A quest for a Healthy Tax Reform in Chile

This week on PLOS Translational Global Health, Sebastián Peña, MD, MSc, from the Department of Health, Municipality of Santiago discusses the Coordination of the Front for a Healthy Tax Reform.

Chile is undergoing the largest tax reform since the return of democracy in 1989. The goal is to increase the tax revenue in $8,200 million to finance a deep educational reform that will provide free, public and quality education for all.

Flickr / geezaweezerIn this context, the Government of Michelle Bachelet has included a raise in sugar-sweetened beverages (SSBs) and alcohol as “corrective taxes”. The reform seeks to increase an existing ad-valorem tax on non-alcoholic beverages of 13% to 18% for sugar-sweetened beverages. Alcohol taxes would change from its current structure (15% for beer and wine and 27% for spirits) to an ad-valorem base tax of 18%, 0.5% extra per each degree of alcohol content and 0,03 monthly tax unit per litre of pure alcohol. This would result in a raise of 7-23% in tax, affecting more alcoholic beverages with higher alcohol content and cheaper prices, the latter resulting from the per unit tax.

Reactions against these taxes where almost immediate. The day after the announcement, a Senator argued that the alcohol tax was a “grave to the small producers of pisco [a spirit produced from grapes]”. A few days later, Andrónico Luksic, owner of Chile’s largest alcohol producer Compañia Cerverías Unidas -, expressed his concerns about the raise in alcohol taxes. Soon after, 8 MPs signed an agreement to request President Bachelet to drop alcohol taxes to protect the producers of pisco. Flickr / geezaweezer

Taking into account this scenario, a group of public health professionals started to discuss the need to take action to demand a raise in SSBs that would effectively reduce consumption (from 13% to 33%, as suggested by PAHO), to prevent alcohol taxes to be dismantled completely from the reform and to request including a significant raise in tobacco taxes. Perhaps more importantly, our main objective is to bring to the forefront the role of Governments in the health of populations and the use of taxes as cost-effective ways to reduce consumption of alcohol, tobacco and SSBs and the resulting death, disability, low productivity and violence.

With these objectives in mind, we created the Frente por una Reforma Tributaria Saludable (Front for a Healthy Tax Reform). An invitation was sent to a wide range of organizations from the civil society, professional associations, scientific societies and colleagues to join the Front. Currently, the Front consists of 13 organizations including well-known academic institutions, NGOs, trade unions, parents and medical associations and scientific societies. The advocacy work has been divided in three areas: media, parliament and civil society and we have organized three massive twitter events (#ReformaTributariaSaludable), written several columns in national newspapers and blogs, given an open letter for the Minister of Finance and met with the Minister of Health and several members of the Parliament.

Flickr / Latin America for LessThe day after our first Twitter event, the Minister of Finance gave up to pressure from the MPs and agreed to eliminate the per unit tax, resulting in a 50% drop in the alcohol raise. As compensation, the Government introduced a tobacco tax that would only result in a 1% price rise.

Our advocacy work has continued and we are starting to see some results. 50 MPs signed a petition for the Government to raise SSBs taxes to 30% and include a tax on all sugary and salty products. Later and following our proposal, the request has been to include a tax on all processed foods with an energy density higher than 275 Kcal/100 grs, following the recommendations of the World Cancer Research Fund and the experience of Mexico.

But this is a big fight and the opposition, fierce. Two weeks ago Coca-Cola, Nestlé, Compañia Cervecerías Unidas and Carozzi announced the creation of a coalition to fight the raise in corrective taxes. El Mercurio, Chile’s largest newspaper wrote an editorial arguing against “healthy taxes” as effective means to reduce consumption. In their opinion, education was instead a much more effective way.

Flickr / antifluorThe quest for a healthy tax reform in Chile is ongoing and now the discussion has moved to the Senate. The public health community is organized to challenge the economic and political power of the food, alcohol and tobacco industry. To what extent we will succeed remains to be seen.

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Dr Sebastián Peña is a Chilean MD with a European MSc International Health. He is Chief of Quality Unit, Department of Health, Municipality of Santiago and currently a visiting scholar with the National Institute for Health and Welfare, Finland. Follow his work via Twitter - @spenafajuri.

This blog represents the views and ideas of Dr Sebastián Peña.

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#imaginemed: Thinking Outside the Box (Part 1)

This week, PLOS TGH is handed over to the talented and articulate Alexandra Abel. Combining a passion for medicine, global health and the arts, she reports on the recent #imaginemed event, London.

Sandro

The day before show day, like true scientists, we stood up in the gallery at the Royal Albert Hall contemplating what could possibly go wrong. We recalled the time that over 100 members of the audience decided to join Pete Doherty on stage during his solo performance in 2008, but swiftly noted we did not anticipate the same problem at our event. As exciting as cardiothoracic and maxillofacial surgery are, particularly to us, they don’t generally trigger mass stage invasion. Not during lectures anyway.

A pre-show view from the ImagineMed stage. Photography: Alan Liu

A pre-show view from the stage. Photography: Alan Liu

The following day, while setting up and trying to keep to time, I think we all took at least one unscheduled moment to appreciate just how breathtakingly beautiful the Hall really is. When we worked with Focus Active Learning to make our online game, we learned a lot about the Hall in the process.

For example, there are over 13,000 letter ‘A’s around the Hall to commemorate Prince Albert, over 6 million red bricks make up the Hall’s distinctive exterior, and there are 14 bars (as in drinking ones) in the Hall. But no fun facts compare to standing on the stage looking up at the tiers and the fluted aluminium roof and looming diffuser discs.

