs categorized as emerging or reemerging infectious diseases, which are deemed a serious threat and have not been adequately examined in terms of their unique risk characteristics (Mockey et al, 2014).

Lastly, it is important to keep the heat on NTDs in the UN’s post-2015 sustainable development agenda by advocating that proposed goals support efforts to monitor, control and eliminate NTDs. As highlighted by the Ebola crisis, strengthening health systems is paramount. Nevertheless, the future looks optimistic regarding NTDs. Encouraging is the inclusion of neglected and poverty-related diseases on the agenda of the 2015 G7 Summit, which will be held in Germany in June.

References:

World Health Organization. Neglected tropical diseases: becoming less neglected [editorial]. The Lancet. 2014; 383: 1269

Holmes, Peter. "Neglected tropical diseases in the post-2015 health agenda." The Lancet 383.9931 (2014): 1803.

Feasey, Nick, et al. "Neglected tropical diseases." British medical bulletin 93.1 (2010): 179-200.

World Health Organization. Neglected tropical diseases. http://www.who.int/neglected_diseases/diseases/en/                              

Fenwick, Alan OBE. “The Politics of Expanding Control of NTDs.”  A Global Village Issue 7. http://www.aglobalvillage.org/journal/issue7/globalhealth/ntds/

Mbah, Martial L. Ndeffo, et al. "Cost-effectiveness of a community-based intervention for reducing the transmission of Schistosoma haematobium and HIV in Africa." Proceedings of the National Academy of Sciences 110.19 (2013): 7952-7957.

Hotez, Peter J., et al. "Incorporating a rapid-impact package for neglected tropical diseases with programs for HIV/AIDS, tuberculosis, and malaria." PLoS medicine 3.5 (2006): e102.

Mackey, Tim K., et al. "Emerging and Reemerging Neglected Tropical Diseases: a Review of Key Characteristics, Risk Factors, and the Policy and Innovation Environment." Clinical microbiology reviews 27.4 (2014): 949-979.

G7 Summit Agenda. http://www.g7germany.de/Webs/G7/EN/G7-Gipfel_en/Agenda_en/agenda_node.html

World Health Organization. Investing to overcome the global impact of neglected tropical diseases: third WHO report on neglected diseases 2015. 

Managing the Global Burden of Chronic Illnesses

-Written by Mike Emmerich, Specialist Emergency Med & ERT Africa consultant (contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich_

An article on an EMS blog caught my eye in the past week:

"COPD was the third-leading cause of death in the U.S. in 2011 and is expected to become the third-leading cause of death worldwide by 2020." (Source: Hoyert DL, Xu JQ. Deaths: preliminary data for 2011. Natl Vital Stat Rep, 2012; 61(6): 1–65. Lopez AD, Shibuya K. Chronic obstructive pulmonary disease: current burden and future projections. Eur Respir J, 2006; 27(2): 397)

This caused me to dig up a presentation I did in 2006 at a Fitness Seminar, wherein I was discussing chronic medical conditions, which are caused by poor lifestyle choices and I noted then:

" In 1999 CVD contributed to a third of global deaths. " In 1999, low and middle income countries contributed to 78% of CVD deaths. " By 2010 CVD is estimated to be the leading cause of death in developing countries. " Heart disease has no geographic, gender or socio-economic boundaries.

I further stated: Chronic illness have overtaken communicable disease as a major cause of death and disability worldwide. Chronic diseases, including such noncommunicable conditions as cardiovascular disease, cancer, diabetes and respiratory disease, are now the major cause of death and disability, not only in developed countries, but also worldwide. The greatest total numbers of chronic disease deaths and illnesses now occur in developing countries.

I then dug deeper to see how this has changed since 2006, and the outlook has become even more bleak!

More than 75% of all deaths worldwide are due to noncommunicable diseases (NCDs). NCD deaths worldwide now exceed all communicable, maternal and perinatal nutrition-related deaths combined and represent an emerging global health threat. Every year, NCDs kill 9 million people under 60 years of age. The socio-economic impact is staggering. These NCD-related deaths are caused by chronic diseases, injuries, and environmental health factors. Important risk factors for chronic diseases include tobacco, excessive use of alcohol, an unhealthy diet, physical inactivity, and high blood pressure.

The world now suffers from a global epidemic of poor lifestyle choices! Medically we call them chronic illnesses or NCD's, but the issue at hand is that they can be avoided, reversed and prevented; with smarter lifestyle choices. The why and the how of these lifestyle choices is a debate for another blog, but poor socioeconomic conditions, poverty, malnourishment and diets deficient in basic nutritional building blocks all form part of this dynamic.

