NCDs as a Barrier to Social and Economic Development in Asia

NCDFREE is a global social movement, by, for and about young people – against the world’s leading cause of deaths: Non-Communicable Disease. Launched in 2013 at Harvard University and the University of Melbourne’s Festival of Ideas, NCDFREE brings young, local change-makers from around the world to tell their stories and their visions for a world free from preventable NCDs. To engage their peers and inspire global action.

This is the first in a series of articles from our change-makers. Bangladeshi nutritional epidemiologist Shusmita Khan tells us her vision as a young leader in NCDs.

 

I come from a small country with large population and larger challenges – Bangladesh. At the same time it’s also a land of potential, prosperity and possibilities. Often times there will be multiple challenges to manage and all would need similar attention. And also often times by giving attention to something we tend to forget things with similar urgent need of attention. And I suppose it’s like any other developing country on this world.

The NCDFREE Melbourne LaunchOn 5 October this year in Melbourne, a group of young professionals gathered with a dream – the Melbourne launch of NCDFREE. A dream of having a NCDFREE world – a world FREE of preventable NCDs. As a part of this huge but humble initiative, my idea of dream always starts with stories. Stories of happiness and stories of helplessness and stories of hope! Stories of the human face of NCDs. Of real people, living, dying and surviving.

I was born cancer. As a star sign of course! This made me funny, creative and emotional! But lets say the word cancer again! Cancer. What do you think of when you hear this word? Something that comes to your life, uninvited! Something that tries to stop your course of life and make you count your days! Something that gives you the courage to fight back, to see the end of this legacy of death! Ever wondered how this six-letter word changes our life and affects a whole family? Lets hear a story!

Masuda and ChhondaJust like any other 23 year-old, life for Masuda was beautiful. She had a loving husband, and a baby girl – Chhonda. Suddenly, without warning, Masuda’s chronic stomach-ache turned out to be colon cancer. Without wasting a single moment, the young couple came to Dhaka – the capital – for better treatment where her doctors decided to operate. Surgery meant removal of her intestine followed by rounds of chemo. Surgery also meant a huge financial burden to this young couple and they put their whole future at stake. Months of intensive care with her doctors, Masuda came back to Chhonda. The couple started getting better mentally and financially as well – with some struggles of course. But this was not happiness ever after! The six-letter came back like a déjà vu! The worries and struggles all are back again. Again surgery. Doctors. Hospital corridors. Late night. Anxious moments. Prayers. Debt, loans, more mortgages and borrowing! Three months of all this and at the end this time Masuda doesn’t make it! Now all Masuda’s family has is a lifetime worth of worries of how to give Chhonda a better life with so much of debt! For many, life is beautiful, but for this young couple and lovely Chhonda, life is beautifully cruel . . .

Bangladesh Cancer Support GroupHow do I come across these stories? From 2011 our organization Eminence with a group of volunteers are trying to change the story lines through Bangladesh Cancer Support Group – by raising funds. By making innovative approaches to match cancer patients from wealthy family to donate cost for one round of chemotherapy or radiotherapy to a cancer patient from a resource poor family. Baby steps that are always in need of support from all ordinary person like you and me. Does these baby steps solves the whole problem? No it does not. Because when you are talking about Cancer there is no magic solution that can save lives. For families living in resource poor settings, cancer is just another way of spiraling back below the poverty line, right back in the struggling phase. This is just another example of how a NCD can change the storyline of a happy family. This is also an opportunity for people like you and me to change the storyline through initiatives like our cancer support group.

In 2011, when the United Nations high-level meeting on NCDs was taking place, I wrote a blog called the “three letters”. The basic idea about the blog was how we missed the train back in 2000 by not having three letters in there. The letters were “N, C and D”. These missing alphabets costed us 15 years backlog from getting into the global development agenda of Millennium Development Goals, the MDGs. Today, we are at the verge of replacing those global development goals with new ones and life has given us a second chance as a global community. A chance to have those letters in the next focus agenda and changing the course of tomorrow. A chance to recognize that in my country, your country and all countries – NCDs are a barrier to development!

In September 2013 during the 68th UN-GA Secretary General Ban Ki-moon spoke about the post 2015 agenda – sustainable development goals – and in his speech there was only one line on NCDs. Just one line for the highest cause of deaths and disabilities. Just one line for the issues that will ensure breaking the sustainability of any development.

As a young professional, I believe we can and must do better – for the millions around the world who face or will face NCDs. For people like Masuda and little Chhonda! We must keep the conversation going. We must demand that our leaders see these are issues of poverty everywhere – and ensure they are no longer the forgotten burden anywhere.

Let’s keep being engaged and let’s keep trying to change the course of tomorrow – toward an NCDFREE world!

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This article was commissioned by NCDFREE, in collaboration with Remedy Healthcare and Local Peoples.

Shusmita Khan is a Senior Associate Coordinator in a Bangladesh based NGO – Eminence (www.eminence-bd.org). Ms. Khan was trained as a nutritionist in Dhaka, Bangladesh.  

