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.

Battling Cancer across Different Income Settings

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

David Bowie, Alan Rickman and Rene Angelil, are a few of the well-known people that the world lost to cancer in the year 2015. My familiarity with cancer comes not just from losing my favourite celebrities to cancer, or dealing with patients in a tertiary care hospital in Lahore, but also from losing a few people very dear to me in my family. Every case of cancer is a battle for the person, their families, friends and doctors, as well as the healthcare system.

Cancer forms a major proportion of non-communicable diseases today. There were an estimated 14.1 million new diagnosed cases of cancer with an estimated 8.2 million deaths in 2012 (1). The most common sites of cancer have been recognized to be lung, colon, breast, liver, stomach and the cervix while the majority of cancer-related deaths are due to lung, stomach and esophageal cancer (2). Previously, cancer remained a low priority for low income (LICs) and low middle income countries (LMICs), as well as for donors (3). In 2008 72% of deaths due to cancer occurred in LICs and LMICs (4).  This may be a consequence of not only longer life spans and the majority of the world’s population being in the LIC and LMIC countries but also a lack of accessible and affordable treatment in these parts of the world.

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Estimated global numbers of new cases and deaths with proportaions by major world  regions, for all malignant cancers (excluding non-melanoma skin cancer) in both sexes combined, 2012. Source: The Cancer Atlas

While higher income countries have progressed from chemotherapy and radiotherapy to gene therapy, LMICs continue to focus on finding ways for uneducated or less educated to identify cancerous conditions in order to seek medical help before it is too late, for instance promoting breast self-examination. The increasing prevalence of cancer in LMICs exasperates the health sector with an already increasing burden of infectious diseases like tuberculosis, malaria and diarrhea. In these contexts cancer contributes to altering the epidemiology of these countries adding to the burden of non-communicable diseases which in turn worsens the double burden of disease. This creates considerable strain on the healthcare system due to increasing needs of diagnostic and treatment modalities besides the already unmet needs concerning infectious diseases.

There is an immense need for healthcare systems in resource poor settings to focus more on prevention rather than cure. Health professionals working in LMICs need to place greater emphasis on informing and educating people about warning signs of cancer as many resource poor settings have technology constraints and limited means of gaining health information. There are no quick fixes and circumstances are never as simple as they seem. Campaigns against smoking to prevent lung cancer have been addressed by discussions advocating for the rights of the poor who own tobacco farms as their only source of income (5). Modification of social behaviours for instance, requires extensive out-reach programmes by medical professionals but also bring into question the financial constraints of the country in order to pay for the services of these local healthcare workers.

In summary, LICs and LMICs have a longer way to go to provide sufficient healthcare for cancer patients. While high income countries are more likely to make medical advances for cancer treatment, resource poor countries can make strides through preventive measures like vaccination, behaviour modification and self-examination.

References :

1. Cancer. WHO Media Centre. World Health Organization; 2016 [cited 2016 Feb 14]. Available from: http://www.who.int/mediacentre/factsheets/fs297/en
2. World Cancer Report published by the International Agency for Cancer Research, WHO
3. Scaling up cancer diagnosis and treatment in developing countries: what can we learn from the HIV/AIDS epidemic? Can Treat International. Ann Oncol [Internet]. 2010;21(4):680–2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20338877
4. Cancer in Developing Countries International Network for Cancer Treatment and Research. INCTR. 2016 [cited 2016 Feb 14]. Available from: http://www.inctr.org/about-inctr/cancer-in-developing-countries/
5. Tobacco Company Strategies to Undermine Tobacco Control Activities at the World Health Organization. Committee of Experts on Tobacco Industry Documents. World Health Organization. 2000.
   
6. International Women ’ s Day 2014 : women ’ s health equity is progress for all. Ginsburg O. 2014.

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

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

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.

Common Cause: Linking Menstrual Hygiene Management and Long-acting Contraception to Improve Youth Reproductive Health

~ Written by Rebecca Callahan, Scientist, Kate Rademacher, Technical Advisor, & Lucy Wilson, Monitoring and Evaluation Advisor, FHI 360

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What do family planning and menstrual hygiene management (MHM) have in common? Beyond a shared purpose to improve the health and well-being of women and girls, some family planning methods can actually improve menstrual hygiene. Menstrual Hygiene Day on May 28 offers an opportunity to explore synergies between the two fields.

In recent years, the MHM movement has focused on the critical role that good menstrual hygiene management plays in enabling women and girls to achieve their full potential. Reducing the stigma associated with menstruation and ensuring that adolescent girls and women are able to safely manage their menses can eliminate some of the barriers that prevent girls and women in many countries from participating in day-to-day activities, such as attending school.

At the same time, the effort to increase access to long-acting reversible contraceptives (LARCs) for adolescents and young women has gained momentum. The LARCs for youth movement aims to expand reproductive choice and reduce unintended pregnancy. Around the world, the use of LARC methods, including intrauterine devices (IUDs) and contraceptive implants, has increased in recent years. The American College of Obstetrics and Gynecology and the American Academy of Pediatrics now recommend their use among teens.

