This week, we support the great work of The Global Climate and Health Alliance – in time for the release of the latest IPCC WG report. This infographic explains the major ideas and themes – we encourage you to share it far and wide.
The Global Climate and Health Alliance was formed in Durban in 2011 to tackle climate change and to protect and promote public health. The Alliance consists of health organizations from around the world united by a shared vision for a sustainable future. Specifically the Alliance members work together to: (1) Ensure health impacts are integrated into global, national and local responses to climate change; (2) Encourage the health sector to mitigate and adapt for climate change.
This week on PLOS TGH, Christopher Tedeschi, Assistant Professor of Medicine at Columbia University and a practicing emergency physician, explores the global and local epidemic of road traffic accidents. From personal close-call, to big-picture epidemiology…
Last month, Graco Children’s Products recalled 3.8 million infant car seats amid concerns that their buckles could become jammed with spilled food or liquid, making it impossible to remove a child in an emergency. My ten-month old daughter has been using one of those seats—and out of an abundance of caution and maybe some paranoia, my wife and I upgraded to a new model.
Just before the recall we traveled in India for several weeks. In Bangalore and Mumbai, we hopped in the back of taxis and rickshaws with no better restraint than a white-knuckled grip. And now I’m supposed to worry about the tiny chance that some apple juice will gunk up the car seat buckle when I get home?
On our first day in Mumbai we had a near miss. During a poorly executed U-turn, the front end of our taxi came within inches of a speeding city bus. The driver slammed on the brakes. We stopped short. I grabbed our daughter. The bus sped by, we took a deep breath and moved on. It seemed like one of those all-too-common close calls on the roads in India (and lots of other places) — close calls that generally seem to work out without any real bodily harm.
But there is real injury. Each year in India, road accidents claim thousands of lives, and injure many more. India reported more than 130,000 road traffic deaths in 2010, likely an underestimate since statistics are based on police records. The financial cost totals approximately three percent of the country’s GDP.
Regulation may help, but only partly. National seat-belt and helmet laws are on the books, but WHO data suggest that less than 50 percent of motorcycle drivers (and less than ten percent of passengers) actually wear a helmet. The numbers for seat belts are similar. Enforcement is anemic. A quick spin around any major city reveals that the law is followed only intermittently, although more motorcyclists seem to be wearing helmets than even a few years ago. But it’s still gut wrenching to watch un-helmeted drivers, carrying two or even three passengers, including small children, hurtle through traffic unprotected.
The impact of traumatic injuries, many which do not present to medical care in time and many more which are preventable, can be measured in thousands of lives and millions of dollars. Worldwide, 92 percent of road traffic deaths happen in low or middle income nations. In recent years, we have trained our sights in this setting on the prevention of non-communicable diseases—diabetes, heart disease, cancer. But remember that trauma is a disease too, with predictable incidence and injury patterns amenable to primary and secondary prevention. And while it is not now practical to mandate rear-facing car seats for infants in most of the world, we can be aggressive in promoting strategies to minimize trauma morbidity by means of helmet and seatbelt use, safe driving, and coordinated pre-hospital and emergency care.
Secondary prevention means adequate EMS systems to respond to accidents, including ambulances that function as more than souped-up taxis. It also means development of standardized, location-specific protocols with pre-hospital providers trained in basic first aid and advanced trauma care. Legal protections should permit good samaritans to assist the victims of road accidents without the fear of getting caught in lengthy official investigations or police cases.
In some places, US or European-style systems might not be the answer. While working on EMS and disaster preparedness projects in India over the past several years, many people have told me that calling an ambulance wouldn’t even enter their mind in the event of a road accident. Traffic is congested, transport times are long, and many ambulances arrive with little more than a stretcher and a few helpers to lift a patient. Accident victims are often transported to the hospital in private cars or rickshaws. A few years ago, public health officials in Colombo, Sri Lanka, implemented the brilliant idea of simply training rickshaw drivers as first responders. More recently, innovative ideas such as developing a system of motorcycle ambulances have been proposed which may mold a pre-hospital system more appropriate for congested mega-cities.
Back in New York, I work in an emergency department which serves a high volume of patients from the Dominican Republic. We often see patients who have arrived in the US seeking care for everything from heart disease and stroke to recent trauma. And most of those traumas, not surprisingly, are young healthy people who were involved in road accidents.