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Launching a New Global Narrative for NCDs – from Melbourne, Australia

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This past weekend, on the banks of the Yarra River in Melbourne, Australia, and to a packed audience at the Melbourne Convention and Exhibition Centre, NCDFREE was launched. A Saturday night event and part of the University of Melbourne’s Festival of Ideas, the theatrical and educational Global Health event aimed to inspire and engage a new generation to take action on the world’s leading cause of death – Non-Communicable Disease.

An event by, for and about young people, the audience had a full program including three short films from three continents, two interviews with NCD leaders and listened on as six inspiring young health change-makers took to the stage to share their ideas for a world free from preventable NCDs. The entire program was crowd-funded and streamed live to the world via webcast and soon – will be available through vodcast online for anyone who couldn’t be in the crowd.

The audience was sensational, interactive and inspired – watching a program packed of urban planners, design thinkers, economists, doctors, nutritionist and epidemiologists… Not to mention incredible young comedian duo Charlie Ranger and Michael Argus, and Melbourne rockstars Asta and Arowe.

More will be available over the coming days and weeks – but here a taste of the event, the first of three short films focusing on young health advocate Byambasuren Vanchin.

Watch this space for much more soon!

NCDFREE MONGOLIA from NCDFREE on Vimeo.

For more information, go to www.ncdfree.org and @ncdfree.

 

The Conversation

 

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#GlobalHealth: an open letter to the Healthcare Students of the World.

This week, an open letter to the healthcare and public health students of the world – written by Harvard Fellow Dr Alessandro Demaio, for the 2013 Global Health Conference of the Australian Medical Students’ Association.

 

In his speech to the World Health Assembly this year, World Bank chief Dr Jim Kim boldly stated we are at a crossroads in global health.

“Together, we face a moment of decision,” he said, “The question is not whether the coming decades will bring sweeping change in global health, development and the fundamental conditions of our life on this planet. The only question is what direction that change will take.” And of course, who will lead us.

GHC2013

Well I believe there is no group better equipped to choose a healthier future and a fairer trajectory than you. Young, driven, intelligent, articulate and, most powerfully, informed. This is a big responsibility. Taking on the problems that were created and challenges unmet by the generations above you. But as young global health advocates and budding healthcare professionals, you are our white knight. Our secret weapon in global health. As I see it, for three key reasons.

Our White Knights.

First of all, because you can. You are a generation that is globally connected like never before – across time zones, borders and economic divides.  You are native to technologies that older generations will likely take years, maybe decades to master. You are driven and desperate for change and best of all, you combine the traditional knowledge of health and medicine, with a deep sense of social justice and an appreciation of non-health determinants.

ncd3Second, because you must – time is short. With the world rapidly speeding along deeply concerning environmental, economic and social trajectories, you must be the generation that rises above the rhetoric, moves beyond shallow, aspirational targets and political short-mindedness. Put simply, we have just a few more decades to get this right, and you are our best chance of realigning the direction the global community is heading in, to ensure a more sound, safe and sustainable future for our planet.

Finally, because no one else will. I am a realist and, having worked in global health for a few years now, I realise that change is not going to come in the form we need and in the timeframe that is crucial, from the generation you will replace. This is on you, like it or not. It might seen daunting, even unfair, but trust me – with your skills, your insights and your innovative thinking, a better world is well within reach.

Think Big.

This year, I co-founded a global social movement to address the world’s leading cause of death: non-communicable diseases. In a few months, NCDFREE crowd-funded more than US$60,000 and through crowd-sourcing, drew video from smart-phones around the world to encourage societal and political change through short films and personal narrative. Harvard, Oxford, ANU, the University of Melbourne, C3 Health, PLOS, BMJ and many others have come on board (financially and morally) and joined our movement, including the World Health Organization, who will host a specially-commissioned film at their July Ministerial Meeting. The success of this campaign, albeit it in its infancy still, has taught me a few key things I want you to hear.

The Support is There.

Although I outlined some pretty big challenges above, you have support to bring this change. The world is expecting big things from your generation, and they’re willing to back you in making them happen. They know what you’re capable of, and they’re poised to catalyse your solutions. Be bold, think big and don’t compromise. Others will be inspired by your passion and rally with you.

GHC2013I also stress the need to continue to look beyond the clinic. A classic flaw of us medical doctors is to lose sight of the world outside. Exams, patient lists, rounds… Don’t forget to look outside the window and remain globally connected and responsible. Being a public health or healthcare professional is noble and I commend you for dedicating your life to the health of others, but it is not enough. Remember the global challenges which may lay outside your daily routine, but for which your voice can be powerful – even game-changing.

Look Beyond Health.

Finally, I am going to use the “M word” – multidisciplinarity. Before you switch off or roll your eyes, I want to appeal to you – remember to have humility. Whether reflecting back or looking forward, the biggest gains in global health, and even healthcare within nations, have and will be made by innovations from outside the clinic and even medicine.

Ghana SunsetHIV, TB, NCDs… These are all driven by and interlinked with factors we call Social Determinants. The greatest gains in addressing these diseases will come from doctors working with other sectors, within other industries and ministries. Communicators, urban planners, lawyers, designers, anthropologists, economists – the list goes on. Inspire them and be inspired by them, work together and we will achieve much more for many more.

So once again, the challenges are large but there is no group better equipped to rise to meet them. Remember: don’t be afraid of thinking big. Don’t let fear stop you from getting off the conveyor-belt that is healthcare training and tackling some of the bigger picture issues.