These poor lifestyle choices and the death, illness, and disability they cause will soon dominate health care costs and should be causing public health officials, governments and multinational institutions to rethink how they approach this growing global challenge. To exacerbate the matter; the deaths, illnesses and disability are spiralling at even faster rates in the developing world, where the infrastructure is even weaker than in the developed world.

It is estimated that by 2020 the number of people who die from ischemic heart disease will increase by approximately 50% in countries with established market economies and formerly socialist economies, and by over 100% in low- and middle-income countries. Similar increases will also be found in cerebrovascular disease (Stroke) by 2020!

This is indeed a frightening prospect; NCDs are expected to account for 7 of every 10 deaths in the world! The overextended healthcare systems in Africa and Asia will battle to cope with these spiralling patient numbers.

A (positive) point to ponder as we consider this bleak outlook; the principal known causes of premature death from NCDs are tobacco use, poor diet, physical inactivity, and harmful alcohol consumption – all of these are preventable and manageable; as they relate to personal choices. Therefore we need to focus on creating a environment where these same individuals can make the correct choices which will have a positive impact on their lives. This is where governments, aid agencies and multi-nationals should focus their energies, and the approach should be more carrot than stick, which is not the case at present.

References:

http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng.pdf

Health Issues on the African Horizon for 2015

~ Written by Mike Emmerich - Specialist Emergency Med & ERT Africa consultant (Contact: mike@nexusmedical.co.za)

https://twitter.com/MikeEmmerich 

As 2014 draws to a close and we review what has happened over this past year, we also look forward to 2015 and all of it challenges. Numerous organisations and commentators have written of the challenges that lie over the horizon for 2015, as regards Global Health. From my own experience of working on the continent I have identified the following challenges for 2015 for Africa.

Some of the issues/challenges overlap and/or influence one another. They do not stand alone, the one can exacerbate the other.

Water

Water, on its own, is unlikely to bring down governments, but shortages could threaten food production and energy supply and put additional stress on governments struggling with poverty and social tensions. Water plays a crucial role in accomplishing the continent's development goals, a large number of countries on the continent still face huge challenges in attempting to achieve the United Nations water-related Millennium Development Goals (MDG)

Africa faces endemic poverty, food insecurity and pervasive underdevelopment, with almost all countries lacking the human, economic and institutional capacities to effectively develop and manage their water resources sustainably. North Africa has 92% coverageand is on track to meet its 94% target before 2015. However, Sub-Saharan Africa experiences a contrasting case with 40% of the 783 million people without access to an improved source of drinking water. This is a serious concern because of the associated massive health burden as many people who lack basic sanitation engage in unsanitary activities like open defecation, solid waste disposal and wastewater disposal. The practice of open defecation is the primary cause of faecal oral transmission of disease with children being the most vulnerable. Hence as I have previously written, this poor sanitisation causes numerous water borne disease and causes diarrhoea leading to dehydration, which is still a major cause of death in children in Sub-Saharan Africa.

“Africa is the fastest urbanizing continent on the planet and the demand for water and sanitation is outstripping supply in cities” Joan Clos, Executive Director of UN-HABITAT

Health Care Workers

Africa has faced the emergence of new pandemics and resurgence of old diseases. While Africa has 10% of the world population, it bears 25% of the global disease burden and has only 3% of the global health work force. Of the four million estimated global shortage of health workers one million are immediately required in Africa.

Community Health Workers (CHWs) deliver life-saving health care services where it’s needed most, in poor rural communities. Across the central belt of sub-Saharan Africa, 10 to 20 percent of children die before the age of 5. Maternal death rates are high. Many people suffer unnecessarily from preventable and treatable diseases, from malaria and diarrhoea to TB and HIV/AIDS. Many of the people have little or no access to the most fundamental aspects of primary healthcare. Many countries are struggling to make progress toward the health related MDGs partly because so many people are poor and live in rural areas beyond the reach of primary health care and even CHW's.

These workers are most effective when supported by a clinically skilled health workforce, and deployed within the context of an appropriately financed primary health care system. With this statement we can already see where the problems lie; as there is a huge lack of skilled medical workers and the necessary infrastructure, which is further compounded by lack of government spending. Furthermore in some regions of the continent CHW's numbers have been reduced as a result of war, poor political will and Ebola.