 

Meanwhile, over at the Sir Alexander Fleming Building of Imperial College London, an important inaugural event was already underway. Biotech showcase The Cell, in partnership with NeuroPro, sought to showcase a variety of innovative healthcare technologies, and Neuropro showcased their EEG headset, NeuroTrail, which wirelessly monitors real-time EEG. Fifth Sense introduced Scentee, a smartphone attachable olfactory device that can be used to examine users’ sense of smell and indicate anosmia.

Delegates try the Hypnagogic Light at The Cell. Photography: Ellie Pinney

Delegates try the Hypnagogic Light at The Cell. Photography: Ellie Pinney

One of the most lively exhibits was serious games company Focus Active Learning, where delegates tried their hand at several board games including The Nutrition game and Infection Control Game. Among other companies in attendance were socially-minded software company uMotif; Imperial’s MSk Lab; the HELIX Centre, a collaboration between the Royal College of Arts and Imperial looking at design in healthcare; Light Eye Mind, who maintain the UK’s only publicly available Hypnagogic Light; and the revolutionary GoodSAM App for first responders.

The biotech showcase was only our morning activity, and Cell-goers went on to join other attendees as they selected their seats in the Hall. At 2pm, the lovely Dara Ó Briain, who kindly gave up his Easter Monday to host the event, took to the stage to welcome our four thousand strong audience to Imagining the Future of Medicine (ImagineMed)!

Welcome to ImagineMed! Photography: Alan Liu

Welcome to ImagineMed! Photography: Alan Liu

Dara, whose wife is a surgeon, is no stranger to being outnumbered by doctors at social gatherings; and, of course, many attendees were doctors (or medical students), but there was also a number of non-medical, even non-scientific, individuals with an intellectual curiosity, eager to hear about the future of healthcare from the people involved in shaping it.

The first session was called Thinking Outside the Box. Hollywood screenwriter Ira Steven Behr once noted, “…usually when we use that cliché, we think outside the box means a new thought. So we can situate ourselves back in the box, but in a somewhat better position”. Following on from this analysis, and in the spirit of ImagineMed, I like to think ‘outside the box’ represents human imagination. The speakers in this session have certainly all put their imagination to good use, and provided important new perspectives in their areas of expertise.

Francis on stage. Photography: Alan Liu

Francis talks about Looking and Seeing. Photography: Alan Liu

First up was cardiothoracic surgeon Francis Wells, who developed a new way to repair mitral valves after being inspired by the medical drawings of Leonardo da Vinci. Francis noted that in an age where everyone is risk averse, it sets the challenge of ‘how do you make new advances?’ He went on to outline three interconnected principles that have helped him overcome this challenge: 1) Ask the right questions. If we begin with the ‘why’, we can then begin to understand the ‘how’ and the ‘what’. 2) Looking and seeing. We are surrounded by visual data all the time, but turning looking into seeing and perceiving is really important.

“Drawing is a line around a think.” – Francis’ daughter

Francis, a keen artist, explained that drawing and thinking are intimately related, and went on to show some of da Vinci’s astonishingly accurate medical drawings. 3) Form and function in nature. All of us are formed by the forces acting upon us; those forces can be genetic, gravitational, osmotic, or emotional, but everything in nature is a diagram of the forces acting upon it. Francis described how in 1515, da Vinci determined the vortex mechanism by which heart valves close, and five hundred years later, a publication in Nature proved him right. Now with imaging technology, many other vortices have been discovered in the heart leading to a whole new way of looking at how the heart functions as it begins to fail.

Jamil talks about building a brain stethoscope. Photography: Alan Liu

Jamil talks about building a brain stethoscope. Photography: Alan Liu

Second speaker of the day was Jamil El-Imad, Chief Scientist at Swiss-based company NeuroPro. Jamil’s background is in software engineering, but his fascination with neuroscience began when his friend began doctoral research at Imperial College five years ago. He and his friend engaged in an extensive discussion one evening, and came up with their hypothesis: if a healthy brain is rhythmic, then an unhealthy brain must behave in a non-rhythmic fashion. They thought that if they attempted some pattern matching to brain signals, they might learn something new. This approach is very similar to using anti-virus software, which looks for any patterns corresponding to known viruses detected in the past. They wanted to build a brain stethoscope!

They decided to first target epilepsy, a disabling condition that affects 1% of the world’s population. When a seizure strikes, physical injuries result from people losing control and hurting themselves as they fall. Jamil and his friend imagined a portable device, or mobile technology, that can monitor the patient’s EEG readings in real time, and give a prediction or warning before a seizure strikes, allowing the patient to lie down comfortably and safely. Their concept for predicting seizures led to the construction of a headset that can be universally used, to building a mobile lab that can speed up research trials, and some amazing visualisation tools to assist diagnosis.

“Computing has become a utility like electricity and water… opening up a whole new space for us in pursuing opportunities in personalised healthcare.” – Jamil

In his post talk Q&A, Jamil noted that the headset technology can be used for a variety of functions – at the moment, they are using it monitoring coma patients.

Mark talks about Caring Outside the Box. Photography: Alan Liu

Mark talks about Caring Outside the Box. Photography: Alan Liu

Our third speaker of the day was consultant neurosurgeon and prehospital care specialist Mark Wilson. Mark used the stories of his Nan, and a man called Dan, to illustrate how different care is appropriate in different contexts. Nan, one sunny summer’s day, surrounded by family, had ‘keeled over’ in their back garden. Mark’s initial reaction to this situation wasn’t to start CPR. “I thought, wow, what a wonderful way to die,” said Mark, to many chuckles from the audience. Dan is a young man who wrapped his car around a tree a few years ago and suffered a brain injury. Patients like Dan might not look that unwell, but there’s a time-critical emergency going on in their head. Dan had a subdural hematoma (a blood clot on the outside of the brain pushing over the brain).