Above all, don’t be afraid of failure. The only failure, would be to never try.

 

Dr Alessandro Demaio

 

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Sandro_circleAlessandro is a Australian-trained Medical Doctor (MBBS, MPH) who has recently completed a PhD in Global Health and NCDs. He currently holds a Postdoctoral Fellowship at the Harvard Global Equity Initiative, Harvard Medical School and is Assistant Professor at the Copenhagen School of Global Health. Connect with Sandro on Twitter via @sandrodemaio.

 

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Addressing NCDs in Ghana – viewed through a camera lens

This week on PLOS TGH, we hear from Dr Fred Hersch – research fellow with The George Institute for Global Health at the UK’s Oxford University. As part of the crowd-funded NCDFREE Campaign, he and his team have just returned from Wa in the Upper West Region of Ghana, making a short advocacy film on the innovative, community-led, NCD prevention and control activities taking place there – and in particular, the inspiring work of young NCD activist, Emmanuel Sanwuok.

 

NCDFREE Ghana Film

When we think about diabetes, high blood pressure and heart disease, we don’t generally think about Sub-Saharan Africa. And yet it is in the countries of this region, that they sit side by side with persistently high rates of maternal and child health and infectious diseases we traditionally associate with poverty and Africa – HIV, malaria and tuberculosis.

The fact of the matter is that in Sub-Saharan Africa, things are changing. Fast. Just like every other region of the world, the burden of non-communicable diseases (NCDs) is rapidly rising. According to the WHO the burden of deaths from NCDs will climb from 28% in 2008 to 46% by 2030.

Ghana Sunset

The impact of this is dramatic.

NCDs place a huge strain on already under-resourced health systems. In low- and middle- income countries alone, annually, NCDs are responsible for 8 million deaths under 60 years of age. For a family, a society and an economy, this is a huge loss.

Ghana, the Star of Africa, has long been a success story of Sub-Saharan Africa. The first country in the region to gain independence in 1957, it has been relatively stable ever since. Since 2001, Ghana has experienced rapid economic growth and rising human development.

ghana_star_web

Ghana has made some impressive achievements in terms of healthcare. There is a universal health care system and a national health insurance scheme that provides access to health services and prescription medications. Life expectancy at birth is 66 years (2010). For decades Ghana has trained a cadre of physician assistants to make up for the lack of Doctors (15/100,000) – especially in rural areas.

Despite this, resources for health are still relatively scarce. Ghana spends only 5% of GDP on healthcare; a long way short of the 15% agreed to in the Abuja Declaration (2000). At this level, health systems are at risk of being overwhelmed by the emerging epidemic of NCDs.

Wa, the regional capital of the Upper West Region and some 12 hours North of Accra, is like any rural-urban centre in Sub-Saharan Africa. It is a dusty, bustling commercial hub struggling under the weight of a rapidly changing society with ever increasing demands on its meagre resources. Visiting this part of the world it is instantly evident that globalisation and its effects on society are felt everywhere.

Conventional wisdom holds that NCDs should not be a problem here. And yet since 2011, under the direction of the Regional Director for health, the Ghana Health Service has been setting up NCD prevention and control strategies. This is no small task.

Traditionally health systems in such places have been oriented towards addressing maternal and child health or dealing with common infectious diseases. NCDs are different. Prevention strategies that lead to early identification of high-risk individuals are key to curbing the impact. The goal is to prevent as many ‘events’ e.g. a stroke or heart attack, for which there is no treatment. This requires a different approach.

33 year old Emmanuel Sanwuok, the Regional Co-ordinator for NCDs is on a mission. He is driven by a passion to address the neglect for NCDs that he sees. His dream for Ghana is for a country where people are able to lead healthy lives, and for those who need it, access quality health care.

Emmanuel with his wife and 2 young daughters.

Emmanuel with his wife and 2 young daughters.

Central to their efforts has been the formation of a multi-disciplinary team of health workers, the NCD Task Force. The NCD Task Force undertakes workplace and community based screening services where adults are invited to participate in a health assessment. The aim is to identify those at highest risk of common conditions and to intervene early with either lifestyle advice or where required medication.

Sanwuok and his team believe that key to addressing the rising burden of NCDs is to raise awareness amongst the community about the risk factors and the steps that people can take to lead healthier lives – eating more fruit and vegetables, avoiding foods high in salt, and engaging in regular physical activity. They take to the air-waves on a weekly basis and run various activities to spread their positive message about leading healthier lives.

NCDFREE Task force - Multi-disciplinary team of health workers

NCDFREE Task force – Multi-disciplinary team of health workers

The cost of inaction is too high to ignore. In Wa, NCDs cost lives and livelihoods. For a family and society, the loss of a breadwinner is devastating. For a person with diabetes, the costs of seeking care can consume an entire households income (despite health insurance).

Seeing the work of Sanwuok and his team in this corner of the globe is truly inspiring and acts as a solemn reminder that NCDs affect everyone, everywhere. What is needed is more support to build the capacity of health workers and the health system to be able to provide comprehensive care that includes addressing NCDs.

