Health Systems

Poverty, Government Policy, Health Systems, Disease Outbreak, Infectious Diseases, International Aid

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. 

Community Engagement, Health Systems

The Complexity of Health and Wellbeing

~Written by Karen Hicks - Senior Health Promotion Strategist, Auckland New Zealand (Contact: Karen_ahicks@hotmail.com)

Achieving health and wellbeing goes beyond the absence of disease as it is determined by a range of factors such as the environment, culture, gender, biology, and politics and is in fact complex and multi-dimensional.

As a health promoter I suggest that to address such a complex issue requires:

  •  An understanding of what being healthy means to those with whom we are working
  • An understanding of the social determinants of health
  • A holistic approach to health

For practitioners wishing to improve health outcomes we need to explore what being healthy means to those individuals and communities with which we are working. Practitioners often have their own ideas of what healthy means and our contracted outcomes and outputs may also identify what this means but it may not be the reality of our communities. To achieve sustainable health outcomes we need to ensure that we are meeting the needs of our communities.

We also need to understand what affects people’s health and communicate this effectively to the communities with which we work and our colleagues both within and outside of the health sector. The Dahlgren and Whitehead diagram is a few years old but is effective in explaining the range of determinants that influence health both positively and negatively and the interconnectedness of each determinant. 

KHJan122015.png

Another effective resource is the Robert Wood Johnson Foundation frame developed in 2010 to effectively talk about the social determinants of health which has involved translating determinants of health messages for lay audiences such as Health starts where we live, learn, work and play.  For detail on the research and process- http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/a-new-way-to-talk-about-the-social-determinants-of-health.html

As practitioners we need to stop working in silos and with topic or issues based approaches. A holistic approach to health is the most effective approach to achieving sustainable health outcomes. Within New Zealand there is a holistic health model named Te Whare Tapa Whā (Durie, M. 1998). A Māori health model that supports a holistic approach to health and identifies the four cornerstones (or sides) of Māori health. With its strong foundations and four equal sides, the symbol of a house illustrates the four dimensions of well-being which are physical, mental and emotional, social and spiritual well-being.  Should one of the four dimensions be missing or in some way damaged, a person may become unbalanced and unwell.

The approaches identified are ways in which to undertake effective health promotion that reflect its values and principles of empowerment, inclusiveness and respect based on evidence and effective health promotion competencies. The approaches above provide opportunities to communicate with communities and work with them to provide solutions to the complex and multi-dimensional health and wellbeing issues affecting us all locally, nationally and globally.

Reference:

Durie, M. 1998. Whaiora: Maori health development, Auckland: Oxford University Press

Health Systems, Healthcare Workforce

Capacity Building to Address Global Health Challenges

~Written by Karen Hicks – Senior Health Promotion Strategist, Auckland New Zealand. (Contact: Karen_ahicks@hotmail.com)

Increasingly the world is challenged with complex health problems. Developing a competent health promotion workforce is essential to addressing the related inequities and global health challenges.

Global health issues provide both a challenge and an opportunity for a competent health promotion workforce to work across cultures and settings with an international perspective.  An approach requiring an understanding of the determinants of health and the vital role health promotion has in achieving sustainable health gains.

At times health promotion has been challenged by the belief that anyone can undertake health promotion. This is partly the result of its strategy to promote its principles across the community making it everyone’s business. However health promotion is increasingly acknowledged as a discipline with specific knowledge, skills and distinct approaches that challenges such beliefs. 

Health promotion competencies have been developed as a capacity building tool that has successfully defined the knowledge and practice for effective health promotion, ensuring that health promotion principles, values and philosophy are reflected.

There are a number of international health promotion competencies frameworks that can be used to:

  • Guide planning, implementation and evaluation of initiatives
  • Provide the base for accountable practice and quality improvement
  • Inform education, training and qualification frameworks
  • Clarify health promotion roles and develop relevant job descriptions
  • Improve recognition and validation of health promotion
  •   Further reading and examples of some health promotion competency frameworks:

 

References:

http://www.iuhpe.org/images/PROJECTS/ACCREDITATION/CompHP_Project_Handbooks.pdf

http://www.hauora.co.nz/assets/files/Health%20Promotion%20Competencies%20%20Final.pdf

http://www.healthpromotion.org.au/images/stories/pdf/core%20competencies%20for%20hp%20practitioners.pdf

http://www.healthpromotercanada.com/competencies-development/

Disease Outbreak, Poverty, Political Instability, Health Systems, Economic Development, Infectious Diseases, Healthcare Workforce

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.