Ebola

The Ebola crisis, which claimed its first victim in Guinea just over a year ago, is likely to last until the end of 2015, according to the WHO and Peter Piot, a scientist who helped to discover the virus in 1976. The virus is still spreading in Sierra Leone, especially in the north and west.

The economies of West Africa have been severely damaged: people have lost their jobs as a result of Ebola, children have been unable to attend school, there are widespread food shortages, which will be further compounded by the inability to plant crops. The outbreak has done untold damage to health systems in Guinea, Liberia and Sierra Leone. Hundreds of doctors and nurses and CHW's have died on the front line, and these were countries that could ill afford to lose medical staff; they were severely under staffed to begin with.

Read Laurie Garrett's latest article: http://foreignpolicy.com/2014/12/24/pushing-ebola-to-the-brink-of-gone-in-liberia-ellen-johnson-sirleaf/

The outcome is bleak, growing political instability could cause a resurgence in Ebola, and the current government could also be weakened by how it is attempting to manage the outbreak.

Political Instability

Countries that are politically unstable, will experience problems with raising investment capital, donor organisations also battle to get a foothold in these countries. This will affect their GDP and economic growth, which will filter down to government spending where it is needed most, e.g.: with respect to CHW's.

Political instability on the continent has also lead to regional conflicts, which will have a negative impact on the incomes of a broad range of households,and led to large declines in expenditures and in consumption of necessary items, notably food. Which in turn leads to malnutrition, poor childhood development and a host of additional health and welfare related issues. Never mind the glaringly obvious problems such as, refugees, death of bread winners etc...

Studies on political instability have found that incomplete democratization, low openness to international trade, and infant mortality are the three strongest predictors of political instability. A question to then consider is how are these three predictors related to each other? And also why, or does the spread of infectious disease lead to political instability?

Poverty

Poverty and poor health worldwide are inextricably linked. The causes of poor health for millions globally is rooted in political, social and economic injustices. Poverty is both a cause and a consequence of poor health. Poverty increases the chances of poor health, which in turn traps communities in poverty. Mechanisms that do not allow poor people to climb out of poverty, notably; the population explosion, malnutrition, disease, and the state of education in developing countries and its inability to reduce poverty or to abet development thereof. These are then further compounded by corruption, the international economy, the influence of wealth in politics, and the causes of political instability and the emergence of dictators.

The new poverty line is defined as living on the equivalent of $1.25 a day. With that measure based on latest data available (2005), 1.4 billion people live on or below that line. Furthermore, almost half the world, over three billion people, live on less than $2.50 a day and at least 80% of humanity lives on less than $10 a day.

Values and Global Health Governance: Lessons from the Ebola 2014 Outbreak

~Written by J. La Juanie Hamilton, PhD Candidate (Contact: lajuaniehamilton@gmail.com)

Twitter: @jasminogen

Values are critical in shaping the global health (GH) dialogue and landscape. Values and the actions that arise from them (virtues) underlie the policies that ensure universal access to necessary health services, adequate responses to health emergencies and resource allocation. Similarly, the values of health governing bodies can create chasms between people and their health necessities. This truth has been unfolding poignantly on an international level during the handling of the Ebola virus disease (EVD) outbreak in West Africa. 
 

What values did the actions or inaction of the international GH community endorse in handling the current EVD outbreak? Although the uniqueness of the outbreak in terms of location and challenges in diagnosis should be considered, many experts agree that the greatest force contributing to the rapid spread of EVD was inaction (1-4). In June 2014, signs that EVD was spiraling out of control throughout Guinea were flashing brightly but the response from the international community remained slow. The exception was Doctors without Borders (MSF), whose staff was already on the ground, helped to diagnose the first case and pleaded for a more robust response from international health governing bodies (3). 
 

Criticisms of health regulatory bodies grew stronger when EVD entered rich countries, which appeared to produce a marked increase in global support efforts. It is hard to say unequivocally, whether this heightened interest and commitment was inevitable or whether the cases in the US and Europe were the impetus. But it is fair to say that many mistakes were made in terms of prioritizing EVD eradication and surveillance. It may also be accurate to say that major economies responded when EVD was perceived as an immediate threat to their economy. This, I believe, is inevitable in a GH system that is built upon a market-driven approach.
 

Can a GH agenda that is framed around economics prioritize the eradication of emerging diseases and neglected diseases of poverty? Although there are compelling arguments for why high-income countries should help to combat EVD and similar diseases, it is unlikely that great achievements will be made without a values shift (5). 
 

