External Development & Global Health

By Jason Calvert
Posted: March 7, 2013

Health economist Jason with the second in our series of articles about economic concepts crucial to global health… This article looks at the concept of externalities.

 

All actions are associated with both benefits and costs – if we believe the benefits outweigh the costs, we’ll usually take the action in question.

Let’s focus on an example, if I pay 64 cents for a cigarette, and believe the pleasure I get from smoking it outweighs the price, then I might choose to smoke it, ignoring other factors such as advertising or addiction. But there are more than non-financial costs at play here such as the health costs that may occur as a result of smoking. However, cigarette manufacturers don’t pay for any of the non-financial costs, so there is no need for them to raise prices to cover a financial (a.k.a. health) burden. The smoker, or the health system, will pick up these health and other non-financial costs.

These costs that aren’t passed on to the consumer through the price of the product are known as “spillover” costs or negative externalities.

If the manufacturer is only paying their own, private costs such as materials/ingredients, equipment, labour and potentially some taxes, then the consumers will only pay these costs, with a profit margin added on top. On the other hand, the full social costs would be the private costs as well as things like health impacts, environmental impacts and productivity impacts.

Social costs therefore include all relevant externalities.

From an economic viewpoint, this means the market price of cigarettes is below the socially-optimal level, leading to an outcome where the market quantity consumed is above the socially-optimal level (people smoke more, because the cost is artificially low and doesn’t reflect the total social ‘price’ incurred).

Externalities and the Health System

In countries where the government does not provide free healthcare – which is most of the developing world – this situation can lead to financial ruin for smokers and their families who were only made to pay private and not social costs at the time of consumption. Similarly, in countries that have access to free or subsidised healthcare, this burden is shifted from the individual to the government.

Given governments’ constant battle to reduce costs, the presence of externalities is strong reason for governments to explore the need for intervention, such as regulation to limit consumption or taxation to try and align private costs with social costs.

Externalities and Development

The externalities framework is an extremely useful lens to examine actions: micro and macro. Let’s, for example, use that lens to look at an international development project.

Consider a well-intentioned organisation set up to deliver free, treated bed-nets to a region with a high prevalence of malaria. The private costs for this action are around the production of the bed-nets and their delivery to the selected region.

The social costs are a little trickier to identify and require a bit of research into the relevant region. For example you may need to consider that there is already a local industry that produces bed-nets. What would happen to that industry if suddenly they were made available for free? The destruction of the industry would be a social cost because it involves loss of employment, productivity, revenues and output.

Thinking even more broadly, presume that the new well-intentioned organisation only plans to distribute bed-nets for a limited/set period. What happens when they stop? If the local industry was no longer operating, the product will likely have to be imported unless local industry can develop again quickly, leading to higher prices than beforehand.

People’s expectations also change. If they have been receiving the bed-nets free for a period of time, why should they be expected to pay for them all of a sudden, especially if the prices are much higher than before? This could result in a dramatic drop in their usage, leading to a potentially higher prevalence of malaria than before the organisation ran the project.

All of these are substantial social costs and negative externalities. If these aren’t considered, then the organisation will do their figures and falsely believe that their project looks efficient. If the organisation is willing to compensate everyone for the issues they create, then economic theory says we should allow it. But of course, what well-intentioned organisation would go down this path if they were actually aware of the impact they were going to have on the region? Their money and resources could be better spent elsewhere, and other potentially more sensible programs could become more attractive options.

The externality lens can be applied to the countless examples of failed development programs. In many cases their failure is due to the organisation not considering all of the negative externalities of their actions. In addition, environment and climate change issues are rife with externalities, where polluters are generally not made to pay anywhere near the true cost of their actions on the environment.

Something positive?

Externalities are not inherently evil. We’ve been talking about negative externalities.

Positive externalities also exist.

Consider the production of clean drinking water. The private costs can differ depending on the context and the chosen solution, but could range from the construction of a basic hand pump to the implementation of a comprehensive, centralised treatment and distribution system. In a context where clean drinking water was not previously available, the health improvements for the area can be extremely high, with the private costs vastly outweighing the social costs or benefits of building a pump. This is further exacerbated when you consider that the construction of a water pump isn’t associated with a profit margin taken on the amount of water pumped.

In the presence of positive externalities, government subsidisation can assist in facilitating a good return on social investments. But whilst this could be feasible in high-income nations it is not feasible in low-income nations particularly during periods of financial turmoil when the government may not have the capacity to fund subsidies – despite the potentially enormous positive externalities. This is where non-government organisations, including the private and not-for-profit sectors, can play an important development role and cover the private production costs.

Non-government action would allow the social benefits to be reaped without a large profit, if any, to be made. In short, they’re cashing in on the positive externalities and delivering/reaping benefits beyond their investment.

 

 

The term ‘externality’ is commonly thrown around, so hopefully you now have a high-level understanding of this economic concept; how it can be a useful lens to catalyse and analyse actions in global health; and the importance of contextualising the narrow use of this term within the broader social, cultural, political and economic landscape.

 

Until next time.

 

Jason is a health economist from Melbourne, Australia and works for PricewaterhouseCoopers (PwC). Since joining PwC he has undertaken consulting work across a wide spectrum of social policy areas, and this fostered a strong interest in public health. Keen to combine his skills, Jason enrolled in a Master of Public Health and focussed on health economics, economic evaluation and global health.   He recently worked with WHO (Euro) to improve their understanding and usage of health economics concepts in the area of health promotion.

Category: Jason | Tagged , , , | 2 Comments

Students Engaging Students in Global Health – One Egg at a Time…

By Brendon Neuen and Jessemine Pitt
Posted: February 28, 2013

This week, we hand the reigns of TGH over to two young inspiring student doctors from Northern Australia. Jess and Brendon encapsulate the next generation of passionate, globally aware and connected medicos.. Here they explore their already impressive journey in Global Health.

 

Sparked by a strong sense of social justice and a desire to contribute to improving the lives of people worldwide, we are passionate about Global Health and believe students such as us represent an untapped resource with enormous potential for Global Health advocacy and action.

In 2012, on the cusp of becoming doctors, we were thrilled to take up the positions of Academic Convenors of the Australian Medical Students’ Association Global Health Conference. Held annually, the GHC is an event hosted by the peak representative body for Australia’s 17,000 medical students. GHC draws upon Australia and the Asia-Pacific region’s most passionate and motivated future doctors to discover and discuss strategies for addressing our crucial global health challenges.

The challenge: convene a dynamic academic program for Global Health in the new century..