Thus far, the complementarity of the MHM and LARCs for youth campaigns has gone unexplored.

Some LARC methods, such as the levonorgestrel-releasing intrauterine system (LNG-IUS), which is effective for up to five years, as well as shorter-acting methods, such as the three-month injectable depot-medroxyprogesterone acetate (DMPA), substantially reduce menstrual bleeding and often lead to complete cessation of menstruation, a condition known as amenorrhea.

Some women have viewed the menstrual changes associated with contraceptive use, especially increased or irregular bleeding, as a negative or undesirable side effect. However, recent evidence suggests that decreased bleeding, and amenorrhea in particular, is acceptable to women and is even considered an important side benefit.1,2 Surveys have shown that teens and young women are especially interested in limiting or controlling the timing of menstruation through the use of hormonal contraceptives.3,4

For young women in developing countries, where access to menstrual hygiene supplies and safe places to manage their menses are sometimes limited, the advantage of contraceptive-induced menstrual control could be especially important.

Youth-focused family planning initiatives are critical and could create a bridge between the MHM and family planning fields. Such linkages could focus on helping young women who are ready to use contraception learn how different family planning methods may affect their menstruation. In particular, the increasing popularity and availability of the LNG-IUS presents an opportunity both to promote highly effective, long-acting contraception and to reduce the burden of menstruation among youth.

An example of the acceptability of the LNG-IUS among teens in the United States comes from the ongoing Contraceptive CHOICE project, in which nearly one-third of women ages 15–19 enrolled in the study chose the device when offered free access to seven different long- and short-acting methods.5 After one year of use, more than 80 percent were still using this method.6

Although data from developing countries are limited, evidence from Kenya suggests a latent demand for LNG-IUS in low-resource settings when it is made available.7,8

The recent addition of LNG-IUS to the World Health Organization’s Essential Medicines List and the approval of Medicines360’s new, more affordable LNG-IUS, LILETTA™, by the U.S. Food and Drug Administration, are good signs that this method will soon be more accessible to young girls and women in low- and middle-income countries. An ongoing collaboration between FHI 360, Marie Stopes International and Medicines360 to support introduction of Medicines360’s LNG-IUS in Kenya is an important first step in this effort.

Menstrual Hygiene Day calls attention to the importance of equipping girls and young women with the tools and knowledge they need to safely manage their menses. Expanding access to LARC methods for youth offers both the potential to improve reproductive health by reducing unintended pregnancy and an innovative strategy for addressing menstrual hygiene needs. We are optimistic that forging connections between the MHM and family planning fields will lead to improved outcomes for women and girls around the world.

References:

1. Baldaszti E, Wimmer-Puchinger B, Löschke K. Acceptability of the long-term contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year follow-up study. Contraception. 2003;67(2):87-91.

2. Backman T, Huhtala S, Blom T, Luoto R, Rauramo I, Koskenvuo M. Length of use and symptoms associated with premature removal of the levonorgestrel intrauterine system: a nation-wide study of 17,360 users. Br J Obstet Gynaecol. 2000;107(3):335-9.

3. Szarweski A, von Stenglin A, Rybowski S. Women’s attitudes towards monthly bleeding: results of a global population-based survey. Eur J Contracept Reprod Health Care. 2012;17:270-83.

4. Association of Reproductive Health Professionals (ARHP). Menstruation and menstrual suppression survey, 2005. Available from: http://www.arhp.org/Publications-and-Resources/Studies-and-Surveys/Menstruation-and-Menstrual-Suppression-Survey/Full-Report. Accessed 11 May 2015.

5. Secura GM, Madden T, McNicholas C, Mullersman J, Bucket CM, Zhao Q, Peipert JF. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371(14):1316-23.

6. Rosenstock JR, Peipert JF, Madden T, Zhao Q, Secura GM. Continuation of reversible contraception in teenagers and young women. Obstet Gynecol. 2012;120(6):1298-305.

7. Hubacher D, Masaba R, Manduku CK, Chen M, Veena V. The levonorgestrel intrauterine system: cohort study to assess satisfaction in a postpartum population in Kenya. Contraception. 2015;91(4):295-300.

8. Hubacher D, Masaba R, Manduku CK, Veena V. Uptake of the levonorgestrel intrauterine system among recent postpartum women in Kenya: factors associated with decision-making. Contraception. 2013;88(1):97-102.

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.  