Mark explained that there is a constant loop between what you can find out from extreme physiology and critical care, and his advice to anyone hoping to find something new is to look off the beaten track. People have extreme physiology immediately following an accident, and it’s an area we don’t do much research on firstly, because we’re often not there; and secondly, when we do get there, it’s often dangerous, or it’s raining – it’s not conducive to research. But it’s an area where Mark believes we can make a massive difference. The best time to minimise secondary brain injury is in the first few minutes following an accident, but patients die because we’re not 100% at managing these secondary injuries. He believes if we can intervene at this early stage, outcomes would be much better.

“If you’re not dead when the emergency services arrive, you shouldn’t die.” – Mark

Nan's fine, she's over there! Photography: Alan Liu

Nan’s fine, she’s over there! Photography: Alan Liu

Fortunately, Dan made a good recovery, and was even sitting in the audience with his girlfriend; but at the ward round Mark did that morning, he had 10 patients very similar to Dan. Trauma is the commonest cause of death worldwide in under 45s, and brain injury is the commonest cause of that trauma. Dan went through a system of care: pre-hospital care, emergency care, intensive care, surgery, and then rehab. Mark believes that care is the most valuable thing doctors do, but it doesn’t appear on any tariff, and therefore, what makes good quality of care is difficult to define. Mark said he feels very privileged to be able to care for people with brain injury because is not like other types of injury – it can change a person profoundly, and he is very passionate about maintaining people as they are.

So what happened to Nan? Luckily, she had only fainted, and was also sitting in the audience.

Talented teenagers from Islington Community Theatre. Photography: Alan Liu

Talented teenagers from Islington Community Theatre. Photography: Alan Liu

Final speaker of the first session, Sarah-Jayne Blakemore, brought 25 teenagers with her to illustrate her interesting research on the teenage brain. But they weren’t just any teenagers; they were very talented members of Islington Community Theatre, who created a unique performance. Sarah-Jayne explained that during adolescence, we develop a very strong sense of self, especially social self. Research shows that teenagers feel worse than adults do after being ‘left out’, suggesting that adolescents are hypersensitive to social exclusion. This might also help to explain why some adolescents are more prone to taking risks, especially when they’re with their friends.

Brain-imaging studies have shown what happens in the brain when we think about other people are thinking and feeling – this is called mentalising. The social brain network is involved in this mentalising, and the social brain undergoes significant change during adolescence. When adults and adolescents do the same mentalising tasks, different brain regions are shown to be active. Sarah-Jayne said these findings show that the adolescent brain is not broken or dysfunctional, it is just activating differently.

 

That’s all for the first session.

Thanks to Cell Coordinator Zinah Sorefan for her information on the activities of The Cell.

Check back for #imaginemed Part 2!

Alex

Alexandra Abel is a graduate from Imperial College London and the Royal College of Music. She has a keen interest in both Global Health and Performing Arts. From September, she will be a medical student at Hull York Medical School.

Join her on twitter @alexandraabel

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NCDFREE Bootcamp for Global Health Advocacy, Melbourne

10320451_729359773753428_5023284381833903433_nA mid-week morsel from NCDFREE.

The wrap-up film from their recent Advocacy and Innovation Bootcamp. Bringing together 50 bright young minds from all disciplines the organisation had three outcomes in mind. The first, for the group to mingle, strike friendships and develop new link and maybe collaborations with other sectors. The second was to impart new skills in design and innovation thinking, leadership, public speaking and social entrepreneurship. Finally, NCDFREE wanted something from these bright young minds. NCDFREE sourced their next film and campaign ideas through a challenge-pitching competition.

A fun day for everyone, but enough talk, here’s an insight into the real deal…

 

Sandro_circle

Follow Sandro on Twitter.

 

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Interview: Global Health Film-Maker

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This week, we continue our PLOS TGH podcasting – as Melbourne-based Global Health enthusiast Lilli Morgan interviews film-maker Lali Houghton on location, as he films a short film for NCDFREE, GlobalRT and UICC in Lima, Peru.

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Wearable. Edible. Huggable. #WIREDHEALTH

This week we hand over to regular blogger Alex Abel – who recently returned from London’s WIRED Health.

Earlier this year, in a blog post for the World Economic Foundation, Jamie Ferguson said:

“The so-called revolution in digital health has been slow moving for many years, more like an undercurrent. But, lately it has become a tide, with all stakeholders fully invested and ready to catch the wave.”

We were certainly riding the face of that wave at London’s WIRED Health.

Main Stage talks took place in the comfortable Brunei Auditorium.

Main Stage talks took place in the comfortable Brunei Auditorium, hosted by editor David Rowan and science editor João Medeiros.

This inaugural event was held at the Royal College of General Practitioners on 29 April, and focused on innovation in the health sector.

Unsurprisingly, how we can collect, analyse, and benefit from our individual health data dominated discussion at both the Main Stage talks hosted by David Rowan, and the parallel Bupa Startup Stage where a range of companies gave 9-minute pitches to a panel of judges.

Sensors and self-monitoring

Maneesh’s wearable counts step, but also notifies him of tube delays. Image via @ManeeshJuneja

Maneesh’s wearable counts step, but also notifies him of tube delays. Image via @ManeeshJuneja

With the vast array of wearable sensors available (Amazon.com even launched a wearable tech store last month), we can now keep track of every waking (and sleeping) moment of our lives. My friend Jing noted that there seemed to be so many health-tracking devices that he couldn’t quite see the need for all of them. How many, and what kinds of tools, do we really need? But Sonny Vu, founder of Misfit Wearables, more than adequately addressed this common question with a nice analogy:

“I’ve heard people say, oh wearables, that’s a really crowded space. No. That’s like saying in 1997 that the Internet is really crowded because there’s a lot of websites.”