The DR ranks second (only behind the Pacific island of Niue, where a tiny population leads to skewed statistics) on WHO’s list of death rates due to road traffic deaths. Although Dominican law prescribes that motorcycle riders (but not passengers) wear helmets, few comply. A proposed points system and stricter enforcement may help, but only real a cultural shift that enables drivers to assess risk and make safe choices will effect change. Studies by Dominican and American researchers show that drivers feel that helmets are unnecessary for short distances, in rural areas, or for passengers, and are perceived as costly and unattractive.
Sure, I’ll bring my daughter to India again, and hopefully to plenty of other places. We won’t necessarily use the same precautions that we use at home in New York. As I buckle her into her government-approved, rear-facing, upgraded car seat, I think of the difference between the risk I am taking, and the risk to which all those families riding two-wheelers are exposed every day. The gap is too big, and there are too many young, healthy lives at stake. A technological fix only represents a small part of the problem—after all, helmets and seat belts are generally available and reasonably affordable.
The real challenge is to promote a culture that emphasizes the idea that road accidents happen, that their terrible consequences can be mitigated, and that home-grown systems can be developed to care for trauma patients.
Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician. He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine. He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies. He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College. Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries. He lives in NYC.
This week, regular PLOS blogger and Oxford academic Dr Kremlin Wickramasinghe writes about the nexus of public health and business thinking – as well as some reflections on the global Hult Prize. Kremlin is currently doing a DPhil alongside his work as a researcher, quantifying the outcome of health policies addressing sustainable healthy diets.
Do public health academics and entrepreneurs think along the same lines? What would happen if we asked them to identify solutions to a problem that both groups care about? Would solutions be the same or drastically different? I had an opportunity to find some answers to these questions at the Hult Prize regional finals.
The Hult Prize is funded by the Clinton Global Initiative to provide start-up funding (one million dollars) for the young social entrepreneurs who come up with the most compelling ideas to solve a problem faced by billions of the world’s population. This year the challenge was around solving the problem of rising non-communicable diseases (NCDs) such as cancers, diabetes and cardiovascular diseases amongst slum dwellers. The judges for the prize largely come from a business background including top multi-nationals.
One of the doctoral students in my research group within the Nuffield Department of Population Health at the University of Oxford took the initiative to form a team and enter this competition. The focus of my research group is also solutions to the problem of NCDs and we felt this would be a great opportunity to contribute to a global issue that we have a passion for. Our team comprised of three members with a background in public health and two engineers from the Healthcare Innovations Unit at the University. We were delighted to hear that we have been selected for the regional final which was held on 8th March in London from more than 10,000 entry level applications. I am going to explain the thought process we (public health researchers) used to analyse our potential solutions and how the judges (who predominantly represented the business community) analysed them at the regional finals.
Before I go on, I need to make it clear that we did not win the regional final. But the judges gave our solution a “special mention” before announcing the winner. They said it was innovative and we should think about taking it forward. This is exactly what we heard earlier, that only one team would win, but that we should use this as an opportunity to find the energy to develop our idea into a successful social- enterprise.
One of the key criteria was that the winning solution should be able to reach 25 million people in five years. We started brainstorming, produced a list of possible ideas and critically analysed them within the team.Through our research group, we had access to expertise in NCDs to inform our thinking.
One of the questions we considered was how to make screening for NCDs more affordable and accessible in slums. However, when we shared our thoughts with public health experts they asked us what we would do when we identified people with the disease and whether we could provide the cost for treatment and further management. The majority of slum dwellers do not have access to free healthcare and can’t afford to pay for treatment. The public health community generally believes that it is “unethical” to screen people unless you can provide any necessary treatment. We struggled to come up with a sustainable business plan which could provide affordable treatment to patients identified through screening.
The post 2015 development goal discussions have recognised “universal health coverage” as a major priority, but discussions with global health experts confirmed that it is unlikely to be achieved within 5 years. Therefore we thought it would be impossible to win, if we only increased screening without assuring treatment. We dropped that idea and decided to move ahead with a different idea that didn’t involve screening.
At the London regional finals, three out of the top four winning solutions were based on screening. It was interesting to see how judges with a business background approached their task. The winning team clearly showed how they were going to screen people for diabetes with bees! Clearly innovative and excellent presentation by them. They said they would send any patients they identified to the “local hospital”. They did not say how people would afford treatment. As the reason for their winning, the judges mentioned that they were able to “ focus” on one important aspect of the problem of NCDs amongst slum dwellers. This clearly shows the difference in how public health and business communities analysed the same solution.