A daunting task but an inspiring opportunity, we believe that within the multi-disciplinary field of Global Health, professionals can make a meaningful difference through consultation, advocacy and research. In addition though, we believe students have a powerful role to play too. Our aim was to create an academic program with a robust and diverse agenda that would engage and encourage our peers to pursue future opportunities in health, beyond their backyards – to undertake studies in Public Health, intern for NGOs, or to launch projects at local or national levels.

In 2012, we wanted a program that reflected the latest ideas and issues in the Global Health arena. With this in mind, the four-day program featured a variety of clinicians, development economists, climate change scientists, food security experts, sociologists, and population demographers. We believe that cross-disciplinary literacy and co-operation is vital in achieving tangible improvements in the health of our global community – a concept we were keen to impart on our peers and let them experience first hand.

In an effort to create structure around a number of overlapping and complicated global health issues, the program was tiered into international, regional and humanitarian/ethical perspectives. We incorporated a mixture of lectures, fora and practical workshops to engage with delegates. There were highlights everywhere from international to local issues; a forum on the political, health and environmental implications of evolving growth in China and India, to an update on the spread of multi-drug resistant tuberculosis in Papua New Guinea, to finally the historical context of cardiovascular disease in Indigenous Australian communities.

Crucially, speakers at the Conference were of the highest calibre. Delegates had the chance to meet and learn from leading world experts, including a former Chief Economist of the Australian Agency for International Development, a former Greenpeace CEO and the Regional Representative for the United Nations High Commissioner for Refugees.

From local to global…

We knew there was a strong hunger in the Australian medical community for Global Health education. From humble beginnings in 2005, GHC has grown from a small one-day workshop to a stand-alone, 500-student conference that sells out nation-wide in 10 minutes. This is a testament not only to the success of the annual conference, but more importantly, the ever-increasing interest in Global Health from medical students.

In an interconnected world facing multi-national challenges such as climate change and non-communicable diseases, the Global Health Conference plays a vital role in supplementing the core curricula of Australian medical schools.

The highs and lows..

This was not to say it was always smooth sailing. At times it was difficult to balance this responsibility with clinical, research, and part-time work commitments. But by sharing the workload, and developing a shared vision of the kind of Conference we wanted to hold, we managed to juggle our desire to host an inspiring and informative conference, with the day-to-day of university.

A favourite conference moment of ours came from one of the staunchest of clinicians. He is a respiratory physician with significant clinical and research experience in Indigenous health – someone who, by his own admission, “has to be dragged kicking and screaming to the policy table”. In a panel discussion, he mentioned that throughout his career, the decisions that have led to the largest improvements in the health of communities have always involved strong policy leadership and implementation. For us, this resonated loudly.

As soon-to-be doctors, we believe our strongest suit will always be bedside advocacy – we must be vocal and relentless in our call for a response to 21st century healthcare challenges, and we must demonstrate leadership in the implementation of evidence-based interventions.

So where to next?

This year, Jessemine and I will join the Australian delegation at the International Federation of Medical Students Association (IFMSA) General Assembly in Washington D.C. in March. Its mission “to champion health access, health equality and the social determinants of health for global citizens” reflects our own Global Health Conference. Jessemine will also complete her final year of medical school whilst commencing her Masters in Public Health and Tropical Medicine. She will then spend the remainder of 2013 gaining some remote medicine experience in Cape York, Queensland, and on clinical elective in Takoradi, Ghana. Through these experiences, she hopes to develop a career that contributes to the improvement of health outcomes in vulnerable populations through fieldwork, practice-driven research and local capacity building.

I will take this year to focus on completing my Honours project in renal medicine, as well as spending two months in the clinics of remote Indigenous communities. In addition to this,  I will also update the Australian Medical Students’ Association policies as part of the Global Health Policy Review Committee. In my spare time, I am also volunteering with the Humanitarian Settlement Services program, assisting new refugees to settle in Australia. In a few years, I hope to combine physician training with a research career within the Global Health sphere, with the goal of commencing a PhD at the George Institute for Global Health in Sydney.

A call to all.

For those reading this, whether you are an undergraduate student, a young professional or an experienced professor, there has never been a more important and easier time to become engaged with the concerns facing our global community.

Technology and social media have not only allowed unprecedented access to information, but it also provides a vehicle for engagement in public discourse and contributes to policy advocacy. Social media has fundamentally changed the way that we connect – news now breaks on Twitter, citizen journalism is now as valuable as paid journalism, and the increasing presence of public health ambassadors in the digital era has created a new gateway for social mobilization in times of international crisis.

Although by their nature, global health challenges transcend national boundaries and may seem insurmountable, collaborative efforts and small steps are the best ways to overcome these challenges. It is therefore vital, that from each experience we convert inspiration into concrete action, however small those steps may seem. As a West African proverb puts it succinctly, “nice words are good, but hens lay eggs”.

 

Jessemine is a final year medical student at James Cook University. In 2012 she took on the role of Academic Convenor for the Australian Medical Students Association (AMSA) Global Health Conference. In addition to physician training and acute medicine, her interests lie in sustainable development, the politics of global investment, and international relations shaping trade, investment and finance in the developing world.

Brendon Neuen is a final year medical student graduating with honours from James Cook University, Australia. Prior to his position as Academic Convenor of the Global Health Conference, he spent two years as an executive member of his University’s Global Health Group. He has a strong track record in evidence based medicine and research, including consecutive Summer Research Scholarships at the Cochrane Renal Group in Sydney. His main interests are in internal medicine, nephrology and global health. 

 

Category: Brendan, Jessemine | Leave a comment

A Journey to the Frontline: Humanitarian Healthcare in Afghanistan

By Jennifer Jamieson
Posted: February 17, 2013

This article is a transcript from a recent interview with Prue Bentley on 774 ABC Melbourne Radio, Australia. Prue interviews doctor and humanitarian advocate Dr Jenny Jamieson about her recent 6-month mission to Afghanistan with Médecins Sans Frontières. PLOS Translational Global Health is proud to have Jenny as a guest blogger.

 

There are few places in the world that appear as inhospitable as Afghanistan. The news from there is almost always awful and I think in many ways we have become inured to the images of people there that we see from there  – the dead, the injured, the military, all against the backdrop of the desert. There are these recurring images of Afghanistan that we take for granted and we place as automatic when we think of the country.

Today we are going to find out what it is really like being there. Jenny Jamieson is an emergency doctor from Melbourne who has just spent 6 months working in Kunduz in northern Afghanistan for Medecins Sans Frontieres.