Aside from keeping check on general health, sensors have huge potential to aid the management of chronic disease as people with chronic conditions are already self-managing 8700 hours a year, and only 3 hours a year with their clinician. Andrew Thompson explained that when a patient swallows a Proteus pill, it connects and communicates with their mobile phone, letting them know if they are responding properly to the medication. The sensor in this smart pill is made of silicon, copper, and magnesium – designed to be cheaply and easily embedded into any product. Andrew hopes that ‘digital pills’ will enable patients and doctors to better monitor and treat chronic conditions without the need for endless physical checkups.

From management of complex chronic disease to prediction… Jack Kreindler of the CHHP has been using expensive biosensor technology for a very long time, helping David Walliams swim the length of the Thames recently, but he explained that self-tracking devices used by elite athletes can now be used to predict major health problems, reducing unnecessary hospital admissions.

Jing and I meet Teddy the Guardian, a huggable sensor for children.

Jing and I meet Teddy the Guardian, a huggable sensor for children.

A particular favourite of mine from the Startup Stage was Teddy the Guardian. Certainly the cuddliest sensor tech around, Teddy can measure a child’s temperature, heart rate, and oxygen levels through his ‘smart paws’ in about six seconds. When Teddy’s owner checks their pulse, the bear’s LED heart beats at the same rate, a soothing effect intended to create a bond between child and bear. Teddy data is transmitted in real-time to a mobile app where data is analysed, managed, and downloaded by medical staff and parents.

Apps, wearables, and even edibles empower people to manage their own health and wellness, but we need to aid and guide the take up and use of these devices. As Sir Mark Walport explained, “Science without the social science will not reach its maximum”. The main message of the day can be nicely summed up by the content of one slide, which read: Sensor technology + big data + expert support = success. The challenge becomes how we can best harness our data for personal and global health purposes, and how to secure this expert support when and where it is required.

“We want indiscriminate, continuous, multi-sourced data streams to really realise the global health impact and great potential of digital health.” – Leslie Saxon

And the winner is…

Startup Stage winner was Peter Hames for his novel insomnia-fighting CBT app Sleepio. Their placebo-controlled RCT was published in Sleep in 2012, showing Sleepio users had improved sleep efficiency compared with the online placebo course, and those who continued with usual treatment for insomnia.

Fun fact of the day

Catherine Mohr (Intuitive Surgical) on stage. The dog's nose is a key talking point.

Catherine Mohr (Intuitive Surgical) on stage. The dog’s nose is a key talking point.

A dog’s nose is an amazing diagnostic tool. Dogs can detect ovarian cancer with 90% accuracy. Billy Boyle, Co-founder of the exciting Owlstone Nanotech, told us how this keen chemical analysis has led to their creation of diagnostic sensors that can ‘sniff out’ a range of cancers.

Sharp statistics

One in three couples that have IVF could conceive naturally (Claire Hooper, DuoFertility).

Someone in the world develops Alzheimer’s disease every 6 seconds (Elli Kaplan, Neurotrack Technologies).

Most inspiring statement

“Never under-estimate your ability to make a difference.” – Elli Kaplan

Visit #WIREDHEALTH in 2015

WIRED Health's partner Cisco showcase their Internet of Everything #TOMORROWstartshere

WIRED Health’s partner Cisco showcase their Internet of Everything.

There were twenty-two incredible talks in one day, but every speaker captivated me and made me want to learn more about their work.

After a thoroughly enjoyable day at the RCGP, I was inspired to walk the five miles home, monitoring my heart rate the old fashioned way because I’m a bit short on wearables.

The talks are now available to watch via the WIRED UK YouTube Channel.

WIRED Health will be returning to London next year, and I’d highly recommend it to anyone.

Many thanks to João Medeiros for inviting me, and curating such a wonderful programme. Congratulations to the entire organising team, and best of luck for 2015!

 

Alexandra Abel is a graduate from Imperial College London and the Royal College of Music. She has a keen interest in both Global Health and Performing Arts. From September, she will be a medical student at Hull York Medical School.

Join her on twitter @alexandraabel

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Supporting population-based approaches to preventing NCDs

For our latest post, we go to Oxford, UK with regular blogger Dr Kremlin Wickramasinghe who explains some exciting news in research on Global Health and NCDs.

This week, the British Heart Foundation Centre on Population Approaches for Non-Communicable Disease (NCD) Prevention in the Nuffield Department of Population Health, University of Oxford was officially designated as the WHO Collaborating Centre on Population Approaches for NCD Prevention.

Dr Shanthi Mendis, Senior Advisor, NCDs, World Health Organization Head Quarters, explained how this new collaborating centre would contribute to the Global action plan for the prevention and control of NCDs 2013-2020, which set a global target of reducing the premature mortality from NCDs by 25% by 2025. She indicated that the new centre will mainly contribute to the following two objectives of the Action Plan:

  • To reduce exposure to modifiable risk factors for NCDs through creation of health-promoting environments
  • To promote and support national capacity for high quality research and development for prevention and control of NCDs

She said that an interesting question to ask  is why  we need another collaborating centre in a developed country when we see more than 80% of NCD deaths occurring in low and middle income countries (LMICs)? In her answer she pointed out that we have large research and evidence gaps to support the implementation of the most cost effective interventions in high income countries and well as in LMICs and that collaboration with this new centre would enable the sharing of experience and the strengthening of the WHO’s response to the growing problem of NCDs.