Sanwuok and those around the world like him are in a David and Goliath struggle. Unlike malaria, TB and HIV, there is no global fund to fight NCDs. If countries like Ghana are to meet the ambitious targets that have now been set, more support for programs like these are needed. After all, in slaying Goliath, even David had a sling-shot.

NCDFREE Team Ghana; Fred Hersch, Batsheva Lazarus, Emmanuel Sanwuok, Tom Eagar

NCDFREE Team Ghana; Fred Hersch, Batsheva Lazarus, Emmanuel Sanwuok, Tom Eagar

 

fred_circleFred Hersch is a medical doctor (MD/MPH) and technologist. He is passionate about global health and the role of technology in transforming health care delivery for the better. Prior to medicine and public health he worked in the web development space implementing medium to large scale web content management projects. He was an early pioneer in the tele-medicine space co-founding MedTech Outreach Australia and developing one of the first web based tele-medicine platforms. He is now a research fellow at The George Institute for Global Health where he is involved in research around the application of technology, particularly smart phones and clinical decision support tools and how these can be used to improve access to “essential healthcare” in resource poor settings. 

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Global Health 2.0 – from the team at MPH@GW…

This week on TGH, we let the picture say a thousand words – literally. From the online Masters in Public Health program at The George Washington University is this innovative infographic! It explores how health care in the U.S. compares to 16 other countries around the world, using WHO data. 

Global Health needs more infographs like this – if you know of a great one, be sure to share it with us below!

 

US Health Care vs The World

 

This sensational example of innovative communications for Global Health, was brought to you by The George Washington University’s Online Masters in Public Health.

The data in the graphic is provided by the World Health Organization (WHO)’s World Health Statistics 2013 report – the annual compilation of world health data.  

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Is Financial Protection for Cancer Enough?

Saying that cancer is an expensive disease is an understatement, particularly in such low and middle income countries (LMICs) as India. According to estimates from 2004, one inpatient admission for cancer in India can cost 40-50% and 80-90% of annual per capita income in public and private hospitals, respectively. Given that cancer is a chronic disease, often requiring multiple admissions, it’s no wonder that over 45% of families with one cancer patient face catastrophic expenditures and 25% are pushed below the poverty line (BPL). To put this in perspective, the likelihood of catastrophic expenditures is 160% higher for cancer than for communicable diseases in India. On top of these direct medical expenses, cancer patients also face unaffordable and indirect costs of transportation and loss of daily wages.

Aarogyasri Health Care Trust in Hyderabad, Andhra Pradesh

Aarogyasri Health Care Trust in Hyderabad, Andhra Pradesh

These alarming statistics, and the fact that NCDs including cancer are the leading cause of death in India, have encouraged individual Indian states to devise insurance schemes that increase financial protection for the poor. Andhra Pradesh, a state in south India, aims to alleviate this financial burden through the tax-funded Rajiv Aarogyasri Scheme (RAS). The primary objective is to improve the poor’s access to quality treatments for a specific list of diseases. The state government recognized that public hospitals alone cannot achieve this goal, due to staff and supply shortages, and low quality standards. On the other hand, private hospitals, initially only accessible to the rich, are well equipped and staffed to provide specialist services. Thus, RAS empanels and funds tertiary care in both private and public hospitals using tax revenues.

RAS, in many ways, seems too good to be true. The scheme provides completely cashless tertiary care – including transportation, food, investigations, and therapies – for BPL families, which apparently constitute 87% of the state’s population. Among the treatments covered are medical, surgical, and radiation oncology. Since its inception in 2007, RAS has covered approximately two million surgeries and therapies. Due to its apparent success, RAS has received international accolade as an innovative public-private partnership (PPP) which has promoted access to good quality healthcare.

Yet recently, the cost-effectiveness of the scheme has been called into question. Every year, approximately 20% of RAS therapies are related to cancer, but whether this money is being used in the most efficient manner is unknown. In an effort to answer this question, I talked with state government officials and oncologists in both public and private hospitals and attempted to learn from their experiences and opinions on cancer policies in the state.

From these key informant interviews, two major flaws in cancer care and control (CCC) efforts became immediately clear: the absence of consistent prevention efforts and inability to follow up with patients. Every single provider I talked with lamented the fact that the majority of cancer patients they see are diagnosed at late stages. Often, due to metastasis and complications, treatments become less effective at advanced stages of the disease. But because a life is a life, these doctors end up performing procedures that are reimbursed through RAS and will likely have little effect in extending or improving quality of life. As the key informants suggested, the problem is that the overly siloed approach toward financial protection for treatment has left gaping inadequacies in access to prevention and screening. And the most common cancers in India happen to be preventable through behavioral change (tobacco-related lung and oral cancers) and treatable if detected early (cervical and breast cancers). So essentially, many cancer patients may be needlessly suffering and the state government may be needlessly spending money on treatments that may not even be efficacious after all. And, to make matters worse, many informants asserted that after treatment, the majority of patients are lost to follow up – providers cannot track and determine whether the patient is “cured,” faces recurrence, or dies.