Two teams, out of the top four, proposed to use animals for screening. When public health professionals consider novel methods of screening we think about false positives and false negatives. So, for example, if we are going to screen people we should know how many actual cases are we going to miss (false negatives) and how many people we are going to take through for treatment even though they don’t have the disease (false positives). No screening test is 100% accurate but we need statistics on false positives and false negatives to decide the cost-effectiveness of a test before scaling up. We thought it would be impossible to win the prize without those statistics, which take time and money to produce. But judges didn’t ask about false positives and negative nor did teams provided this information during the pitch. Judges just asked “can animals survive in slum conditions ?”. This shows that they had concerns beyond the financial model, but they were completely different to the concerns of the public health community.
Our inability to ensure that screened patients had access to treatment and the challenges of quantifying the sensitivity of potential innovative screening methods led us to conclude that it would be impossible to win if we presented a “screening solution”. However, the other teams managed to win without having solutions to these problems. As public health professionals we often attend conferences and meetings with likeminded people and take similar approaches to tackle NCDs. The Hult Prize, by contrast, brings people from different backgrounds to the same stage. It provided me with a unique opportunity to learn that the business and public health communities approach the same problem in completely different ways.
This difference in approaches might explain why most public health professionals are not successful entrepreneurs. My public health colleagues might say that this is why, despite millions of dollars in investments, we still haven’t tackled some of the biggest problems in the world. The problem is this: we invest in ideas that are attractive and “fancy”, but not necessarily tested with public health tools. If we changed the composition of the judges to a panel with 50% public health background and 50% business background, what would have been different? We will never know. This is a business plan competition and (obviously) organisers invited top business professionals to judge. They were very passionate about these issues and provided feedback and comments to teams. But I certainly gathered enough reasons to answer the first question I raised in this blog. Public health academics and entrepreneurs do not think along the same lines.
Why does the public health opinion matter in this competition? The aim of the 2014 competition is to address one of the main public health problems in the world and the solution is supposed to reach 25 million people. The wining solution should be implemented in many countries, which would require the approval from local and national level public health regulators around the world.
How can we move forward to align these two approaches to ensure success in our future endeavours? Clearly we cannot do this by working only within our own disciplines. Here are the important questions: Are public health professionals ready to think out of the box? Would business professionals value public health opinions at all when they make final decisions? As the next generation, we will have to work harder to integrate these various ways of thinking if we really want to change the world.
This week on Translational Global Health, regular guest writer Alexandra Abel returns to share her experiences at the recent TEDxWarwick event. Alex embodies multi-sectoral, Global Health – with academic degrees and a deep interest in both the arts, and population health.
Empty seats before the doors open. Image via @Zena_Agha
Having hosted its first event in February 2009, TEDxWarwick is easily one of the most respected and long-standing TEDx events in the UK. Since inception, the event has grown in scale and scope year-on-year into the 8-hour programme, 1,200-strong audience, and 17-speaker line-up of 2014.
Hiba from our team tells people about Imagining the Future of Medicine
Aside from its reputation as a must-see show, I was keen to attend TEDxWarwick because I am part of the team organising a somewhat similar event called Imagining the Future of Medicine to be held at the Royal Albert Hall on the 21st of April 2014. The Warwick team kindly invited us to tell attendees about our own event during the breaks at theirs.
As we queued to enter the magnificent Butterworth Hall, where the 2012 and 2013 events were also held, we encountered an impressive piece of art, a large oak and metal sculpture, which read, EVERYTHING IS REAL. THERE IS NO AUDIENCE. In 2009, artist Mark Titchner was approached to make this work for the newly refurbished Butterworth Hall, and he developed the text as an allusion to three things…
Oak and metal sculpture outside Butterworth Hall, Warwick Arts Centre
Firstly, the phrase that begins a monologue from William Shakespeare’s As You Like It, which states, “All the world’s a stage”, spoken by the melancholy Jaques in Act II Scene VII. The speech compares the world to a stage, and life to a play. Secondly, journalist Steve Lamacq’s questioning of the authenticity of the Manic Street Preachers. In an interview with NME, Steve confronted the band, questioning their authenticity and their true dedication to punk-rock ethics. Welsh lyricist and rhythm guitarist Richey Edwards tried to convince Steve the band were ‘for real’, and eventually used a razorblade to carve the phrase “4 REAL” into his arm, requiring 17 stitches. And thirdly, the broader cultural question of the digital age regarding the relationship between audiences and live performance.