Forum at the WHO CC launch. Photo:Prachi Bhatnagar

Forum at the WHO CC launch. Photo:Prachi Bhatnagar

Dr Gauden Galea, Director, Division of NCDs and Life Course in the WHO European office discussed current population based approaches in Europe. Although 50 countries in the region have ratified the WHO Framework Convention on Tobacco Control, the majority of those countries have struggled to implement important population based interventions fully. Only two countries have successfully introduced pictorial warning on cigarette packages and only three countries have completely banned advertising, promotions and sponsorships.  He demonstrated that similarly, in tackling alcohol and unhealthy diets, countries have shown a higher level of adoption of policies that raise public awareness or that provide information but smaller numbers of countries have implemented interventions such as taxes and other measures to affect food prices and the re-formulation of food products to reduce unhealthy nutrients. He demonstrated how the new centre would continue to work with the WHO on areas such as nutrient profiling, fiscal interventions, marketing of unhealthy food and the use of new data sources for NCD prevention.

Mr Simon Gillespie, Chief Executive, British Heart Foundation (BHF) welcomed this recognition for a research group they have funded for more than 20 years. As the leading funding body for cardiovascular disease research in the UK, he mentioned that the BHF would continue to support cardiovascular disease prevention research to make a greater impact nationally and internationally.

Dr Mike Rayner Director of the new collaborating centre emphasised the importance of population based NCD prevention approaches to create healthy societies rather than just healthy individuals. He argued that the aim of a population based approach should be to shift the distribution of risk factors for NCDs in the population rather than those at greatest risk and to focus on more the distal risk causes of  NCDs such as the price of goods and services. He concluded by saying that a population approach is complementary to an individual/high risk approach but that population based approaches have been neglected.

Picture, left to right: Dr Gauden Galea, Dr Shanthi Mendis, Dr Mike Rayner, Professor Rory Collins, Mr Simon Gillespie.

Picture, left to right: Dr Gauden Galea, Dr Shanthi Mendis, Dr Mike Rayner, Professor Rory Collins, Mr Simon Gillespie. Photo:Andrew Trehearne

This workshop also highlighted wider trends that NCD prevention community should focus on such as global warming, resource depletion and  rising food prices. It was mentioned that the post 2015 development agenda discussions should be used as an opportunity to link NCD prevention with the sustainability agenda. New areas such as the use of social media data and supermarket data for surveillance and prevention of NCDs were also mentioned by speakers during the panel discussion.

When a question was raised about the advice for the next generation it was mentioned that one important role would be to identify research gaps in areas where countries are struggling to implement cost effective interventions and try to improve our understanding on how to implement them. This would require stronger collaboration within and outside the population health disciplines such as economics, anthropology and politics.

The new collaborating centre will be working with the WHO, the BHF and other partners in capacity building by organising workshops and short courses, contributing to WHO’s work in the development of guidelines/manuals on population level NCD prevention, assisting WHO to develop methods for evaluating NCD prevention programmes and providing WHO with statistical analysis and systematic reviews related to population level NCD prevention.

This launch brought NCD prevention experts from leading academic research groups, the World Health Organization and a major non-governmental organisation concerned with NCDs  (the British Heart Foundation) to a single forum. Discussions ranged from generating evidence, using that evidence to developing guidelines, providing technical support to countries, funding actionable research and advocacy by these different organizations. It was evident that bringing these different organizations to the same forum allowed us to understand how these different roles would contribute to unpack the complexity around determinants of NCDs and the importance of working in collaboration, to develop sustainable solutions.

Connect with Kremlin on Twitter via @KremlinKW

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Part 1: Combating Rheumatic Heart Disease in Kenya

Prevention and Control of Rheumatic Heart Disease in Kenya: Issues and Barriers

Rheumatic heart disease (RHD) is the most common acquired heart disease in children (common age group is 5 to 15 year olds) in developing countries. Over 15 million people suffer from the condition, resulting in about 233 000 deaths annually. RHD is a chronic heart condition caused by rheumatic fever – whose main symptoms include fever, muscle aches, swollen and painful joints, and in some cases, a red rash. Rheumatic fever is as a result of an untreated strep throat that is caused by bacteria called group A streptococcal (strep) infection. Overcrowding, poor housing conditions, undernutrition and lack of access to healthcare play a role in the persistence of this disease in developing countries.

According to the World Heart Federation (WHF), the “primary prevention of acute rheumatic fever (the prevention of initial attack) is achieved by treatment of acute throat infections caused by group A streptococcus. This is achieved by up to 10 days of an oral antibiotic (usually penicillin) or a single intramuscular penicillin injection.” Moreover, regular antibiotics (usually monthly injections) can prevent patients with rheumatic fever from contracting further strep infections and causing progression of valve damage. The decline of rheumatic fever in developed countries is believed to be the result of improved living conditions and availability of antibiotics for treatment of group A streptococcal infection.

Although Rheumatic Heart Disease (RHD) has been eradicated in the developed world (Carapetis 2007), it still imparts significant health and economic burdens in developing countries worldwide (Ozer et al. 2005, Nitin et al. 2013). The irony is that the disease is completely preventable. A study performed in western Kenya showed that 9 out of the 526 enrolled patients exhibited echocardiographic evidence of RHD (Holland 2012). The transthoracic echocardiograms were performed on randomly selected hospitalized patients, aged 5-35, who were not previously diagnosed with RHD, on the surgical wards.

 

The Issues and Barriers to RHD Control

RHD is a neglected ‘preventable’ chronic disease that requires continuous and expensive medical follow-up if not prevented or treated effectively as early as possible. RHD is closely associated with poverty and poor quality medical services, so most RHD patients are not able to access medical services in a timely or effective manner (Okello et al. 2012). After initiating treatment, most patients are lost to follow up. As a result, the disease often progresses to advanced stages with complicating comorbid conditions, in which treatment is rarely successful. This contributes to the high morbidity and mortality rates observed in patients diagnosed with RHD in Kenya.

Kenya’s health system is inappropriately designed and inadequately financed to prevent and to manage RHD – with poorly equipped hospitals, a low doctor to patient ratio, and unaffordable drugs such as penicillin. The issue is exacerbated by a flawed national health insurance plan through which patients are still unable to afford medical services (Kimani et al. 2012, Stone et al. 2014).