The point is, while RAS is certainly increasing access to treatment, a sole focus on tertiary care may not be economically justifiable. According to the key informants, we must recognize that the relationship between cancer and poverty is not one-way, but cyclical. The poor may face a higher incidence of cancer due to socioeconomic differentials in risk factor exposure, such as tobacco consumption. Moreover, cancer is often diagnosed at late stages due to inadequate diagnostic infrastructure, particularly in rural regions, where the majority of BPL individuals reside. These patterns confirm that poverty increases risk and severity of cancer and cancer further entrenches families in poverty.

This is the first of a series of posts that will delineate the main health systems challenges that must be overcome in providing comprehensive CCC, even with such an innovative insurance scheme as RAS. These discussions will show that CCC is inherently tied to the movements toward Universal Health Coverage, which, according to the World Health Assembly, entail two main goals: “to provide all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to be effective; and ensure that the use of these services does not expose the user to financial hardship.” Currently, the state of Andhra Pradesh is focusing on the second aim, but is hopefully in the process of shifting its attention in order to break, or at least weaken, the cycle of impoverishment.

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Pooja Yerramilli is a Yale graduate and MSc. candidate at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health to complete a research project on the Financing of Cancer Care and Control in India.

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Campaigns & public messaging: important aspects of HIV prevention and treatment, but fraught with complex challenges.

HIV/AIDS communications such as campaigns and public messaging are important aspects of successful prevention and treatment agendas, but are fraught with complex challenges that must be recognized and overcome – UCLA MD candidate and Global Health enthusiast Abraar M. Karan explains… 

Flickr / SmathMany countries, in the last decade, have started HIV-related campaigns to help mobilise their populations to get tested, undergo treatment, reduce stigmatisation, and limit risky behaviours. However, finding a way to safely communicate these messages, as we’ve been trying to do while constructing Mozambique’s campaign, has taught our team important lessons in the profound complexity that the HIV epidemic demands.

A starting point for any HIV communications agenda would surely include some of the following questions:

How does one start a voluntary counselling and testing (VCT) campaign? Or a sero-status disclosure campaign? How does this differ from an anti-retroviral therapy adherence campaign? Or a behaviour change campaign? What benefits instead, would a stigma reduction campaign bring?

These are all important questions, each of which we considered and worked through. Let’s explore some of our findings…

VCT Campaign

A campaign for universal Voluntary Counselling and Testing (VCT) in Mozambique, and many other countries in the region, wouldn’t be advisable given that the public health systems currently lack the capacity to test the vast numbers who would be likely to come forward. Thus, there would have to be a focus on high-risk groups. Unfortunately, there is mixed data on how best to target communication to these groups, and for some, such as female/male sex-workers, the strategy is completely different than for others, like, long-distance truck drivers. Thus, a campaign advising everyone to get tested is problematic, particularly if the people who actually do get tested aren’t the people who are sick, further burdening an already struggling healthcare system.

HIV Sero-status Disclosure campaign

An HIV sero-status disclosure campaign would seem like a good choice with an easy enough message. However, disclosing one’s HIV status is more difficult than even finding the immense courage to tell your loved ones or friends that you are infected. In Mozambique, where the legal system is inadequate to protect those who have disclosed, revealing your HIV status could mean, at best, discrimination in the workplace, in the healthcare system, in your community, and in your house. At worst, especially for women, it could mean abandonment or even death. And so for obvious reasons, Mozambique and many countries around the world just aren’t ready for major disclosure campaigns.

ART Adherence Campaign

Flickr / hdptcarFor an antiretroviral therapy (ART) adherence campaign, one would think there are are only so many ways to encourage and empower someone to take their medication. However, aside from the fact that the guidelines have now changed (the new Option B+ regimen recommends all HIV+ mothers are treated for life, regardless of CD4 count), the further confounding consideration is that many people who find out they are HIV+ don’t have low enough CD4 counts to even qualify for treatment. Thus, they are sent home newly informed that they are HIV+, but with no medications because they are essentially not sick enough.

Behavioural Campaign 

A behavioural campaign doesn’t seem easy, but it’s actually really difficult - because we keep finding that we know less about behavioural drivers than we thought. The leading view for the propagation of HIV/AIDS in Sub-Saharan Africa has been the existence of multiple concurrent sexual partnerships—having sex with more than one person regularly in the same general time-frame. So, some campaigns, such as OneLove by the Uganda Health Marketing Group, have focused specifically on pushing people out of these “sexual networks.” However, a recent paper in the Lancet suggests that total life-time partners rather than concurrent ones could be the real driver and the models up to date may have been focusing on the wrong aspect of the epidemic. It’s an immensely difficult and complicated question as to what type of behaviour change is most needed, but it would be wise to try and figure that out before trying to change people’s behaviours (which in itself is unbelievably hard to do).

Flickr / jonrawlinson

Anti-Stigma Campaign

Lastly, we considered an HIV stigma reduction campaign given that stigma affects everything previously discussed.  But alas, even here there is a major catch. On the one hand, we want to create a campaign that would reduce the vilifying attitudes currently pervasive against HIV+ individuals. However, at the same time, we wouldn’t want to completely de-vilify the disease and unintentionally create laxity around precautionary measures to avoid HIV transmission. Separating people living with HIV/AIDS from HIV/AIDS itself is an important distinction that any stigma reduction campaign needs to make.

Conclusions?