Recordings of the talks from TEDxWarwick should be available to view online in a few weeks time. Until then, here’s what happened throughout the day…
The TEDxWarwick audience await the start of the show. Photo credit: Dana Muntean
The first of four sessions was called Crafting a Vision, and opening the show was statistician Nic Marks with his talk ‘Happiness Works’. Nic previously gave talk at TEDGlobal 2010 on The Happy Planet Index, which tracks national wellbeing against resource use – an alternative to GDP as a measure of progress. Nic estimates that unhappiness at work in a 100-person business costs $1 million per year, and convincingly made the case for happiness promotion as a cost-effective investment.
Second speaker of the day Maria Saridaki made us all feel more playful with her talk on games. Maria organised the international street games festival Athens Plaython, and reminded us that the freedom of public space is a beautiful thing – every city can be a playground.
The Sensory Homunculus
I managed to resist the urge to initiate a giant game of tag; but only because it was time for third speaker and doctoral student at the MIT Media Lab Gershon Dublon. Gershon showed us caricatured depictions of the ways we interact with the world around us: Smartphone Homunculus had one giant eye, and one giant finger (for texting etc.), whereas Sensory Homunculus had large hands and mouth, showing what the human body would look like if built in proportion to its sensory significance.
The last speaker of Session one was filmmaker and artist Kristina Cranfeld who challenged the concept of the ‘perfect’ citizen, and played her warmly received short film ‘Manufactured Britishness’, based on the ‘Life in the UK’ test, which examines skills for integrating into a British Society. You can watch the trailer for this film below; it doesn’t give much away, but you can get a feel of Kristina’s fictional future world, where hopeful citizens-to-be are tested on their ability to queue (of course!), remain calm and polite, build a brick wall, and hold the Union Jack steady. Largely concerned with immigration and human identity, Kristina’s art helped us remember that we are all global citizens, and that creative disciplines do have a place in political discussion.
Session two was called Roots of Inspiration and featured five speakers, all of whom have been inspired to create something new. First up was designer Jim Reeves who developed GravityLight, a $6 device that harnesses the power of weight and gravity, requiring 3 seconds charge for 25 minutes or power, instantly available with no running costs. There are currently 1.5 billion people in the world who have no access to reliable mains electricity, and rely instead on biomass fuels. This simple, but effective lighting innovation is a viable alternative to hazardous, but ubiquitous, kerosene lamps.
Alison Benjamin, Society Editor for The Guardian, and co-founder of the social enterprise Urban Bees, left the room buzzing with her talk on how urban Bee Keeping can positively affect people and communities, and change the way you see the world. Alison showed us how bees are great ambassadors for nature, with “1 in 3 mouthfuls we eat pollinated by bees”.
Green Graffiti: Starbucks logo washed onto pavement. Image via @Pittachu
Next, Jim Bowes spoke about sustainable advertising, and surprised the audience with the exciting idea of monetising dirt through reverse graffiti. Reverse graffiti is the process of ‘cleaning’ text or a logo onto a surface such as the pavement or a wall, and people who write, “wash me” on particularly dirty vehicles are inadvertently participating in this art! Jim’s unconventional advertising, Green Graffiti, has a lower impact on the environment and a higher impact on the audience. I think we all looked at dirt a little differently after his talk.
Nahji Chu had the audience in fits of laughter from the start with her ‘fake’ Vietnamese accent, but swiftly brought them to tears with stories of her time spent as a refugee and her move to Australia in 1978. Nahji described her journey as a food entrepreneur and an immigrant. She even uses her refugee visa as the logo of her company, misschu tuck-shop. Nahji appreciates the role and power of humour in society, and “You ling we bling” is the slogan used to promote their home delivery service.
Session two came to a close with the powerful and poignant poetry of Zena Agha. Zena addressed the complex concept of identity, and performed a poem called ‘Writing Identities’. It is hard to believe that Zena started writing poetry only 18 months ago in a library in Warwick. At the TEDxWarwick Salon (women) event, a smaller gathering prior to the main show, Zena spoke about how Islam made her a feminist. You can watch her Salon talk, and experience some of her original performed poetry in the video below.
Session three was called Unchartered Territories, and came to an audibly powerful start with beatboxing sensation THePETEBOX. Pete demonstrated some of his characteristic vocal acrobatics before performing an impressive piece from his album ‘Future Loops’. Next up was Christian Guy, Managing Director at The Centre of Social Justice, a think tank that seeks effective solutions to poverty in Britain. Christian told us stories of a parallel Britain, and why we must put poverty centre stage. He argued that we all have a duty to engage in British politics, and not to abandon it, something with which host Siobhan Benita heartily agreed.