Government Policy, Health Systems, mHealth, Healthcare Workforce

Empowerment is Key to Improving Health Infrastructure in Developing Countries

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

Providing greater health access and more efficient health care delivery, especially for vulnerable populations, are priorities for anyone involved in public health. Poor health systems in developing countries mean a shortage of trained health care workers, inconsistent inventory of medical supplies, and inadequate surveillance systems. This list is not exhaustive, but we can start here. Building a better health infrastructure, like many public health priorities, requires multi-level coordination. Empowerment has to spread out from the government to the community and to the individual.

We can address the problem first by tackling the shortage of health care workers. Doctors in developing countries are in critically short supply. In 2006, the World Health Organization compiled data on the impact of HIV/AIDS on the health workforce in developing countries. Results showed that while European and North American countries have doctors at a ratio of 160 to 560 per 100,000 people, African countries only have two to sixty doctors for every 100,000. In Malawi, for example, there is one doctor for every 50,000 people. The global shortage of trained hospital and health care staff currently exceeds four million. Training more staff and volunteers is one solution for improving health systems in developing countries. Training other previously unqualified individuals could ameliorate these shortages. Providing incentives for already trained workers to stay in a vulnerable state or country could help build a struggling health system. Having a foundation of trained workers and preventing them from migrating to wealthier countries is an important first step. Empowerment and opportunities to grow and help are at the heart of this strategy.

The second hurdle is maintaining a constant inventory of equipment, medicines, and other health supplies. War, along with political and social unrest, in certain regions further dampens the efforts to provide a steady supply chain. There has to be cooperation between donors and the government to work with the private sector to ensure receipt of necessary health supplies. Partnering with emerging pharmacy chains increases the availability of medicines and drives down the cost for the patients. In the Philippines, Generics Pharmacy has thousands of small storefronts that are widely used by both the rich and poor. Convenience and ease of access are often of paramount interest to every person, regardless of income. The issue of payment is another facet of the supply and demand problem. Corruption that trickles to the local governments, and even the health care workers themselves, leads to some patients having to pay for medicine or services that should have been free. Reforming payment systems to ensure that patients have the medicines delivered before payment is processed directly to the provider will empower the patients and promote compliance. 

Compounding the shortage problems, both of trained workers and supplies, are the inadequate surveillance systems in place. This is the third issue that needs to be addressed, and it is arguably the most crucial. Surveillance is necessary to monitor not only the needs within health facilities, but also within the community and surrounding areas. Without real-time tracking of disease and medical supplies, logisticians, doctors and community health workers are unable to properly estimate need and completely evaluate the effectiveness of their clinic’s efforts. This is where data comes into play. The Novartis Malaria Initiative, under the Roll Back Malaria Partnership, has led SMS for Life, which harnesses mobile phones, internet, and electronic mapping technology to track stock levels for health facilities. Sending SMS messages between health facilities and the district medical officers ensures treatment availability. Stock-outs have been reduced in Tanzania during a six-month pilot program from 79% to 26% in three districts. Not only are these stock-outs reduced, but when they occur, they are also resolved much quicker due to the ease of communication. In areas where internet is unavailable or running inconsistently, Relief Watch has offered a similar solution. It also uses mobile technology, but the application allows workers to not only track supplies but also disease (http://www.reliefwatch.com/). The easy and free setup is invaluable to developing countries that have previously relied on paper spreadsheets and forms. Giving workers data at their fingertips gives them more control over their health facility and their patients. These technological innovations are not only crucial for immediate supply tracking and disease surveillance, but they provide research institutions and governing bodies more accurate data. After all, it is data that public health professionals and policy-makers rely on to make decisions and plan strategies. 

The aforementioned plan to improve health systems is by no means novel. Public health practitioners have stressed the importance of training more workers, creating a steady supply chain of treatments, and addressing surveillance shortcomings for decades. Adhering to these solutions requires cooperation and active coordination that extend from the public to the private sector. This is something that cannot be over-emphasized. Empowerment—of individuals, community health workers, and governing bodies of fragile states—is an important foundation from which a better health infrastructure can grow.