Ultimately, we found that there are a number of ways how not to start an HIV communication campaign, and identifying those is just as important, if not more so, than figuring out how to start one. Communication is a public good and continued action on HIV is essential. But once a successful or poor campaign starts, it affects all programs, regardless of which organization put the messages out. Thus, it is critical that all groups currently involved in campaign creation appreciate the challenges and complexities outlined above – and develop appropriate, effective and considered responses.

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Abraar Karan is an MD candidate at UCLA and worked as an external consultant at the CDC in Mozambique where he advised on creating a national HIV communication strategy for the country. He has experience abroad in India, Latin America and Africa and he blogs about his global health experiences at Swasthya Mundial (@swasthyamundial).

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A changing climate & shifting epidemiology: shared risks and opportunities

Flickr /  USFWS HeadquartersI might be a doctor, but actually I wasn’t always medically-focused. In fact, in my final year of High School, I was captain for the environment. A young college leader, I was passionate about the sustainability of our waterways, oceans and forests – I believed strongly in protecting the integrity of our natural surrounds and the wider ecosystem we inhabit.

Jump forward more than a decade, and I am now a medical doctor focused instead on the shifts in epidemiology we are witnessing worldwide and the rapid rise in Non-Communicable Diseases.

From climate health, to human health.

For many, this transition may seem disjointed and unrelated. How could someone go from being so passionate about the environment to being passionate about human population health?

The answer is, nothing changed. There was no leap and it wasn’t a conscious transition – it was a gradual shift along a single continuum. You see, these two issues are not polar opposites, but in fact largely overlapping.

Human health and the environment are really two sides of the same coin.

A few stunning Lancet series later, much more accepted science and the fulminant effects of Climate Change playing out around the globe, people are awakening to the overlap of these two issues. People see the link between human health and a healthy environment, that if our natural environment is sick – we in turn are likely to become sick. That our health is reliant on the health of the natural surroundings – our oceans, our forests and our air.

But actually, this relationship goes a long way further. It is not only that a struggling planet makes for an unhealthy human race, but also that the process of becoming unwell as a population fuels the degradation of our planet. In fact this is an important concept to appreciate – because it is not our planet’s fault that we are in fact becoming unwell. Both are our fault, and each are fuelling the other.

Shares Risks.Flickr / shirokazan

Think of NCDs – or Non-Communicable Diseases. These are the leading cause of global deaths and present an enormous and time-critical challenge to the global community. Largely, these diseases are a reflection of the technological gains we have made in the past century, and the hyper-consumerist lifestyles many around the globe now lead. Mechanised lives lead to less and less caloric expenditure, cars replace our morning walk to work or school, we use electronics instead of being outdoors and largely, we have replaced manual labour with desk-bound work. At the same time, our diets which were once based on natural, seasonal, local, unprocessed foods are now calorie-dense, ultra-processed and served to us on a tray. Many of us eat meat most days whilst added sugar and fats have become ubiquitous ingredients in even our food staples.

But hang on a moment, they were some of the major drivers of the NCD epidemic. Or were they the drivers of climate change? Carbon-intensive, mechanised lifestyles; passive, fuel-reliant transport; ultra-processed foods; meat, sugar and oils.

The reality is, that these drivers of NCDs are also some of the major drivers of climate change. That in many regards, these two fundamental challenges for our global community this century are one and the same. Yes, an unhealthy world makes for an unhealthy population. Pollution and fragile eco-systems make populations more vulnerable to a range of disease outcomes, but furthermore, the drivers of both are actually shared!

9350882245_85d2f47454Shared Opportunities.

The exciting part, is that the reverse is also true. Mitigation for one, will lead to mitigation for both and actually, additional positive externalities. If we build cities which are conducive to the use of active or public transport – we could go a long way to addressing burdens of diabetes and lung conditions, but also cut our carbon emissions. If we encouraged a few more people to be weekday vegetarians and only enjoy meat on weekends, we would likely protect a few of them from a heart attack, but also reduce the methane emissions related to the production of that meat. If we could teach more of our children to connect with food, understand food and to cook wholesome food, we might find that they’re able to make healthier, more local and seasonal food choices – foods which don’t require carbon-intensive hot houses, long-distance transportation or high levels of processing.

We can have both.

I would argue that our two pressing Global Health challenges are in fact one. That environmental activists are public health activists and vice versa. A classic story of the whole being much more than the sum of the parts.

Climate health is human health, and human health is climate.

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Connect with Sandro on Twitter via @SandroDemaio.

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Dr Alessandro Demaio trained and worked as a medical doctor in Melbourne, Australia. While working as a doctor at The Alfred Hospital, he completed a Masters in Public Health including field work in Cambodia. In 2010, Alessandro relocated to Denmark and began a PhD fellowship in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). This year, Alessandro holds dual Postdoctoral Fellowships at the Harvard Global Equity Initiative, Harvard Medical School and the Copenhagen School of Global Health.

The Conversation

 

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Regulation – big brother, or just good governance?

Dr Fiona Lander is a medical doctor and law graduate based in Melbourne, Australia.  In this, her first post for TGH, she explores the concepts around effective public health regulation, including the new global initiatives in health law, and questions the limits of lawmakers’ powers to constrain individual liberties in the name of health.