Kenneth Cukier, Data Editor at The Economist, spoke about Big Data dystopia. Big Data is a term that seems to be popping up everywhere in a variety of contexts, from healthcare to international security, but Kenneth gave us a better understanding of the concept itself, and the kingdom over which Big Data inevitably rules. If someone is deemed to be 95% likely to commit a crime in the next week, what should be done? Could someone really be arrested for statistical culpability?
“Will the legal standard of probable cause become probabilistic cause?” – Kenneth Cukier
Martin shows different stages of human regeneration
Session three ended with Martin Birchall,one of the world’s leading Otolaryngologists, who co-led the pioneering research team that carried out the first transplant of a human windpipe reconstructed using stem cells. Anyone looking to gain further insight into Martin’s fascinating work (highly recommended) can watch his Royal Free London NHS Trust talk Building organs from stem cells.
Nicola plays some Bach on her Stradivarius violin
The final session of the day was called Conquering Mountains, and began with the stunningly talented Nicola Benedetti, most sought after violinist of her generation, and winner of a string of awards (no pun intended), including Best Female Artist at the 2012 Classical BRIT Awards.
Nicola started off by, of course, performing, and then stepped into the red circle for her first ever public speaking appearance. Nicola related her musical journey to a delighted audience, from the moment she truly emotionally connected with classical music at the age of 6, to becoming a proud ‘big sister’ to Sistema Scotland children. Nicola ended by once again picking up her Gariel Stradivarius, made in 1717, and playing unaccompanied Bach, music of almost identical age to her instrument.
Next up was photographer Matej Peljhan who told us of Luka, a little boy with muscular dystrophy who wanted to be photographed doing the things he could not do in reality. Matej made Luka’s wish come true, taking photos from above with Luka strategically positioned on the floor, images of Le Petit Prince, and received a well-deserved standing ovation from several members of the audience.
“The imaginary world is not an escape, but a part of our reality, a never ending source for our creativity.” – Matej Palijhan
George’s drawing of 11 year old Halid as he told his story. Image: www.georgebutler.org
Penultimate speaker of the day George Butler shared his passion for drawing and the incredible stories he’d uncovered through this art. George recounted tales of his time in Syria, where he travelled specifically to location draw. He spent some time with the Free Syrian Army, and returned to record stories amongst the refugees and the field hospitals. He heard unimaginably heartbreaking accounts of conflict from civilians, including 11-year-old Halid who had witnessed the brutal killing of his entire family only two weeks earlier. I have to say, I found George’s talk particularly moving, and thought he offered a unique and under-reported look at life in a state of prolonged conflict. It is remarkable how something so simple allowed him to take a step into the lives of others and make such a strong connection.
The final speaker of the fourth session, and of the day, was Kah Walla, the first woman to ever run for presidency of Cameroon. Kah’s talk was titled ‘Daring to invent the future of Africa’. She spoke about development, corruption, and governance – telling us Africa is not poor, but poorly run – and described her personal and political struggles.
“No matter what type of violence and brutalities we face, we still have power.” – Kah Walla
Kah’s passionate speech, and show finale, also received standing ovation, and she exited the stage to rapturous applause. This level of appreciation continued in recognition of the organising team, as all 26 of them took to the stage to thank the audience for their participation and thank the speakers for their time and efforts.
I always feel that one of the downsides of TED and TED-style events is the limited opportunity to ask questions, although the Warwick programme did include ‘breakout sessions’ at lunch with a couple of speakers, and superficially, this dialogue now continually takes place in the twittersphere. I’m a big fan of Q&A, but I also appreciate that this kind of event is more of a show than a conference, and the intention is to inform and inspire, rather than debate.
TEDxWarwick 2014 is over for another year. Image via @Em216H
This unique story-telling style has rapidly captured the attention of a global audience, and continues to excite and engage people of all ages and backgrounds. Only so much can be achieved in a day; and TEDxWarwick managed to achieve a lot. Undoubtedly, many people (including me) are already looking forward to 2015.
Many congratulations to the team!
Alexandra Abel is a graduate from Imperial College London and the Royal College of Music. She has a keen interest in both Global Health and Performing Arts, and in her spare time, enjoys performing with her local theatre company. She is also part of the team organising the aforementioned ‘Imagining the Future of Medicine’ event at the Royal Albert Hall in London in April. From September, she will be a medical student.