RHD requires specialized care, only accessible in Nairobi and a few urban centers across Kenya (Jowi 2012). Even in such places, availability of services at public hospitals is limited due to inadequate numbers of cardiologists or lack of necessary diagnostic and treatment facilities. “We need to treat approximately 500 patients with RHD, but we can only handle about 50 open heart surgeries locally due to resource constraints.” stated Prof Gerald Yonga, Chair Department of Medicine at the Aga Khan University Hospital, Kenya.

Widespread lack of awareness and accurate information about RHD in part explain why prevention is rare and many RHD cases are diagnosed too late to treat effectively (Mondo et al. 2013). Furthermore, the presentation of RHD often mimics many other tropical fevers (malaria, typhoid), and thus also presents a challenge to early detection. At presentation, many healthcare workers misdiagnose, prescribe inappropriate treatment, and do not design adequate follow-up mechanisms for their patients, contributing to late presentation, complications, and meager patient follow-up.

 Action required to reduce barriers to RHD Prevention and Care

1.3RHD is preventable by detecting and treating streptococcal sore throats early, ensuring access to penicillin as well as by streamlining the healthcare infrastructure. There is thus a role for urgent multi-sectoral promotion of holistic healthcare in Kenya to ensure early diagnosis and affordable access to health services for those at risk, so as to alleviate this preventable burden.

Part 2 of this blog highlights some multisectoral actions in place in Kenya to combat RHD.

 

References

  1. Carapetis, Jonathan R. 2007. “Rheumatic      Heart Disease in Developing Countries.” New England Journal of Medicine      357 (5): 439–41. doi:10.1056/NEJMp078039.
  2. Holland, Thomas. 2012. “The Prevalence of      Rheumatic Heart Disease in Western Kenya: An Echocardiographic Study”.      Duke University. http://dukespace.lib.duke.edu/dspace/handle/10161/6204.
  3. Joseph Nitin, Deepak Madi, Ganesh S Kumar,      Maria Nelliyanil, Vittal Saralaya, and Sharada Rai. 2013. “Clinical      Spectrum of Rheumatic Fever and Rheumatic Heart Disease: A 10 Year      Experience in an Urban Area of South India.” North American Journal of      Medical Sciences 5 (11): 647–52. doi:10.4103/1947-2714.122307.
  4. Kimani James, Remare Ettarh, Catherine      Kyobutungi, Blessing Mberu, and Kanyiva Muindi. 2012. “Determinants for      Participation in a Public Health Insurance Program among Residents of      Urban Slums in Nairobi, Kenya: Results from a Cross-Sectional Survey.” BMC      Health Services Research 12 (March): 66. doi:10.1186/1472-6963-12-66.
  5. Mondo Charles, Charles Musoke, James Kayima,      Jurgen Freers, Wanzhu Zhang, Emmy Okello, Barbara Kakande, and Wilson      Nyakoojo. 2013. “Presenting Features of Newly Diagnosed Rheumatic Heart      Disease Patients in Mulago Hospital: A Pilot Study.” Cardiovascular      Journal of Africa 24 (2): 28–33. doi:10.5830/CVJA-2012-076.
  6. Okello Emmy, Barbara Kakande, Elias Sebatta,      James Kayima, Monica Kuteesa, Boniface Mutatina, Wilson Nyakoojo, et al.      2012. “Socioeconomic and Environmental Risk Factors among Rheumatic Heart      Disease Patients in Uganda.” PLoS ONE 7 (8).      doi:10.1371/journal.pone.0043917.      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3428272/.
  7. Ozer Sema, Olgu Hallioğlu, Süheyla Ozkutlu,      Alpay Celiker, Dursun Alehan, and Tevfik Karagöz. 2005. “Childhood Acute      Rheumatic Fever in Ankara, Turkey.” The Turkish Journal of Pediatrics 47      (2): 120–24.
  8. Stone GS, Titus Tarus, Mainard Shikanga,      Benson Biwott, Thomas Ngetich, Thomas Andale, Betsy Cheriro, and Wilson      Aruasa. 2014. “The Association between Insurance Status and in-Hospital      Mortality on the Public Medical Wards of a Kenyan Referral Hospital.”      Global Health Action 7 (February). doi:10.3402/gha.v7.23137.      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925809/.
  9. Jowi Christine Awuor. 2012. “African      Experiences of Humanitarian Cardiovascular Medicine: A Kenyan      Perspective.” Cardiovascular Diagnosis and Therapy 2 (3): 231–39.      doi:10.3978/j.issn.2223-3652.2012.07.04.

Authors

Dr. Duncan M. Matheka is a Kenyan Medical Doctor and Public Health Researcher. He is a member of Young Professionals Chronic Disease Network (YPCDN) and is the Nairobi RHD Patient Club Coordinator. Twitter @duncoh1

Dr. Laura Musambayi is a Kenyan Medical Doctor and the Nairobi RHD Club Assistant Coordinator.

Mohamed A. Omar is a fourth year medical student at the University of Nairobi, Kenya.

Dr Kate Armstrong is the Founder and President of CLAN (Caring & Living As Neighbours) and the Executive Secretary of NCD Child (a global coalition committed to integrating children and adolescents within the global NCD, health and development discourse). Twitter @ncdchild

 

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Climate Change – Health Threat or Opportunity?

This week, we support the great work of  The Global Climate and Health Alliance – in time for the release of the latest IPCC WG report. This infographic explains the major ideas and themes – we encourage you to share it far and wide. 