 

Flickr/  khawkins04From the inception of public health as a discipline, separate to mainstream healthcare, a body of law has developed in many countries which is intended to aid in preventing and containing disease.

Public health law has come a long way from its beginnings in the original health acts of the 19th century, focussing on condition of sanitation and noxious environments. Now, most high-income countries (and a substantial proportion of low and middle-income countries) have enacted more or less comprehensive legislation around control and reporting of infectious disease; quarantine; food hygiene, and so forth.

These laws operate quietly in the background to greater or lesser extents throughout the world, and are an integral part of any country’s strategy around preventive health.

Many countries, though, are now also seeking to regulate risk factors relating to non-communicable diseases (NCDs) such as cancer, diabetes and heart disease, which were once thought to be the subjects of individual choice and responsibility – and in the minds of many, still are.

The regulation of risk factors around these illnesses previously referred to as “lifestyle diseases” is now also occurring on a global scale. For instance, the Framework Convention on Tobacco Control (the first global health treaty concluded since the International Health Regulations were introduced in 1969!) contains comprehensive recommendations in relation to implementation of laws regulating tobacco use, which are all designed to reduce the harms associated with smoking.

These, and other, legislative changes often lead to an outcry from proponents of individual responsibility; they lament the “nanny state” mentality taking over the country, and the world. The view of those who rail against overregulation seems to be that all individuals are rational self-maximisers, whose decisions to take risks with their health are always well-informed, and influenced by evidence.

The problem is that this assumption that people will always act reasonably, and in their own best interests, simply isn’t correct! Humans are imperfect. Our environments often have a far greater impact on our health than the amount of evidence we are presented with through health promotion campaigns. Put simply, an environment in which it is substantially harder for an individual to engage in unhealthy behaviours will be much better for that individual – and, of course, will save enormous amounts of future expenditure on healthcare.

Flickr / erinarinnnThis is where the law plays an important role in levelling the playing field. A substantial number of the myriad public health laws that operate to protect our health – the regulations around safe food preparation in restaurants, the taxes on tobacco, the laws around seat belts – have been shown to be effective in reducing health-related morbidity and mortality.

I agree that simple rules don’t fit a complicated world. I agree that some areas are overregulated, without sufficient flexibility to avoid absurd outcomes. I agree that certain laws may be overly paternalistic. But the problem is that extreme examples of absurdity are, on occasion, held up to argue against all regulation, without acknowledging the substantial benefits we receive as a society from certain limits being placed on our civil liberties. It is important that the risks and benefits of any new approach are fully debated, so that it cannot be claimed that such interventions undermine liberal democracy. Media coverage of both sides of the debate is a good starting point.

It is obvious that more research needs to be done in establishing an evidence base in this area, to ensure that laws genuinely achieve their stated goals without infringing too much on people’s liberties. But this needs to be balanced by an acknowledgement that, in some areas, evidence attributing a drop in morbidity and mortality to one particular law will be difficult or impossible to obtain. Insistence on evidence should not preclude enactment of appropriate regulation.

An important thing to recognise is that, in many regions, these regulations operate so efficiently and silently that it is too easy to forget that they have not always existed. For me, two years living in India was enough to make the value of such laws – and their enforcement – very obvious. In the majority of countries, laws concerning public health either don’t exist or simply aren’t enforced, and basic activities of daily living become risky, or even downright dangerous.

It is a lesson I will not forget quickly.

Flickr /  www.BackgroundNow.comEnactment and enforcement of public health laws are incredibly important steps in achieving the highest attainable standards of mental and physical health for a population. More cooperation is needed to ensure low and middle-income countries catch up to high-income countries in this respect, and that new legislative challenges relating to issues such as prevention of NCDs are tackled comprehensively, without unnecessary imposition on individual liberty.

There will be significant challenges in this balancing act, but if these issues are approached collaboratively by states, the corresponding benefits for individuals will likely be much greater.

 

Dr Fiona Lander holds degrees with dual honours in Medicine/Surgery and Laws from Monash University. She works in the areas of intellectual property and pro bono law, alongside her medical practice in the field of emergency medicine. Fiona previously worked in India as Senior Officer assisting the United Nations Special Rapporteur on the right to health, and has also worked with the Health and Human Rights team of the World Health Organisation in Geneva, Switzerland. She is the founder of the Health and Medicine working group at the Henley Club, Melbourne.

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Reflections on the 8th Global Conference on Health Promotion (8GCHP), Helsinki – Part two

Last week I shared my key lessons and highlights of some sessions from the conference. This week’s blog aims to reflect upon some further interesting aspects of the conference.

Diversity of participants

A key feature of the conference was the diversity of backgrounds of the delegates and its interactive nature.  As an academic I am more familiar with academic conferences and the discussions at the 8GCHP were different in many ways.  Nearly a fifth of participants were from non health sectors. We did not spend much time on arguing on minor methodological issues or calculation of error bars in graphs. Instead discussions were around practicality, relevance and the challenges to implementing policies and programmes. Here is something I heard on the second day “The researchers’ goal of publishing papers is not important for politicians. Can we change this culture so we can have useful evaluations?”