Jenny, take us to Afghanistan. You are a woman from Melbourne. You fly there, you get off the plane and you go to a trauma hospital where you are going to be working for the next 6 months. What’s your first impression?

My first impression is that Kunduz is a very mountainous area, with this staggering backdrop of mountain ranges which are placed in amongst the desert as well. It’s dry and dusty, it reaches these extreme temperatures in summer with temperatures of 49*C and drops down to -15*C in winter. So you’re sort of struck by the climatic extremity first of all! And then you have to deal with the day-to-day medical practice of the trauma hospital. So it’s a lot to take in at first, that’s for certain. 

What is the day-to-day routine like in a trauma hospital? Is it anything like you experiences here?

Well, no! It’s quite different. The trauma hospital there was set up initially to provide trauma care and assistance to war-wounded patients, those affected by violence and the consequences of the conflict. But it also provides standard trauma care to patients who have been injured in road traffic accidents, domestic violence and falls.

When I read about this, I was actually quite surprised, because I immediately assumed that this is all about the conflict, all about the war going on there. And you do forget that people forging their own lives and they may have a trauma that has nothing to do with the conflict there.

Absolutely, that’s true. Due to the poor infrastructure in parts of Afghanistan, there are a lot of road traffic accidents from cars, rickshaws, motorbikes and pedestrian accidents. 

What was the main thing that you were doing there? Was it a constant stream?

Yes, it was a bit of a constant stream! Actually my role was quite interesting. As many people know, Medecins Sans Frontieres is a humanitarian medical  organization and most of their field projects will work in emergency epidemics, nutrition programmes and vaccination campaigns. The trauma hospital in Kunduz was something a little bit different, particularly because they decided to set up a small intensive care unit. Intensive care units in low-income countries are usually viewed as a bit of an unaffordable luxury. Because critical care is so integral to trauma care, MSF decided to do a small trial with four ICU beds and I was actually there to oversee that and work as the intensive care doctor.

How many other people were you working with?

We had quite a big team in Kunduz. We usually had two surgeons, a general and orthopaedic surgeon. We had an anaesthetist, a surgical nurse, an emergency doctor & nurse, two inpatient nurses, a physiotherapist. plus the intensive care nurse and myself. Additionally, we then had a large team of national medical staff whom we were working alongside and helping. Then there were all the non-medical people who are integral to many of these medical missions – the logisticians, the supply team, the administration team and the field coordinator.

When it comes to hospital services and trauma services, how does Afghanistan stack up? Is there anything there at all without the services of MSF or international organisations?

Yes there are, but these have been adversely affected by years of conflict. Many people think of Afghanistan as coming on the map simply after 9/11 but the country has been plagued by conflict, both internal and external, for decades.  This has had quite a devastating effect on many of the healthcare facilities there. The government hospitals are quite poorly run and poorly staffed and a lot of the medical doctors working at these institutions have left the country. As well as that, the hospitals are not necessarily neutral. As you know, MSF is neutral and impartial. We are not affiliated with any government or military organizations. We don’t take sides in the war or discriminate against patients. So this means that a member of the Taliban were injured and they turned up to a government hospital they might be turned, they may be actively discriminated against and turned away, not receiving any medical care in Afghanistan. Because MSF is there and we practice this neutrality and impartiality, we were treating anyone and everyone.

What was the hardest thing about living in a war-zone?

There were many many challenges. I think one of the hardest things for me was seeing the mass casualties and this is something that I don’t deal with on a daily basis here at all – in fact, I’ve never seen anything this before!  Whilst I was there, there were two suicide bomb attacks in the town of Kunduz, with up to 40, 50 or 60 casualties turning up to the MSF hospital all at one time.  Learning how to deal with that many trauma casualties turning up all at one time was definitely a very challenging thing to deal and very hard. 

Did you see positive things over there?

Absolutely. Without doubt, the positives outweighed the negatives and as you were alluding to before, we get plagued by images of the war, conflict and injuries. But there are many positive aspects. The people there are lovely and were an absolute constant source of inspiration for me. The team I was working with were all trying to work towards a better future for Afghanistan. 

It may be a long time coming though?

I think it will be.

As a woman in Afghanistan, how did you feel?


I think my role was a little bit different and I certainly can’t comment on what it is like to be a woman in Afghanistan. As an expatriate who is there in a medical role, it is probably a little bit different and I was working alongside a highly educated team of Afghan doctors, so I never experienced any setbacks as a result of my gender. The only thing that was a little bit different for me, was that instead of wearing my scrubs to work, I was wearing the long traditional shalwar kalmeez, with tunics down to my knees, and a headscarf or veil on as well, so learning how to do some medical procedures with this was a bit tricky at times.

You mentioned the expat community in Afghanistan. And I’m sure they’re probably quite tightly knit. You’re not working an all the time, so what did you do when you weren’t working?

To be honest, we did work an awful lot – 7 days a week and I remained on-call 24 hours a day. Our downtime was spent with the rest of the MSF team in the field as we don’t have much to do with the other expat organizations there, especially none of the military organizations In Kunduz. Simply for security reasons, we had quite limited movement restrictions. We had 15 other expats living in one guesthouse, so when we were not at work, we had to be at the guesthouse – you couldn’t just go for a run or a walk down the street.  So our existence could be described as quite contained. But we kept ourselves amused – we created a rooftop cinema and we had a small treadmill in the basement or bunker, so there were activities to do in our spare time. 

There is obviously going to be a culture shock going over to Afghanistan. But is there a culture shock coming back to Melbourne?

Absolutely. And I think this is something that doesn’t really get talked about very much and it’s the concept of a “reverse” culture shock. This is when you’ve actually been somewhere that is so completely different and you come back home to reality and find that you’re confronted by your normal everyday life. So for sure, there is, but as long as you expect a certain degree of this, then it is something you can come home prepared for.

Is it something you would do again?

Yes.

Why?

Because I believe in humanitarian emergency medicine. And this is something that MSF has been doing since 1971. I believe in their principles of independence (they are not affiliated with any governments or military organizations), they are neutral (so they don’t take sides in any conflict), and they are impartial (they don’t discriminate against anyone based on age, gender, ethnicity, political affiliation). So for sure, I will absolutely go and work with MSF again.

It’s a brave thing to do. We’ve spoken to a few people this week who have taken themselves out of their normal lives and gone somewhere they never thought they would go. Do you keep in touch with many of the people over there?

I do. I exchange emails with many of my MSF colleagues and ICU team quite frequently.  When you’re in such an intense environment you really do forge lifelong friendships. And I don’t know when I will return, so it’s important to keep in touch with them.