This week on PLOS Translational Global Health, we continue our podcast series in Global Health with medical doctor and human rights lawyer, Fiona Lander. Coming from Melbourne, in South-East Australia, Alessandro asks Fiona about her time with the United Nations, in medical practice and travelling the globe.
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 Global Health and Medicine working group at the Henley Club, Melbourne.
This week on Translational Global Health, regular blogger Jo Jewell - recently of the World Cancer Research Fund (WCRF) - offers an important reflection and summary on the progress thus far, in the global prevention and mitigation of NCDs.
In September 2011, public health NGOs were gearing up for the High-Level Meeting of the United Nations on Non-Communicable Diseases (NCDs). This was only the second time that the UN General Assembly had met on a health issue. As such it was both a landmark occasion and an unprecedented opportunity to raise political awareness of the catastrophic impact of NCDs around the world.
Public health advocates wanted the meeting to bring a similar level of political attention and sense of urgency to NCDs as had previously been achieved for the HIV/AIDS epidemic. Critically, it was hoped that the Political Declaration that was to be agreed would secure much greater action worldwide on the prevention and control of NCDs. In so doing, all governments would set in stone their political ambition, commitment and accountability to addressing NCDs.
It was in this optimistic context that I joined the policy department at World Cancer Research Fund International. Thankfully, the Political Declaration was universally adopted by governments from around the world. In it they agreed a roadmap for international action. As such, my work at WCRF International has been influenced by the outcomes of this meeting. As I sadly prepare to leave WCRF International to take on a new career challenge, it seems like a good moment to reflect on the impact of that High-Level Meeting and what has happened during this exciting period for NCD policy worldwide.
Action since the UN Declaration on NCDs.
The UN Political Declaration has been instrumental in galvanising global action on NCDs. It has mandated international agencies such as the World Health Organization (WHO), Food and Agriculture Organization and the UN Development Programme to expand their work programmes on NCDs and to collaborate on this issue more than ever before. While there is still a need to ensure that NCDs are truly integrated in all the relevant areas – such as the ongoing discussions around the post-2015 global development agenda, it is undeniable that the profile of NCDs has risen as a result.
In the years since the Political Declaration, the WHO has successfully adopted a global policy architecture for NCDs, including a Global Action Plan, a set of global targets (designed to incentivise and drive action), a framework for monitoring progress, and a voluntary global target to reduce premature deaths from NCDs by 25% by 2025.
As a result, NCDs are well and truly established on the health policy map, and the WHO – as the lead agency on health – has articulated what it would like to see national governments do in terms of developing and implementing policies.
What has this meant for our work?
For World Cancer Research Fund International the new global policy architecture on NCDs galvanised our work advocating the wider implementation of effective policies for the prevention of cancer and other NCDs. We developed the NOURISHING Framework to bring together key areas where governments need to take policy actions to promote healthier eating and ultimately to help achieve the 25 by 25 goal. Having an agreed policy framework is critical because it allows the political discussion to move from the “what” to the “how”, which is where there is most potential to support national governments in developing policies.
As part of NOURISHING we pulled together the policy actions that countries are taking around the world (e.g. on nutrition labelling) so we could see – and share with others – what countries are doing to implement these global agreements. What are other countries doing”? is a question we heard often from government officials. Even more, I used to hear “what is the evidence that policy is effective?” So we developed a plan to collate, review and interpret the evidence base. This is work I will be excited to see WCRF International develop into the future, and which I look forward to using in my new role at the WHO’s Regional Office for Europe.
Working internationally is different to working at the national level. Nationally, policy actions have to be tailored to contexts and populations; internationally, it’s about identifying the core elements of well-designed policy that are transferable globally. One of those elements inevitably involves the law, which is why we explored the role of law in obesity prevention in our first working paper, and collaborated with the McCabe Centre for Law and Cancer.
Where are we going next and what are the challenges?
By its very nature, public health evidence is complex. This is particularly the case for multi-factorial issues such as obesity. As I leave World Cancer Research Fund International my hope is that it ultimately does for policy what it has always done so well in its science programmes (notably for Second Expert Report and now with the Continuous Update Project). That is, to ensure that all the evidence is brought together in a way that we can learn from it and take action. Communicating what has been learned to governments, including analysis of the real-world effects of innovative policies, should enable even more policy action on NCDs and a greater confidence in our understanding of the “how” part of the equation. This will be the true legacy of the Political Declaration.
Jo Jewell has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network.