Site visits rather than lectures

Thursday 13 June was the WHO Europe day.   It involved visits to various locations in Helsinki. WHO Europe shared their most important health promotion initiatives and other regions discussed how they could be relevant to them. There were several site visits including a visit to the Finnish House of Parliament. I participated in this visit and we were welcomed by MPs from the Social Affairs and Health Committee of the Parliament. The discussion showed how Finland can maintain its policies to promote public health through the values of its people. A good memory from this site visit is the statue of a mother with a baby who is saluting the MPs in the chamber for thinking about the future generation when forming policies. MPs said it is difficult for politicians to deviate from that approach, if in general, society believes in better outcomes for the next generations.

MPs of the Social Affairs and Health Committee

MPs of the Social Affairs and Health Committee

A life time achievement award for health promotion was given to Kemo Lepo who was cited as the father of health in all policies. Lepo et al’s book Health in All Policies – Seizing opportunities, implementing policies  was launched at the conference and it provides very good information on the topic.

Emerging voices in health promotion

Another highlight of the conference was the meeting of the group of energetic young professionals. Although there were no formal arrangements, due to the dedicated leadership of a few individuals, we met as a group on several occasions to compile our comments for the Helsinki declaration on health promotion. We were very pleased to see those comments were incorporated in the final draft of the conference statement .

A group of participants who appeared on the video of emerging voices at the 8GCHP

A group of participants who appeared on the video of emerging voices at the 8GCHP

Roopa Dhatt, President of the  International Federation of Medical Students’ Association’s addressed the delegation on behalf of emerging leaders and recommended global leaders should  get younger people involved in a meaningful, participatory way in every stage and every level (global, regional, national and local) in their multi-sectorial work. A video was screened to show the vision of emerging leaders and to highlight the need for opportunities to take part in global health promotion activities. Ilona Kickbusch Tweeted “Great young voices at final plenary – come on! take over from us dinosaurs!   Quickly! SOON!” Twitter was the other key feature of the conference.

Use of Twitter at the conference

Use of Twitter changed the environment completely during this week. The #healthinall was used to communicate and there was a big screen with the live Twitter feed. This allowed participants in the audience and watching the webcast to post questions and chairs picked interesting questions for speakers. Delegates used this opportunity to agree, disagree or to express their concerns during sessions.

A snap shot of the Twitter wall in the main conference hall

A snap shot of the Twitter wall in the main conference hall

The extent of the Twitter activity around the conference was demonstrated by a Twitter analysis disseminated by WHO- PAHO showing more than 1000 tweeters and more than 22,000,000 impressions. Dr Gauden Galea, WHO Europe conducted a network analysis of more than 3500 of those tweets and re-tweets which used #healthinall to show the largest connected group of nodes. We can use this information to plan better dissemination of future health messages.

The younger generation was very active in the Twitter conversation and I met many participants who opened their Twitter accounts during the conference as they didn’t want to miss any interesting Twitter interactions they saw on the big screen. It clearly kept more delegates involved during and after the sessions. Colleagues who didn’t attend the conference, but who followed the Twitter feed said they felt like being there with the live Twitter updates. This clearly convinced participants to expand the use of social media in future events and campaigns.

What’s next after Helsinki?

After an inspiring week in Helsinki most of us asked, “What changes can we expect in health promotion as a result of this conference?” Perhaps this is a difficult question to answer and we will only be able to find the answer in retrospect.

The framework for country action  provides countries with a practical means of enhancing health in all policies (HiAP) approach.  When we heard remarks from different WHO regions in the final plenary, Dr Temo Waqanivalu from the Pacific said we need to take actions before we develop “framework fatigue”. A response to that statement on Twitter said “May be. But we need to agree on a policy framework action to ensure implementation mechanisms are in place”.

With all the different opinions, I would like to pick capacity building through partnerships as the top priority. My choice could be biased by my current position in an academic institution. But I have several reasons to justify this choice. Capacity building could be started immediately at any country from any level depending on the available resources. It is unlikely to be challenged by all the other external forces which are against health promotion. If we build capacity for health promotion solely amongst healthcare workers, we will be going backwards in time. We need to have different professionals such as lawyers, economists, and development agents alongside public health professionals in the same room. The friendships and understanding they build during these events will result in innovative programmes for HiAP approach.

I would like to see the WHO and governments playing a key role to support and coordinate these capacity building activities through strong partnerships as stated by Zsuzsanna Jakab, WHO Regional Director for Europe. We will be able to reflect on those activities at the next global conference on health promotion and decide whether we have been successful or have just developed framework fatigue!

You can read further details about each day of the conference and reflections on  Professor Fran Baum’s BMJ blog.

Connect with Kremlin on Twitter via @KremlinKW

Kremlin Wickramasinghe is a researcher in the Department of Public Health, University of Oxford and also a DPhil Candidate. He works on the Cardiovascular Disease Epidemiology project in the British Heart Foundation Health Promotion Research Group. Kremlin graduated in 2006 with a medical degree (MBBS) from the Faculty of Medicine, University of Colombo, Sri Lanka. He completed his Masters in Global Health Science in 2009 from the University of Oxford. Kremlin started his DPhil in 2010 on environmentally sustainable healthy diets and he is the Course-Director of the “Short course on NCD prevention strategies” offered by the University of Oxford.

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