Did you get any sense whilst you were over there of the future of Afghanistan post-conflict and what it would take to rebuild the country?

That’s a million dollar question, isn’t it? Maybe it’s a multi-billion dollar question actually! I think there’s no easy answer. MSF is aware that medical assistance and healthcare provision is really only part of the answer. The answer is going to enailI think it will entail addressing the social, political, cultural and economic aspects of healthcare. I don’t think there is a quick-fix solution there. 

Thank you so much for coming in today. You’ve certainly given us all a different perspective of Afghanistan.


Dr Jenny Jamieson is an emergency doctor who has just returned to Australia after spending 6 months working in a trauma hospital in northern Afghanistan. She is a co-founder of the Global Health Gateway, an organisation dedicated to keeping young health professionals engaged in global health activities and work. She has returned to Melbourne to continue her specialty training and global health pursuits.

Category: Jamieson | Tagged , , , , , , , , , | 1 Comment

Politics and Global Health – Are we missing the obvious?

By Greg Paton
Posted: February 11, 2013

This week, a group of prominent health academics and leaders will meet in London to launch a renewed effort to narrow the evidence and implementation gap in the fight against humanity’s largest cause of premature death and disability.

Convened by The Lancet to launch its latest series on non-communicable diseases (NCDs), this gathering presents a critical opportunity for researchers to forge consensus on a plan of action to achieve the global NCD targets agreed by governments in November. Policy discussions in this area can easily be spread thin given the complexity of the systems that shape our health – global food systems, lifestyle patterns, physical environments, and culture, to name a few. A recent forum hosted by The Economist on NCDs and their social determinants featured what seemed like hundreds of suggested priority areas for action from the expert panellists.

The difficulty of distilling simple interventions from these broad areas should not be underestimated. Challenges the world once approached with hubris – polio eradication, for example – are now recognized as complex problems, intertwined with deep cultural and social factors. Despite such complexity, scientists and policy makers must derive simplicity from these challenges to create interventions that can be implemented and measured.

At a similar meeting convened by the Lancet in 2010, former UNAIDS Director Dr Peter Piot was asked how a group of diverse advocates, academics and politicians managed to agree on a set of concise targets at the United Nations Special Session on HIV/AIDS in 2001. “We scribbled them on the back of some napkins a few weeks before the meeting”, he quipped.

He explained that the process threatened to devolve into a diluted effort and lose direction, given the social complexity surrounding AIDS and lack of scientific consensus on interventions at the time. It ultimately fell to a few leaders to identify a small set of measurable actions and rally support. Although many of those targets did not address the core societal causes of AIDS, they were based on the best evidence of what could be achieved within political realities.

The NCD community woke up to these realities in 2009 and took a page from the AIDS playbook when it began pushing for its own global targets. The result, governments have now agreed to reduce salt consumption, trans-fats and tobacco use, increase access to exercise and healthy food, and a host of other targets that could create unprecedented health gains by their end date in 2025.

A major question still remains though – how can we incentivise governments to achieve these targets and change the systems that impede their achievement? They are non-binding and were agreed within the World Health Organization (WHO), where precedence exists for governments making aspirational speeches, endorsing resolutions, and then failing to translate this rhetoric into meaningful action.

Long progress reports will be issued by WHO containing pages of data, but these will likely avoid venturing into political territory or holding governments accountable. Are we beginning to see the limits of solving a problem that requires political change through an apolitical entity that has little power to influence the policies that create NCDs?

This is a key reason why many have advocated for bringing NCDs under an umbrella partnership that unites UN agencies working on food, development, trade, health and other areas, hoping that this approach would trickle down to countries. Such a global structure would inform and shape multi-disciplinary approaches at national and regional levels. Ministers of Health often lack the power of their counterparts overseeing trade, economic development, and agriculture. Their ability to address the wider determinants can be hindered or even impossible, without these counterparts on board and in the room.

If we play the politics wisely, the targets agreed by governments could offer a carrot and stick to incentivize countries to improve the social, political and economic policies that frame people’s behaviours and decisions – a necessity if the targets have any hope of being reached. If we don’t, there is little likelihood that progress reports and plans issued by intergovernmental agencies will have much impact or change the rules of the game. Lancet Editor Richard Horton said it best: “if we miss dealing with these determinants, we will have failed catastrophically.”


Greg Paton is a psychology and business graduate from Vancouver, Canada who has worked in international health since 2006 and consulted with NGOs, intergovernmental organisations and the private sector. He coordinated the initiative for the 2011 United Nations Summit on NCDs and played a lead role in developing and launching the NCD Alliance, serving as its first manager from 2009-2011. Greg currently lives in Kampala where he works as a consultant to organisations engaged in addressing cancer and other NCDs.

Category: GregPaton | Tagged , , , , , , , , , | 2 Comments

Cancer and the Global Equity Divide: A Call for Action.

By Toni Kuguru, Sebastian Rodríguez Llamazares, Alessandro Demaio and Felicia Knaul
Posted: February 1, 2013

This year more than half of the nearly 13 million new cancer cases diagnosed worldwide and two-thirds of cancer deaths will occur in the world’s low and middle income countries (LMICs). Nearly a third of these deaths could have been prevented with the knowledge and technology already available today. For example, only 10% of children diagnosed with leukemia in the 25 poorest countries of the world will survive compared to 90% of children diagnosed with leukemia in Canada.
The disease burden in developing nations is growing. Caused by an inequity in health, healthcare and resulting disease, the disparities across the cancer care continuum found between rich and poor countries remain largely unaddressed.  The cancer divide is the result of these disparities — explained in the report of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries-GTF.CCC and in the book Closing the Cancer Divide:  An Equity Imperative.

The Cancer Divide

Evidence of this growing burden in LMICs is only beginning to be translated into effective and practical solutions. Traditional rhetoric argues that the challenge of addressing cancer in poor countries is unnecessary, unaffordable, unrealistic, and detracts resources from other more pressing development programs.  However, the impending cancer crisis in LMICs remains too large to be ignored. The Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries-GTF.CCC, building on work of agencies such as the World Economic Forum and the American Cancer Society, estimates the worldwide economic losses from cancer (including loss of income and suffering) amount to 4% of global GDP. Further, cancer affects human development as it has the potential to be both the cause and outcome of poverty.  And in many cases, cancer will only drive the poor into deeper poverty. Inaction is unaffordable at both the micro and macro settings.