A market driven approach inherently prioritizes the need of a few versus the need of many. This model enables the interests of major economies to outweigh the greater good of the whole, if left unchecked. The most important consequence of this approach is that it undermines international health regulatory bodies, whose actions and budgets are heavily influenced by larger economies. This is a problem which, when combined with poor health systems, harmful microbes and permeable borders will inevitably lead to threats in local communities and global security. More importantly, with the movement of people forming a major characteristic of this era, the market driven approach is an unsustainable value upon which to build GH interventions. 
 

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There are many points worth considering (schematic above). Major questions moving forward should consider creating a GH model that is more oriented toward equity, security and creativity. Resolutions that create a space in which poor nation states help to set the GH agenda without being threatened by the loss of aid from larger economies must be discussed. Additionally, addressing ways in which the GH dialogue can be re-framed to include stakeholders that currently operate based on virtues stated above should be considered. For example, is there a way to ensure a more official decision-making role for organizations like MSF?

What is next for GH governance and what will the values shift towards? EVD 2014 is a strong indicator of the limits of theoretical values, political indifference and passivity in achieving health and well-being for all. But the stories emerging from West Africa provide an opportunity for EVD 2014 to serve as a “meaning making” event in GH. It provides an impetus for changing priorities from passive verbiage of values of human dignity to a model of creativity, equity and accountability which proactively contextualizes GH policies, innovation and interventions. 

References
1. Gostin LO and Friedman EA 2014 Ebola: a crisis in global health leadership. The Lancet, 384; 1323-1324. 
2. Cohen J 2014.Ebola vaccine: Little and late. Science, 345 (6203): 1441-1442. 
3. Ebola: Massive Deployment Needed to Fight Epidemic in West Africa: http://www.doctorswithoutborders.org/news-stories/press-release/ebola-massive-deployment-needed-fight-epidemic-west-africa
4. Farrar JJ and Piot P 2014. The Ebola Emergency-Immediate Action, Ongoing Strategy N. Engl J Med 371(16):1545-1546.
5. Rid, A., & Emanuel, E. J. (2014). Why Should High-Income Countries Help Combat Ebola? JAMA, 312(13), 1297-1298.

A Comprehensive Approach to HIV and Hepatitis C Interventions

~Written by Kathleen Lee, MPH Epidemiology, Vanderbilt University Medical Center (Contact: kathleen.g.lee@vanderbilt.edu)

One of the primary goals of public health, epidemiology, in particular, is estimating and examining the burden of disease. The burden in a population, however, is usually not just attributable to one illness or one causative agent. Many disease states carry with them the high likelihood of co-infections or opportunistic infections. Human immunodeficiency virus (HIV) and Hepatitis C (HCV) share at least one common route of transmission and often co-infect individuals. There are an estimated 40 million people worldwide who are infected with HIV and about 60-180 million globally are infected with HCV.1 Understanding the disease process as a whole means taking into consideration not only biological aspects of co-infection, but how this co-infection is propagated, or even mitigated, by patients’ behavior as well as their access to care. An all-inclusive and early detection approach to HIV-HCV treatment can help reduce the burden of disease in the affected population, and can help decrease transmission.

Effective interventions should focus on prevention, or at least early detection and treatment. This is not only good for the patient, but also for the health system. Between 2010 and 2019 it was estimated that HCV expenditures would be $10.7 billion.2 As disease progresses, costs increase (more medications, hospitalizations, etc.). Treatment should not only concentrate on drug therapy, but also address risk behaviors. Interventions, such as needle and syringe exchange programs (NSP) and opiate replacement therapy (ORT) are just some options that public health officials can use (and have used effectively) to curb HCV and HIV transmission in the community. Counseling is not a tool that should be overlooked as many of the co-infected population are affected with mental illness, a known risk factor for HIV acquisition. 

Both diseases separately represent a serious health concern, especially among injection drug using populations, but HIV-HCV co-infection introduces additional complications in treatment and disease progression of both conditions. Early interventions, especially during the acute phases of both diseases, can lead to better patient outcomes. Early treatment in co-infected individuals who have not yet been on antiretroviral therapy (ART) do better than those on existing ART regimens. The latter should be considered for treatment regimen changes to ensure minimal side effects and maximum adherence. Alcohol use in both HIV and HCV populations is a contributing factor to liver-related morbidity.3 Inclusion of alcohol and drug rehabilitation programs with drug therapy could decrease liver-related morbidity among co-infected patients. This is incredibly important because liver disease is the leading cause of mortality among co-infected individuals. 