The aims of Universal Health Coverage (UHC), as defined by the World Health Organization, are: “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.” Yet as I studied cancer care and control policies in Andhra Pradesh, India, I realized that I did not fully grasp what this definition of UHC actually entails. I particularly took issue with the phrase “to provide all people with access.” When we say that a country or a state has achieved universal coverage – or in the case of the Rajiv Aarogyasri Scheme (RAS), 87% coverage of the state’s population – what does that mean in practice? At first, I assumed that the expansive reach of RAS ensured that 87% of the population could access free tertiary care. But my conversations with state government officials and health care providers suggested otherwise.
As I delved deeper into the state’s policies, I discovered that the widely lauded statistic actually signifies that 87% of the state’s population is simply eligible for RAS, by way of possessing a white ration card. And I came to understand that there is a huge difference between eligibility and accessibility. The focus of my last two posts was the fundamental barriers to care, both on the supply and demand sides. But these posts merely highlighted few of the multitude challenges faced by patients in seeking health services. It is therefore highly unlikely that all those who are technically eligible to benefit from RAS when sick actually do.
Perhaps the most fundamental barrier to care, I realized, was one that is seldom discussed – the linkage between services. Even if the state removes the financial barriers to each service along the cancer care and control continuum, from primary prevention to survivorship and palliation, patients may remain unable to access comprehensive care if referral networks are inadequate. In fact, one oncologist I spoke with admitted that he discontinued screening efforts for cervical cancer because he had no way of reaching the patient after testing was complete. Despite obtaining Pap smear results, he could not find the patients for further diagnostics, counseling, and treatment.
Certainly, other government-funded programs attempt to mitigate these challenges and improve access. In 2010, for example, the Government of India approved the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS). The broad objectives of the NPCDCS are to: prevent NCDs through behavioral changes, promote early diagnosis of NCDs, train doctors and other health staff to monitor and treat NCDs, and establish and strengthen palliative and rehabilitative care facilities. Notably, the program strengthens existing public health infrastructure established through the National Rural Health Mission to reach even those populations residing in remote areas. The central government aims to scale up the NPCDCS, which has thus far been implemented in only 100 districts, to cover the whole country by 2017.
But whether or not even this program will facilitate UHC depends on how it links to existing state-funded insurance schemes. From my conversations, it became clear that at the moment, the NCPCDS and RAS seem entirely disconnected.
Because cancer is a chronic disease that requires preventative, screening, diagnostic, treatment, palliative, and rehabilitative services, investigation of cancer control policies provides some insight into the extent to which states have achieved UHC in practice. RAS has certainly improved the poor’s access to inpatient care, but we must be critical of such health financing mechanisms in order to improve their efficiency. The point of this series of posts is that pouring money solely into tertiary care may not be sufficient to improve financial protection, let alone increase quality and quantity of life, reduce the disease burden, and ultimately achieve UHC. We must aim to design programs that truly minimize supply side barriers to all health services and innovate to address such demand side barriers as cultural stigmas. Only then can we truly realize universal health coverage as defined by access rather than merely eligibility.
Pooja Yerramilli completed her B.A. at Yale University and MSc. 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 and is currently collaborating with the Harvard Global Equity Initiative to research the financing of cancer care and control in low and middle income countries.
This week on PLOS TGH, we continue exploring the medium of Global Health podcasts. Coming from central Melbourne, in South-East Australia, Alessandro interviews the globally recognised and respected Professor in Nutrition and Public Health – Kerin O’Dea.
Professor Kerin O’Dea is Professor: Nutrition and Public Health in the Health Sciences Division of the University of South Australia. Professor O’Dea is currently engaged in research on an NHMRC Program Grant titled ‘Improving Chronic Disease outcomes for Indigenous Australians: Causes, Interventions, System Change.’ Professor O’Dea is interested in the therapeutic potential of traditional diets and lifestyles of numerous populations, including Indigenous Australians.
Key previous senior academic and research leadership positions include: Director of the Sansom Institute for Health Research, UniSA (2009-2012), Professorial Fellow, University of Melbourne, Department of Medicine, St Vincent’s Hospital (2006-2009); Director, Menzies School of Health Research, Darwin NT (2000-2005); Deakin University (1988-1997) as Professor of Human Nutrition, Dean of Health & Behavioural Sciences (1993-1994) and Pro Vice Chancellor Research (1995-1996).
She has been an active part of numerous national committees over many years advising government on health and medical research, Indigenous health, nutrition, and diabetes.