IPCC Climate Change Infographic 02

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The Global Climate and Health Alliance was formed in Durban in 2011 to tackle climate change and to protect and promote public health. The Alliance consists of health organizations from around the world united by a shared vision for a sustainable future. Specifically the Alliance members work together to: (1) Ensure health impacts are integrated into global, national and local responses to climate change; (2) Encourage the health sector to mitigate and adapt for climate change.

Category: Uncategorized | 3 Comments

An Epidemic of Trauma on the Road

This week on PLOS TGH, Christopher Tedeschi, Assistant Professor of Medicine at Columbia University and a practicing emergency physician, explores the global and local epidemic of road traffic accidents. From personal close-call, to big-picture epidemiology…

 

Last month, Graco Children’s Products recalled 3.8 million infant car seats amid concerns that their buckles could become jammed with spilled food or liquid, making it impossible to remove a child in an emergency.  My ten-month old daughter has been using one of those seats—and out of an abundance of caution and maybe some paranoia, my wife and I upgraded to a new model.

Flickr / Cars10s PhoToesJust before the recall we traveled in India for several weeks.  In Bangalore and Mumbai, we hopped in the back of taxis and rickshaws with no better restraint than a white-knuckled grip.  And now I’m supposed to worry about the tiny chance that some apple juice will gunk up the car seat buckle when I get home?

On our first day in Mumbai we had a near miss.  During a poorly executed U-turn, the front end of our taxi came within inches of a speeding city bus.  The driver slammed on the brakes.  We stopped short.  I grabbed our daughter.  The bus sped by, we took a deep breath and moved on.  It seemed like one of those all-too-common close calls on the roads in India (and lots of other places) — close calls that generally seem to work out without any real bodily harm.

But there is real injury.  Each year in India, road accidents claim thousands of lives, and injure many more.  India reported more than 130,000 road traffic deaths in 2010, likely an underestimate since statistics are based on police records.  The financial cost totals approximately three percent of the country’s GDP.

2861747022_82260c0bd1_bRegulation may help, but only partly.  National seat-belt and helmet laws are on the books, but WHO data suggest that less than 50 percent of motorcycle drivers (and less than ten percent of passengers) actually wear a helmet.  The numbers for seat belts are similar.  Enforcement is anemic.  A quick spin around any major city reveals that the law is followed only intermittently, although  more motorcyclists seem to be wearing helmets than even a few years ago.  But it’s still gut wrenching to watch un-helmeted drivers, carrying two or even three passengers, including small children, hurtle through traffic unprotected.

The impact of traumatic injuries, many which do not present to medical care in time and many more which are preventable, can be measured in thousands of lives and millions of dollars.  Worldwide, 92 percent of road traffic deaths happen in low or middle income nations.  In recent years, we have trained our sights in this setting on the prevention of non-communicable diseases—diabetes, heart disease, cancer.  But remember that trauma is a disease too, with predictable incidence and injury patterns amenable to primary and secondary prevention.  And while it is not now practical to mandate rear-facing car seats for infants in most of the world, we can be aggressive in promoting strategies to minimize trauma morbidity by means of helmet and seatbelt use, safe driving, and coordinated pre-hospital and emergency care.

Flickr / Peter RichmondSecondary prevention means adequate EMS systems to respond to accidents, including ambulances that function as more than souped-up taxis.  It also means development of standardized, location-specific protocols with pre-hospital providers trained in basic first aid and advanced trauma care.  Legal protections should permit good samaritans to assist the victims of road accidents without the fear of getting caught in lengthy official investigations or police cases.

In some places, US or European-style systems might not be the answer.  While working on EMS and disaster preparedness projects in India over the past several years, many people have told me that calling an ambulance wouldn’t even enter their mind in the event of a road accident.  Traffic is congested, transport times are long, and many ambulances arrive with little more than a stretcher and a few helpers to lift a patient.  Accident victims are often transported to the hospital in private cars or rickshaws.  A few years ago, public health officials in Colombo, Sri Lanka, implemented the brilliant idea of simply training rickshaw drivers as first responders.  More recently, innovative ideas such as developing a system of motorcycle ambulances have been proposed which may mold a pre-hospital system more appropriate for congested mega-cities.

Back in New York, I work in an emergency department which serves a high volume of patients from the Dominican Republic.  We often see patients who have arrived in the US seeking care for everything from heart disease and stroke to recent trauma.  And most of those traumas, not surprisingly, are young healthy people who were involved in road accidents.

The DR ranks second (only behind the Pacific island of Niue, where a tiny population leads to skewed statistics) on WHO’s list of death rates due to road traffic deaths.  Although Dominican law prescribes that motorcycle riders (but not passengers) wear helmets, few comply.  A proposed points system and stricter enforcement may help, but only real a cultural shift that enables drivers to assess risk and make safe choices will effect change.  Studies by Dominican and American researchers show that drivers feel that helmets are unnecessary for short distances, in rural areas, or for passengers, and are perceived as costly and unattractive.

Flickr / Satish KrishnamurthySure, I’ll bring my daughter to India again, and hopefully to plenty of other places.  We won’t necessarily use the same precautions that we use at home in New York.  As I buckle her into her government-approved, rear-facing, upgraded car seat, I think of the difference between the risk I am taking, and the risk to which all those families riding two-wheelers are exposed every day.  The gap is too big, and there are too many young, healthy lives at stake.  A technological fix only represents a small part of the problem—after all, helmets and seat belts are generally available and reasonably affordable.

The real challenge is to promote a culture that emphasizes the idea that road accidents happen, that their terrible consequences can be mitigated, and that home-grown systems can be developed to care for trauma patients.

Any ideas?

 

Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician.  He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine.  He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies.  He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College.  Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries.  He lives in NYC.