In LMICs, for many cancers, over half of deaths could have either been prevented or avoided. In 2008, infection-related cancers accounted for almost one in four of diagnosed cancers in LMICs compared to less than one in ten in richer nations.  For some cancers such as breast and cervical, early detection and treatment are key to successful outcomes.  However, due to weak health systems struggling to deliver screening programs, many cancers are diagnosed late and cancers that should be treatable become terminal.

A lack of access and availability of affordable drugs and chemotherapies in LMICs, essential in treating or even curing many cancers, further drives avoidable mortality.  Similarly concerning, given that LMICs account for less than 6% of worldwide morphine consumption, millions of cancer patients in LMICs needlessly die in pain due to a lack of access to basic pain medications.

Some Good News

Closing the cancer divide is an equity and moral imperative.  While the challenges seem daunting, there is good news.  Affordable and effective cancer care programs already exist and demonstrate that strategies for prevention, detection, treatment and relief of suffering can succeed in resource-poor settings.

  • Promoting healthy lifestyles, including tobacco control, can significantly impact the cancer burden in LMICs where more than 80% of smokers reside and tobacco use accounts for over 30% of cancer deaths.
  • Integrating detection programs with current initiatives such as MCH and HIV/AIDS programs can also increase the likelihood of early detection resulting in better outcomes.
  • Innovative service delivery strategies such as telemedicine are in operation or being explored, linking hospitals in LMICs to specialty centers, such as St. Jude Hospital in Tennessee.

Globally, governments, funding bodies and development-partners of LMIC are beginning to recognize the growing burden of cancer. Nations such as Kenya are developing national cancer control strategies. Kenya’s first Cancer Prevention and Control Bill was tabled in Parliament in 2011, which focused on cancer registration and prevention as well as introduced policies protecting the cancer patient against discrimination in the workplace, schools, insurance schemes, and health institutions. Similar comprehensive strategies in Mexico have demonstrated that including childhood cancers in its Seguro Popular insurance program increases survival significantly.

Our Call: What we can do together

World Cancer Day is approaching. To celebrate, highlight lessons learnt globally and promote affordable, effective, country-specific cancer care and control (CCC) initiatives, the Student Government of HSPH, Students in Latino Public Health, the Harvard Global Equity Initiative, and the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, are raising awareness and dispelling the myths about cancer. Dedicated to improving global health, we are empowered to translate what we are learning and sharing in the classroom into evidence-based advocacy. As global advocates, we are mobilizing students and people from around the world to collectively have our voices heard: we will not ignore the cancer divide.

We strive to empower people that live with cancer as well as those who seek to support efforts to meet the challenge of the disease in LMICs.  We aim to dispel the myths and collaborate with the global movement launched and led by the Union for International Cancer Control (UICC) by collecting signatures for the World Cancer Declaration. We feel it is time to raise our voice and undertake this challenge.

Inaction is unacceptable.  Join us in this call-to-action to close the cancer divide and sign the World Cancer Declaration today.

 

 

Toni Kuguru is a MSc candidate (2014) at the Harvard School of Public Health (HSPH) and an intern at the Harvard Global Equity Initiative (HGEI). At HGEI, she is researching cancer survivorship in low and middle income countries. She also serves on the Harvard Africa Development Conference planning committee. Prior to HSPH, she worked at the Nairobi Cancer Registry at the Kenya Medical Research Institute (KEMRI).

Dr. Sebastián Rodríguez-Llamazares is a Mexican physician with experience working in underserved rural communities. Because of this, he is now pursuing a Master in Public Health degree at Harvard School of Public Health. He strives to design and implement feasible interventions that bridge the gaps of health inequities worldwide.

Dr Alessandro Demaio is a medical doctor, originally from Melbourne, Australia, with a Masters in Public Health. In 2010, Sandro began a PhD in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). His primary research project is based in Mongolia. As a Director for NCD Action, in 2013 Alessandro will be a fellow at the Copenhagen School of Global Health and Harvard Medical School.

Dr. Felicia Marie Knaul is Associate Professor at Harvard Medical School and Director of the Harvard Global Equity Initiative, where she serves as Co-Director of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, an initiative she helped to found in 2009 and for which she is lead author and Editor of Closing the Cancer Divide available as a report in English, Spanish and Russian; and a book distributed by Harvard University Press in 2012. After being diagnosed with breast cancer in 2007, Dr. Knaul founded Cáncer de Mama: Tómatelo a Pecho, a Mexican civil society organization that promotes research, advocacy, awareness, and early detection initiatives for breast cancer in Latin America. Dr. Knaul has more than 130 academic and policy publications spanning topics including breast cancer, cancer care and control in developing countries, health system reform, women and health, and children in poverty. Dr. Knaul has held senior government posts in Mexico and Colombia and has worked for bilateral and multilateral agencies including WHO, the World Bank, and UNICEF. She is a board member of several organizations including the Union for International Cancer Control.

Category: FKnaul, HSPH | Tagged , , , , , , , , , , | 1 Comment

What can global social movements learn from microbes – Part 1

By Sandeep Kishore
Posted: January 15, 2013

I love social movements. I started working on them ever since my university days over a decade ago. The passion. The creativity. The hope. It’s life-affirming. I also like microbiology. I completed my PhD in microbiology and am now completing my medical training. I see suffering daily, often needless suffering, for which I believe social movements can help mend.  But I also see failures in myself, in peer communities and beyond, on building and sustaining human social movements. Something isn’t quite right. Slowly, but surely, ego, turf wars and inefficiencies dominate and the movements die out. They do not evolve. Recently, my science word and social movements world began to collide as I realized that we can learn an awful lot from how some of the most ‘primitive’ creatures on the planet – microbes – organize themselves.  Indeed, Human social movements can learn from microbial ones.

I will focus on this in 3 parts  over the coming months.

Let’s start the series with amoebas.

You see, 100 million years ago, amoebas were in trouble. Big trouble. As single-celled, haploid protists they were individually starving for food. They were dying off.

Then, some amoebas underwent an adaptation so fundamental that it changed the world: they came together.

One by one, members would come together to form a slug-like creature, a plasmodial slime mold, that moved with collective polarity towards a food source. Once fed, the slug like creature would transform to a stalk-like creature with 80% of amoebas forming the stalk and 20% the spore seeking a vector in the soil (usually a snail) to transport the spores to newer pastures. This initial cohesion was incidentally the dawn of multicellularity. This was, simply said, nature’s first social movement. And, it was magnificent.

These adaptations in moments of crisis remind us humans of what is at stake right now in the parable of our species — of our human history. It’s easy to forget. For the first time in human history, there will be more people over the age of 65 then under the age of 5. And yet there is regress, not progress: in rich countries, the children of today may not live as long as their parents – life expectancy is stalling and may even decline. Globally, rich or poor, we are expanding, not compressing, morbidity. We are headed in the wrong direction.