Comprehensive interventions are useless if they cannot reach the population. Much has to be done to ensure that the delivery of these interventions captures as wide of an audience as possible. This includes having a well-trained staff of health workers and specialists who are able to support and motivate patients, convenient locations and times that are easily accessible for patients, and pricing should be affordable, if free is not an option.3 Many of the individuals taking advantage of such programs are often low-income, marginalized, and stigmatized by society. Giving these individuals the ability to take control of their condition and be aware of the risk behaviors and prevention strategies available for them could allow for better adherence to treatment, and consequently, better medical outcomes. Much like any other infectious disease that disproportionately affects low-income and vulnerable populations, the distribution and availability of resources are of utmost importance.

All of the above would be futile if there are no set standards to test and screen individuals who are most in need of these treatments. The lack of consensus among public health officials and the government regarding standardized screening among high-risk populations may contribute to the ongoing transmission of HIV and HCV, as well as co-infection. Ensuring sustainability of screening and treatment programs requires engagement and cooperation at all levels, from the patient to the care provider, to the community, to researchers, and even outward to national and international governing bodies.

1. Alter MJ. Epidemiology of viral hepatitis and HIV co-infection. J Hepatol. 2006;44, Supplement 1(0): S6-S9.

2. Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating future hepatitis C morbidity, mortality, and costs in the United States. Am J Public Health. 2000;90(10): 1562-

3. Viral Hepatitis: Hepatitis C Treatment. US Department of Veterans Affairs.  http://www.hepatitis.va.gov/provider/reviews/HCV-treatments.asp. Page updated December 9, 2013. Accessed October 21, 2014.

The Politics of Health Promotion

~Written by Karen Hicks, Senior Health Promotion Strategist (Contact: karen@hauora.co.nz)

As an individual with over twenty years’ experience in the health sector in clinical, managerial and health promotion roles, I am passionate about the role of health promotion as an approach to reduce health inequities.

In addressing health inequities, health promotion is very political, as people’s health is influenced by the resources and opportunities available to them.  As health promoters we need to question who is responsible for such resource allocation, how are allocation decisions made, and who has the power to allocate these resources?

As health promoters we witness how the approach of health promotion is increasingly affected by neoliberalism, where neoliberal governments promote minimal government interaction with a person’s freedom to choose.  The result is that some communities experience victim blaming when ‘choosing’ unhealthy health behaviours and the government’s health outcome graphs don’t improve. Such communities are identified as failing and accountable for their ill health and poor lifestyle choices.  

Effective health promotion places people and communities at the centre, working with communities to find their own solutions in influencing the determinants of their health and wellbeing. As health promoters we have declarations and reports such as the Ottawa Charter for Health Promotion and the WHO Commission on Social Determinants of Health that identify best practice health promotion.

The WHO “Closing the gap in a generation, health equity through action on the social determinants of health” report clearly identifies that:

"..inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces."

So while we know that empowering communities and addressing the social determinants of health is the best health promotion approach, why do governments continue to provide contracts that focus on individual behaviour change? 

• Offering contracts with behavior related outcomes are easy to measure e.g. how many individuals attended the health day, how many individuals have lost weight or become smoke-free. While these outcomes are laudable we know that such health outcomes and behaviour change are often unsustainable if a person’s environmental, socioeconomic and cultural settings also do not change. 
• Short term contracts focusing on behaviour change also fit neatly into electoral terms so governments have something to report against in the hope of being re- elected for such commendable work.
• Committing to long term planned outcomes in partnership with the community to address the social determinants of health takes time and does not generate the same media coverage as purchasing hospital beds or employing doctors.
• Focusing on personal responsibility also means that governments can continue their relationships with large multinational companies such as the food industry, relationships that could be put under strain if healthy eating legislation was put in place.

What can we do?

• As health promoters wishing to address health inequities and improve the health and wellbeing of our communities we must communicate that health inequity is a moral and justice issue, and the role of governments in addressing these.
• We need to communicate with and involve our communities in addressing the social determinants of health that continue to influence their health and well-being.
• We need to strengthen the capacity of the health promotion workforce ensuring they understand their vital role in improving health locally, regionally and globally.

As health promoters we have a role in providing evidence on best health promotion practice to strengthen the value of health promotion in the wider public health field and to clarity its role and ability to respond to global health challenges.