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Public health vs business thinking: a case study from the Hult Prize Competition

This week, regular PLOS blogger and Oxford academic Dr Kremlin Wickramasinghe writes about the nexus of public health and business thinking – as well as some reflections on the global Hult Prize. Kremlin is currently doing a DPhil alongside his work as a researcher, quantifying the outcome of health policies addressing sustainable healthy diets.

Do public health academics and entrepreneurs think along the same lines? What would happen if we asked them to identify solutions to a problem that both groups care about? Would solutions be the same or drastically different? I had an opportunity to find some answers to these questions at the Hult Prize regional finals.

hultThe Hult Prize is funded by the Clinton Global Initiative to provide start-up funding (one million dollars) for the young social entrepreneurs who come up with the most compelling ideas to solve a problem faced by billions of the world’s population. This year the challenge was around solving the problem of rising non-communicable diseases (NCDs) such as cancers, diabetes and cardiovascular diseases amongst slum dwellers.  The judges for the prize largely come from a business background including top multi-nationals.

One of the doctoral students in my research group within the Nuffield Department of Population  Health at the University of Oxford took the initiative to form a team and enter this competition. The focus of my research group is also solutions to the problem of NCDs and we felt this would be a great opportunity to contribute to a global issue that we have a passion for. Our team comprised of three members with a background in public health and two engineers from the Healthcare Innovations Unit at the University. We were delighted to hear that we have been selected for the regional final which was held on 8th March in London from more than 10,000 entry level applications.  I am going to explain the thought process we (public health researchers) used to analyse our potential solutions and how the judges (who predominantly represented the business community) analysed them at the regional finals.

Before I go on, I need to make it clear that we did not win the regional final. But the judges gave our solution a “special mention” before announcing the winner. They said it was innovative and we should think about taking it forward. This is exactly what we heard earlier, that only one team would win, but that we should use this as an opportunity to find the energy to develop our idea into a successful social- enterprise.

One of the key criteria was that the winning solution should be able to reach 25 million people in five years.  We started brainstorming, produced a list of possible ideas and critically analysed them within the team.Through our research group, we had access to expertise in NCDs to inform our thinking.

Visiting slums in Sri Lanka One of the questions we considered was how to make screening for NCDs  more affordable and accessible in slums. However, when we shared our thoughts with public health experts they asked us what we would do when we identified people with the disease and whether we could provide the cost for treatment and further management.   The majority of slum dwellers do not have access to free healthcare and can’t afford to pay for treatment.  The public health community generally believes that it is “unethical” to screen people unless you can provide any necessary treatment. We struggled to come up with a sustainable business plan which could provide affordable treatment to patients identified through screening.

The post 2015 development goal  discussions have recognised “universal health coverage” as a major priority, but discussions with global health experts confirmed that it is unlikely to be achieved within 5 years.  Therefore we thought it would be impossible to win, if we only increased screening without assuring treatment.  We dropped that idea and decided to move ahead with a different idea that didn’t involve screening.

At the London regional finals, three out of the top four winning solutions were based on screening. It was interesting to see how judges with a business background approached their task. The winning team clearly showed how they were going to screen people for diabetes with bees!  Clearly innovative and excellent presentation by them.  They said they would send any patients they identified to the “local hospital”. They did not say how people would afford treatment. As the reason for their winning, the judges mentioned that they were able to “ focus” on one important aspect of the problem of NCDs amongst slum dwellers. This clearly shows the difference in how public health and business communities analysed the same solution.

Two teams, out of the top four, proposed to use animals for screening. When public health professionals consider novel methods of screening we think about false positives and false negatives.  So, for example, if we are going to screen people we should know how many actual cases are we going to miss (false negatives) and how many people we are going to take through for treatment even though they don’t have the disease (false positives). No screening test is 100% accurate but we need statistics on false positives and false negatives to decide the cost-effectiveness of a test before scaling up. We thought it would be impossible to win the prize without those statistics, which take time and money to produce. But judges didn’t ask about false positives and negative  nor did teams provided this information during the pitch. Judges just asked “can animals survive in slum conditions ?”. This shows that they had concerns beyond the financial model, but they were completely different to the concerns of the public health community.

Our inability to ensure that screened patients had access to treatment and the challenges of quantifying the sensitivity of potential innovative screening methods led us to conclude that it would be impossible to win if we presented a “screening solution”. However, the other teams managed to win without having solutions to these problems. As public health professionals we often attend conferences and meetings with likeminded people and take similar approaches to tackle NCDs. The Hult Prize, by contrast, brings people from different backgrounds to the same stage. It provided me with a unique opportunity to learn that the business and public health communities approach the same problem in completely different ways.

This difference in approaches might explain why most public health professionals are not successful entrepreneurs. My public health colleagues might say that this is why, despite millions of dollars in investments, we still haven’t tackled some of the biggest problems in the world. The problem is this: we invest in ideas that are attractive and “fancy”, but not necessarily tested with public health tools. If we changed the composition of the judges to a panel with 50% public health background and 50% business background, what would have been different? We will never know. This is a business plan competition and (obviously) organisers invited top business professionals to judge. They were very passionate about these issues and provided feedback and comments to teams. But I certainly gathered enough reasons to answer the first question I raised in this blog.  Public health academics and entrepreneurs do not think along the same lines.

Why does the public health opinion matter in this competition? The aim of the 2014 competition is to address one of the main public health problems in the world and the solution is supposed to reach 25 million people.  The wining solution should be implemented in many countries, which would require the approval from local and national level public health regulators around the world.

How can we move forward to align these two approaches to ensure success in our future endeavours? Clearly we cannot do this by working only within our own disciplines. Here are the important questions: Are public health professionals ready to think out of the box? Would business professionals value public health opinions at all when they make final decisions?  As the next generation, we will have to work harder to integrate these various ways of thinking if we really want to change the world.

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Connect with Kremlin on Twitter via @KremlinKW

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