The slime molds and their seminal movement may provide some hints for us humans.

First, they put ego and turf aside. Too often in social movements there is turf that keeps individuals or organizations operating as single, isolated amoebas (or ‘siloes’). I would argue, that this cost lives and does not maximize individual & collective good. Slime molds knew better. They were social.

Second, the slime mold movement was not perfect, but there was movement. Lots of it. Slime molds moved toward higher ground where food was more abundant. Human social movements often, well, stagnate quietly and then start to rot.

The next part is my favorite: slime molds differentiated themselves to figure out tasks – each amoeba assumed a task (much as the individuals cells in humans do). There was little redundancy; and great support. One curious question is whether the 80% of amoebas that supported the 20% that were able to leave to other pastures were truly unselfish; or whether the 20% that made it to the top were simply out-competing the other 80% in the amoeba race to the top. It’s not clear –  we still don’t quite know. But what is very clear is there is great organization and role definition in how these social amoebas organized themselves to get things done.

Finally, slime molds were humble. Sometimes, they needed a champion (in the form of a snail or some other soil-dwelling creature) to get things done — and they used the champion wisely. We should always be asking who our champions are – on the lookout for asking other humans the basic question of “Will you be my snail?”. It could mean the difference between life and, well, extinction.

Where are the real-world applications you ask?

Just ask the winners of the 2010 and 2008 Ig Nobel Prize, given for science that at first is laughable, but then makes you think. These Japanese and British researchers won the prize for comparing how one slime mold (Physarum polycephalum) can inform how the Tokyo rail system could optimize their train networks (2010). They observed biologically inspired networks that could help solve costs, inefficiencies and provide solutions to human infrastructure problems. And in 2008, they showed slime molds are smart: they showed slime molds can solve puzzles (Intelligence: Maze-solving by an amoeboid organism).

Taking a lesson from slime.

Thus, cooperation, cohesion and community were vital for nature’s first social movement. 100 million years later, in humans, we can/should/must learn from slime molds – after all if social amoebas can (and still do) inform how we build rail networks in Tokyo, can they not help us solve the puzzle of building better, more robust social movements for Global Health in the 21st century? Perhaps for our greatest leap forward, we must look millions of years backward.

Stay tuned for more parts on translating what we humans can learn from microbes.

Sandeep Kishore is a microbiologist (with a PhD on the evolution of how malaria came to infect humans), and an M.D. student at Cornell University. He is the current Chair of the Advisory Council for the Young Professionals Chronic Disease Network & NCD Action Network. He is interested in crafting approaches to 21st century health with emerging knowledge leaders globally. Find him on twitter @sandeep_kishore or @ncdaction

Category: SKishore | Tagged , , , , , , , | 4 Comments

TGH NEWS: Women’s health must not be forgotten

By Alessandro Demaio
Posted: January 11, 2013

In the coming weeks, the eyes and ears of the global health community should be firmly fixed on two exciting developments aiming to highlight, support and address the inequity and suffering associated with a continued global gap in maternal health.

The first is the official launch of the Year 1 Maternal Health Task Force (MHTF)-PLOS Collection on Maternal Health.. The MHTF is supported by Harvard School of Public Health and the Bill & Melinda Gates Foundation, who, together with PLOS, have created a collection to  improve women’s and children’s health worldwide through greater access to more comprehensive maternal health information and knowledge.

This Year 1 Collection has been accompanied by a recent call for papers for Year  2, which together aim to highlight and advocate for increased scientific evidence on maternal health and against a persistent lag in progress towards Millennium Development Goal 5. An important opportunity to further and share science in an under-explored domain, the Collection aims to reach out to researchers and professionals, medical professionals and policy makers worldwide.

The official launch of Year 1 will occur at the Global Maternal Health Conference, taking place in the middle of this month in Tanzania. Focusing on challenges to maternal health and disease, the Arusha meeting will see the launch of the first PLOS series on Quality of Maternal Health Care, with scientific contributions from India, Vietnam, Sri Lanka, Ghana, Zambia, Nigeria, Lesotho and other parts of sub-Saharan Africa. Arusha will also see the formal call for papers for the second series this coming year entitled “Maternal health is women’s health – maternal health in the context of women’s health throughout their lifespans”.

The MHTF-PLOS Collection on Maternal Health is a three-year open access collection.

More information is available on the Year 2 call and conference, including live streaming of the plenary sessions, online or via the Twitter tag #GMHC2013.


Dr Alessandro Demaio is a medical doctor, originally from Melbourne, Australia, with a Masters in Public Health. In 2010, Sandro began a PhD in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). His primary research project is based in Mongolia. As a Director for NCD Action, in 2013 Alessandro will be a fellow at the Copenhagen School of Global Health and Harvard Medical School.

Category: Sandro | Tagged , , , , , | 1 Comment

Climate Change and Obesity?

By Alessandro Demaio
Posted: January 4, 2013

This is likely to cause controversy, but I am going to draw a line in the sand. We have a number of massive Global Health challenges to address as a society, but to me, there are none more pressing, threatening or crucial to act upon than Climate Change and Non-Communicable Disease (NCDs).

The BIG Two.

At face value, one could be forgiven for seeing these two defining global health challenges as unrelated. Forgiven for thinking of them as separate problems with distinct causes for which we need two groups charged with the implementation of unique solutions.

But take a closer look, and you will realise a few things. These are two massive challenges largely resulting from, and solved by, the same determinants. Also, that the immediate and long-term benefits of addressing one are enormous, dwarfed only by the benefits and co-benefits of addressing both together.

The global health community has a lot to do in the coming decades, with increasingly less. Limited fiscal, human and natural resources available – compounded by austerity and economic conservatism during what could be a lengthy or permanent downturn in government budgets and overseas aid. As a collective, we must look more to opportunities for common progress and gains, and less to siloed initiatives as we have seen in the past few decades. We must seek out social investments which will maximise the benefits returned. One way of doing so, is to look for measures which will solve multiple problems, or address problems which are caused by the same determinants.

We must acknowledge that slicing major challenges into verticalised problems diminishes or precludes opportunities for common progress.

You see, NCDs and Climate Change do in fact share the same causes and largely require the same solutions. Carbon-intensive and labour-conserving lifestyles; highly-processed food requiring large energy inputs; larger portions of meat and higher calorie diets; increasing air pollution… Yet we separate their responses and those commanded with their mitigation. Health is dependent on a healthy environment, both urban and natural.