Motor Vehicle Accidents - A Growing Public Health Burden

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

https://twitter.com/MikeEmmerich

“Road Traffic Crashes do not just happen! They are caused by Fatal Moves (actions) by a driver. The message is simple - DON'T DO FATAL MOVES!”@FatalMoves https://twitter.com/FatalMoves* 1990 to 2010: Deaths from road traffic injuries increased by almost half.*

The largest category of fatal events are transport related. In 1990, according to Global Burden figures, these were the 10^th leading global killer. By 2013, they were fifth! Ahead of malaria, diabetes, chronic obstructive pulmonary disease, cirrhosis or any kind of cancer. In part, this is because of progress against these diseases. But it also because as incomes have risen worldwide, more people are buying, and crashing, motorbikes and cars.

Most global road traffic deaths occur in low and middle-income countries and are rapidly increasing because of the growth in motorisation. Mortality rates caused by traffic related injuries are increasing in low and middle-income countries and they account for 48 percent of the world’s vehicles but more than 90 percent of the world’s road traffic fatalities. Pedestrians are most often affected, followed by car occupants and motorcyclists. Alcohol plays a key factor in the drivers and pedestrians, notably in South Africa, where as many as 65% of all pedestrians have increased blood alcohol levels. Conversely, traffic deaths are decreasing in high-income countries, Sweden is an excellent case study that we will review further on in this article.

10 countries are responsible for 600,000 road traffic deaths annually (see this link to see if your country is on the list). Each year, 1.3 million people die in car accidents, so these 10 countries are responsible for nearly half of all road deaths! India tops the list for the highest overall number of road deaths, followed by China and the U.S. If public health leaders are to catch up on accident prevention, the Global Burden of Disease study (Lancet links below) findings can help them see where and how. “Now that somebody’s done the work and we recognize that there’s a difference we may not have seen before, we can go to work and ask why,” said Dr. Schauben

Besides the rapidly rising fatalities we must also take cognisance of the rising number of injured persons and their cost on the (Global) health burden. Road-traffic crashes were the number one killer of young people and accounted for nearly a third of the world injury burden, a total of 76 million DALYs (Disability Adjusted Life Years) in 2010, up from 57 million in 1990. Most of the victims were young, and many had families that depended on them, who know have to rely on other sources of support, in most instances, the state.

What does the current research then tell us about this rapidly rising burden on global public health; transport injury prevention shows that collective action is as important as individual efforts. Motorcycle helmets, car seatbelts and sober drivers are important, but so are safe vehicles, consistent law enforcement and a reliable infrastructure. Thanks to a combination of insufficient, nonexistent or poorly enforced safety laws, poor infrastructure and a lack of enforcement and corrupt enforcers, the bulk of the countries globally keep aiding and abetting in the deaths of over 1.3 million persons annually! Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all five risk factors (speed, drunk driving, helmets, seat-belts and child restraints). Over a third of road traffic deaths in low and middle-income countries are among pedestrians and cyclists. However, less than 35% of these countries have policies in place to protect their road users.

India has the dubious distinction of registering the highest number of road fatalities in the world (250,000), despite the fact that its population is much smaller than neighboring China and there are more vehicles on the roads in the USA than in India. "A large proportion of these deaths can be prevented by simple measures. The most important of these is strict enforcement of traffic rules, which is conspicuous by its absence in our cities as well as on highways," says the Times of India, and this would be true of the top 10, and also of the country where I reside, South Africa, where 47 persons die each day!

Further compounding the cost of the traffic fatalities is the actual real cost impacting on the affected countries economies; many who cannot afford to have the extra burden on their already strained public health budgets. The economic cost of road collisions to low and middle income countries is at least $100 billion a year! The risk of dying as a result of a road traffic injury is highest in the African Region (24.1 per 100 000 population) It's such a big problem, in fact, that the U.N. feels it needs an entire decade to fix it. In 2011, the U.N. launched a "Decade of Action" that aims to “stabilize and then reduce” global road traffic fatalities by 2020.

Is there any good news? Sweden is one success story, in 2013 only 264 people died in road crashes, a record low. How have they done this? Planning has played the biggest part in reducing accidents. Roads in Sweden are built with safety prioritised over speed or convenience. Low urban speed-limits, pedestrian zones and barriers that separate cars from bikes and oncoming traffic have helped. Globally we need to reduce human error, or eliminate the opportunity for drivers to make fatal moves; human error can even further be reduced, for instance through cars that warn against drunk drivers via built-in breathalysers and making the implementation of safety systems, such as warning alerts for speeding or unbuckled seatbelts/child-seats, compulsory on all new vehicles, built in any factories across the globe.

Individually we need to be aggressive in safe and sober driving habits and not allow our friends and family to place themselves, their passengers and fellow pedestrians at risk by not looking kindly on their unsafe driving practises. Bad and drunk driving should become as unpopular as using a cellphone while driving.

References:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961682-2/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2962037-6/fulltext

http://www.worldlifeexpectancy.com/cause-of-death/road-traffic-accidents/by-country/ http://apps.who.int/gho/data/node.main.A997 http://apps.who.int/gho/data/node.main.A998 http://mikebloomberg.com/BloombergPhilanthropiesLeadingtheWorldwideMovementtoImproveRoad_Safety.pdf

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