Resources:

The impact of HIV/AIDS on the health workforce in developing countries http://www.who.int/hrh/documents/Impact_of_HIV.pdf
Healthcare logistics: delivering medicines to where they're needed most
http://www.theguardian.com/global-development-professionals-network/2013/jul/29/healthcare-logistics-best-practice
SMS for Life http://www.malaria.novartis.com/innovation/sms-for-life/
Relief Watch http://www.reliefwatch.com/
Avert: Universal access to HIV treatment http://www.avert.org/universal-access-hiv-treatment.htm

Disease Outbreak, Economic Development, Government Policy, Health Systems, Infectious Diseases, Vaccination, Research, International Aid

Politics and Medicine

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

https://twitter.com/MikeEmmerich

"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

Politics is defined as "organised human behaviour", thus we can postulate that Medicine is micro managed organised human behaviour, at times right down to the molecular level. If we examine the Ebola outbreak/s (globally) and how it is being managed on a macro (politics) and micro scale (medicine) we can begin to see the cracks in the system, and hopefully then move to addressing these cracks, before they begin yawning chasms that are not repairable.

The region (Liberia, Sierra Leone and Guinea) has had success (we could add Nigeria and Senegal to the successes) and failures in both areas. Neither is Spain and the USA exempt from this analysis as can be noted from the various press releases (government and medical) over the past few months.

Since the first outbreaks in 1976 (Sudan and The DRC) till the current one in West Africa; care has generally been palliative and symptomatic, questions have often been asked during this period; What of a vaccine and/or other means of treating the infected patients? There was a report in the British Sunday Times (12/10/14), cited a Cambridge University zoologist as saying that “it is quite possible to design a vaccine against this disease” but reported that applications to conduct further research on Ebola were rebuffed because “nobody has been willing to spend the twenty million pounds or so needed to get vaccines through trial and production”. Globally this has been one of the failures of the pharmaceutical companies, and most probably even the WHO, for not pushing harder over the years to get this in motion.

In her 1994 book /The Coming Plague: Newly Emerging Diseases in a World Out of Balance http://lauriegarrett.com/#item=the-coming-plague, //Laurie Garrett warned that there are more than 21 million people on earth “living under conditions ideal for microbial emergence.” http://www.independent.co.uk/arts-entertainment/science-mutating-microbes-1601604.html Garrett when on to win the Pulitzer Prize in 1996 for reporting on Ebola. In 1995 Joshua Lederberg, the American molecular biologist said: "The world is just one village. Our tolerance of disease in any place is at our own peril. Are we better off today than we were a century ago? In most respects, we're worse off. We have been neglectful of the microbes, and that is a recurring theme that is coming back to haunt us."

Jump forward to the 23^rd of September 2014, US President Obama issued an unprecedented ‘Presidential Memorandum on civil society http://www.whitehouse.gov/the-press-office/2014/09/23/presidential-memorandum-civil-society’ recognising that: Through civil society, citizens come together to hold their leaders accountable and address challenges that governments cannot tackle alone. Civil society organisations…often drive innovations and develop new ideas and approaches to solve social, economic, and political problems that governments can apply on a larger scale./

If we look at the current crises in West Africa civic leaders are what is missing, hence the inability to track and trace potential infected persons, motivate communities to change risky behaviours (handing of the deceased), agitate with government to create better health care systems, this all adds fuel to the fire of the current epidemic.

Have we listened and learnt as governments, NGO's and Multinational Pharmacare companies since then?

Despite Medical Advances, Millions Are Dying, this is a banner from 1996, not 2014! from the WHO, which was "declaring a global crisis and warning that no country is safe from infectious diseases, the World Health Organization says in a new report that diseases such as AIDS, Ebola, Hanta, Mad Cow, tuberculosis, etc., killed more than 17 MILLION people worldwide last year”.

As Laurie Garrett wrote in her the closing section of her book, The Coming Plague, /“In the end, it seems that American journalist I.F. Stone was right when he said, ‘Either we learn to live together or we die together.’ While the human race battles itself, fighting over ever more crowded turf and scarcer resources, the advantage moves to the microbes’ court. They are our predators, and they will be victorious if we, Homo sapiens, do not learn how to live in a rational global village that affords the microbes few opportunities. It’s either that or we brace ourselves for the coming plague.” Time is short.

The Ebola outbreak in West Africa is “unquestionably the most severe acute public health emergency in modern times,” Dr. Margaret Chan, the director general of the World Health Organization, said Monday 20/10/2014). We do seem to be going in circles... circa 1995.. have we learnt nothing from history.

Sooner or later we learn to throw the past away History will teach us nothing ~Sting – Musician, singer-songwriter
Where have all the people gone, long time passing? Where have all the people gone, long time ago? Where have all the people gone? Gone to graveyards, everyone. Oh, when will they ever learn? Oh, when will they ever learn? ~Pete Seeger - American folk singer and activist