The GOOD News.

What’s exciting though, is that given their shared causes and mitigation strategies, by addressing one we will also be addressing the other. By tackling climate change, in addition to bringing the health benefits associated with this alone, we could also bring co-benefits of a reduced burden of chronic disease. By investing in ways to make healthier, less-processed food more affordable we reduce the carbon-intensiveness of our diets but are also likely to see a reduction in diet-related diabetes and heart disease. Providing safe public environments conducive to biking or active living will not only reduce carbon emissions and environmental pollutants, but may also reduce community rates of asthma, lung disease and even cancers.

This idea, or the inter-linked nature of Climate Change and NCDs is not new. But it continues to largely fly under the community radar. A greater awareness could lead to further discussion, engagement, collaborative mitigation and collective action.

–

The Conversation

This article was simul-blogged at The Conversation.


Dr Alessandro Demaio is a medical doctor, originally from Melbourne, Australia, with a Masters in Public Health. In 2010, Sandro began a PhD in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). His primary research project is based in Mongolia. As a Director for NCD Action, in 2013 Alessandro will be a fellow at the Copenhagen School of Global Health and Harvard Medical School.

Category: Sandro | Tagged , , , , , , , , | 8 Comments

Transforming health care: one SMS at a time?

By Fred Hersch
Posted: December 26, 2012

I’m Fred Hersch, a medical doctor and techy with a passion for global health. I’m interested in the role of technology for improving access to essential healthcare. With years of experience developing web solutions (prior to studying medicine though I still do it), I bring a bit of pragmatic reality to the discussion about technology and healthcare. Don’t get me wrong, I’m a believer that technology has a huge role to play but it’s no silver bullet either. It’s what you do with it that counts. This article is the first that looks at what is going on in the health technology space and thoughts about how technology can be harnessed to improve the health of people everywhere.

mHealth is everywhere you turn these days. The mobile phone has become the new “must have” for any serious “innovative” global health project. Everyone’s doing it, hell, we’re even making jokes about it! Have you heard the one about how there are more pilots in mHealth than there are in the US Air Force? So, what is it about the mobile phone that has the global health community so excited, and what are the opportunities offered by technology and innovation?

The context

Health for all has been a long held goal.  The Alma Ata declaration of 1978 laid out the Primary Health Care (PHC) model which emphasised people centered care and advocated for equitable access to essential services. The Millennium Development Goals re-invigorated efforts at PHC in many countries, and as we attempt to deal with the growing threats of non communicable diseases, strong primary care systems are essential.

At the heart of this definition lies access and equity which in turn bring up two very important issues; that of an adequate health workforce to deliver the care, and who pays the bill.

On the first, according to the WHO, there is a global health work force shortage of 4 million health workers. In 57 countries, this shortage is at critical levels.

In terms of who pays the bills, it is not just the USA that lacks some form of universal health care. A quick look at the map, and it becomes apparent very quickly, that universal access (in green) is the exception not the rule.  In many poor countries (most of the gray), out of pocket health expenses can be so great that they lead to poverty.

Towards solutions

Mobile telecommunications have been a true revolution. Many countries have leap-frogged traditional “copper wire” landlines and gone straight to mobile. In 2012 there are approx 6 billion subscriptions. 4.5 billion in developing countries with approx. 1 billion in each of India and China. It is the ubiquity and the accessibility – in terms of both affordability and equity that make the mobile phone such an attractive platform for healthcare.

The global health community has been quick to see the potential opportunities across the health system spectrum. Over the past few years there has been a proliferation of activities, pilot projects and (mostly small scale) implementations. Examples include: (i) improving health care services at the community level e.g ChildCount or Project Mwana based on RapidSMS, (ii) real time public health promotion e.g.  Project Masiluleke – HIV/AIDS prevention via SMS in South Africa, (iii) clinical decision support and patient management e.g. via CommCare, (iv) real time data collection in the field e.g. EpiSurveyor.

The list goes on.

The mHealth arena whilst still in its infancy is maturing. Companies like DataDyne (makers of EpiSurveyor/Magpi) and CommCare provide supported hosted cloud-based solutions. The RapidSMS framework is open source and freely available for download. The mHealth alliance and TechChange have teamed up to run a course: “mHealth: mobile phones for public health“ (in which I recently participated). And smart phones and tablet computers are becoming more available in low and middle income countries, providing another avenue for supporting primary care workers e.g. for clinical decision support in rural India.

The transformation of health care

Disruptive innovation is a transformational process by which the existing “status quo” is challenged to such an extent that a new model takes over or “disrupts”. Often driven by technology, it is the process innovation that leads to new value networks or outcomes. In our case, “affordable healthcare” for example.

And this is where the exciting opportunities lie.

Solving the health care problem for the ‘bottom 3 billion’ will take new partnerships and new ways of working together. It will require smart use of technology (such as the humble mobile) and the development of affordable health care devices (such as diagnostics) that enable health workers to deliver more for less. And most importantly it will require new ways of thinking. How technology is used by innovative minds trying to solve this problem in the field will lead to the new approaches and models.

The final word?

For all of us interested in the health of populations, the mobile phone is an exciting tool for improving health service delivery. As global health professionals we need to understand this potential and how to harness it for driving innovation. Whether it be m-health or e-health, we are at an exciting time where if used properly, technology can move us towards reimagining health care in such a way that “health for all” is a bit closer.

Category: Fred | Tagged , , , , | 4 Comments

Global Trade: for healthy populations or healthy profits?

By Jo Jewell
Posted: December 17, 2012

If we go back to the basics of epidemiology, it is abundantly clear that patterns of disease are converging globally, with NCDs emerging as the major threat to population health worldwide. Other threats of course remain – indeed low- and middle-income countries must now grapple with a potentially debilitating double burden of disease – but NCDs are ubiquitous. Tobacco smoking, alcohol consumption, unhealthy diet, physical inactivity and obesity are pervasive as risk factors globally. Last week’s launch of the Global Burden of Disease study confirmed this.

While it is clear in many cases that lifestyle behaviours associated with these risk factors are the immediate causes of disease, it is also clear that other underlying factors (or actors) must be driving this rapid convergence in behaviour and patterns of consumption. These changes have resulted in unprecedented levels of NCDs. Governments are indeed looking for solutions, but not always in the right place.

In this light, let’s explore the principle of ‘first, do no harm’, and examine it from a specifically global perspective – trade and globalisation.

The production line of (ill-) health

As many are aware, NCDs are largely preventable. In fact, the biggest opportunity (and challenge) is to reduce the contribution of risk factors such as tobacco smoking, alcohol consumption, unhealthy diet and physical inactivity to the rising burden of disease. In order to make meaningful progress in tackling NCDs, we need action that goes to the core of these risk factors by addressing supply-side factors and the environmental determinants. These are the push factors that drive trends towards increased consumption.

But what are supply-side factors and environmental determinants?

When we talk about supply-side factors and environmental determinants we immediately think about what is being produced (in what context and with which incentives); what is available; how much it costs; and, how it is marketed. An important factor in the obesity epidemic, for example, has been the availability, affordability and promotion of fast food, and the incentives along the food supply chain for its production and sale.

When faced with serious health challenges, government has a clear role to play in using these lever points for public benefit. But, as we will see, a government’s ability to take action to address this is sometimes limited by existing commitments to international trade.

Tobacco control policies are the most advanced in this field, and primarily aim to reduce demand by changing the environmental push factors. The Framework Convention on Tobacco Control (FCTC), the first and only global health treaty, sets out specific steps for governments to use taxation and pricing to reduce consumption; ban tobacco advertising, promotion and sponsorship; create smoke-free work and public spaces; use prominent health warnings on tobacco packages; and, curb illicit trade in tobacco products. This model has been hugely successful at empowering government and controlling the activity of tobacco corporations. Health advocates often look to the tobacco example to inspire policy action in other areas, including alcohol and food.

Trade, Globalisation and Health

Despite the many successes in tobacco control, it’s been far from plain sailing to this point. Since negotiations on the FCTC first opened, 63 million people (and counting) have died from tobacco-related diseases. Yet governments wishing to take regulatory action to tackle tobacco smoking still face an increasingly bitter fight from ‘Big Tobacco’ to protect their own interests. There has also been aggressive expansion to target new markets (women in established markets; new smokers in emerging low- and middle-income economies).

A recent high-profile example of this struggle against ‘Big Tobacco’ has been the introduction of plain packaging for cigarettes in Australia.

Congratulations to the Australian Government, who successfully defended their policy in the domestic courts. This was in spite of complaints from tobacco companies, working in unison, that the plain packaging infringed upon their brand ownership (intellectual property rights) and undermined trade investments. This month Australia rolled out its policy across the country, in a bid to further restrict the marketing activities of tobacco companies.

However, there are a number of international legal challenges that remain. These have been brought against the government by the tobacco industry, seeking new avenues to block regulatory action. As they lose clout with national governments, these companies increasingly tries to circumvent national policy through international trade law.

This new global dimension to public health policy reflects the structural dynamics that underpin both the supply side and the environmental determinants that affect demand – namely global integration of investment, trade and communication. Globalisation, to use a broader but more widely recognised term, has completely reshaped the policy playing field. The overhaul of the economic model, including trade liberalisation, has driven changes in the supply and promotion of consumer goods, with the emergence of transnational companies, retailers, foreign direct investment and global advertising. Global factors now stand right up there alongside national context in influencing the consumer environment.

But what does this new global playing field mean for health?

The World Trade Organization supervises the strict implementation of rules affecting global trade and commerce (chiefly international trade agreements), and provides a forum for complaints against countries considered to be ‘flouting the rules’.

One such legal challenge facing Australia over its bid to implement plain packaging comes via Ukraine, Honduras and the Dominican Republic (but financed significantly by the tobacco industry). The threat of such cases is a major disincentive for low- and middle-income countries looking to take policy action, as the legal costs to challenge such complaints can be astrononmical.

Another international legal challenge comes in the form of an investor-state dispute, whereby complaints can be made against a country deemed to be in contravention of bilateral trade agreements. Phillip Morris Asia claims that Australia is violating the terms of a 1993 trade pact between Hong Kong and Australia. In effect, they are seeking to block plain packaging as they frame it as a threat to trade.

The Australian government has since stated that, in addition to fighting this challenge, it will no longer support provisions in bilateral trade agreements that constrain its ability to implement national laws on social, environmental or economic matters. A clear sign that governments have concerns over the interplay between health policy and trade.

Other countries have faced down challenges and threats to national health policies from international trade agreements, including Norway when it introduced bans of retail display of cigarettes, and Denmark whose ban on trans fats in foods was scrutinised by the European Commission. The Scottish Government is currently awaiting an opinion from the European Commission as to whether its proposed policy on minimum unit pricing for alcohol contravenes EU trade rules.

Lessons for future health policy

The fact that a policy arena for NCDs is now operating at the global level means that policy-makers must consider the challenge of global trade when formulating national policy, but it also indicates that globalisation may be a significant factor (or amplifier) in the emergence and spread of the global NCD epidemic.

An expanding body of work suggests that the rate of increase in consumption of ‘unhealthy commodities’ (soft drinks, processed foods, tobacco and alcohol) is fastest in low- and middle-income countries, and that multinational companies have now penetrated these markets at similar levels to those seen in high-income countries.

Foreign-direct investment and free trade agreements are understood to be key factors behind this emerging trend, and that the heralded economic benefits of free trade are compromised by unexpected negative externalities (e.g. changing patterns of disease), and cost/benefits are not distributed evenly.

In 2002, the WHO and WTO prepared a joint report on the public health implications of trade. This found that trade agreements do take some account of health, permitting national measures that protect human health—but only those that are the least trade-restrictive relative to any other measure. The report emphasised the common ground between trade and health, but – recognising the potential for dispute – argued for health and trade policy ‘coherence’.

Certainly, trade policy continues to be one of the most contentious issues in global health.

Trade, globalisation & our new global health agenda

Global trade rules present genuine and substantial risk to health policies seeking to address supply side determinants and alter the consumer environment to reduce risk factors for NCDs. They affect what people eat and drink, and whether they smoke.

As it currently stands, when there are implications for trade, countries must construct a powerful case that demonstrates the relationship between the intervention and protection of public health – this requires capacity to construct a case and ability to participate fully in international policy-making to defend this case. Health policy can, and should, trump trade law, but this is not guaranteed and may come at very high cost to governments.
When faced with major global health challenges of a globalised nature, it seems counterintuitive that health policy is held hostage to trade policy (when we know that health is a pre-requisite to effective economic development…) and corporations are able to manipulate it to their own advantage. This is particularly frustrating when governments are trying to take upstream – pre-emptive – action on health, yet face barriers imposed by trade rules that seemingly serve the interests of big business.

Given these concerns, isn’t it time the health community tabled governance reforms to ensure this is no longer the case moving forwards?

Category: JoJewell | Tagged , , , , , , , , | 1 Comment