Prof O’Dea in The Lancet:
Having contributed to the explosion in nutrition-related research in the past few decades, O’Dea says it’s now time for concerted action. “One of the things that characterises much public health research is that we describe how bad things are but don’t do enough intervention,” she says. “Today, taking no action can be more expensive than the interventions themselves.”
This week on PLOS blog Translational Global Health, two emerging health leaders from Kenya lend their voices on the topic of cancer control and care.
Meet Mary, a 43 year-old mother of 5 children and a poor peasant farmer from rural Kenya, who has been battling breast cancer for 7 years. In denial of her condition, Mary has held the firm belief that her breast lump is a result of witchcraft against her. She received her initial diagnosis at a rural health facility 7 years ago, but declined the advised mastectomy.
After her diagnosis, Mary went 5 years without any medical follow-up until she finally visited the health facility again. At this time her breast was ulcerated and oozing, but she still did not agree to a mastectomy. Earlier this year, Mary was sent to Kenya’s main public referral hospital in Nairobi, Kenyatta National Hospital, where specialists found that her breast cancer had metastasized to her spinal cord. An aggressive treatment regimen was initiated, but radiotherapy could not reverse the complications. Unfortunately, the only remaining option is to manage her pain, although her breast cancer could have been manageable had it been detected sooner. Sadly, Mary is a prime example of the many people struggling with cancer in Kenya.
The issues and barriers to cancer control
Cancer accounts for approximately 18,000 deaths annually in Kenya, with up to 60% of fatalities occurring among people who are in the most productive years of their life [1, 2]. Men are most commonly diagnosed with prostate or esophageal cancer, and women are most frequently affected by breast and cervical cancer .
A huge disparity exists in patient outcomes between low-income countries like Kenya and high-income countries like Canada. Take cervical cancer as an example: due to pap testing, cervical cancer is rare in Canada or the US; however, it is the number one cause of cancer deaths in Kenyan women . Prevention and screening has just not been available or accessible to most people in Kenya. Most cases are often undiagnosed or misdiagnosed, which is partly due to inadequate healthcare infrastructure.
The issue is exacerbated further by a faulty national health insurance plan that doesn’t allow patients to afford medical services . The health system is inadequately designed and resourced – particularly for people with cancer – with poorly equipped hospitals, a low doctor to patient ratio, and a lack of access to affordable drugs. These factors lead to late presentation, complications and meager patient follow-up .
Widespread lack of awareness and accurate information about cancer is another reason why screening is rare and many cancers are detected when it is too late to treat effectively. Several cultural myths exist regarding cancer, which are critical obstacles to expanded cancer control and care in Kenya, especially when it comes to early detection . One popular myth, as demonstrated by Mary’s case, is that cancer is caused by curses from ancestors and elders. In such cases, people even believe that you can ‘catch’ the disease from those who have it.
Although developing countries bear 80% of the cancer burden, only about 5% of global resources devoted to cancer are found in these countries . Most cancer care services in Kenya are concentrated within a 5 km radius of each other in Nairobi, making it difficult for most Kenyans to access necessary care. The public national hospital hosts most of Kenya’s oncology expertise and technology. About 78% of Kenyans live in rural areas, which mean that many patients requiring care may travel up to 600 km to access cancer services . The wait time for treatment at Kenyatta National Hospital is extremely long, and this is a problem, as there is a narrow window of opportunity to treat cancer effectively.
The other option of private cancer care, is not actually an option for the majority of Kenyans, as treatment costs in these hospitals are so astronomical that many patients travel to India for cancer treatment instead. More effort and resources are needed to make treatment more widely available and accessible.
Action required to reduce barriers to cancer prevention and care
Prevention efforts, both on a personal and policy level, must be scaled up for cancers that are amenable to prevention such as cervical cancer.
Non-communicable diseases (NCDs), which include cancer and other chronic conditions, share common behavioural risk factors that must be reduced to facilitate disease prevention: physical inactivity, tobacco use, harmful use of alcohol, and unhealthy diet [1, 2]. Smoking and alcohol abuse are on the rise in Kenya, air pollution is potent in urban areas, schools do not prioritize physical activity, obesity is on the rise, and the list goes on .
Reduction of these NCD risk factors is not addressed sufficiently by the Ministry of Health and other policymakers. Only 5% of the Kenyan budget is spent on health – instead of the recommended 15%, and much of the cost is on treatment rather than prevention . Robust prevention policies will result not only in lives saved in the long term, but also in long-term economic gains.
Some community awareness campaigns are happening at the grassroots level, but these must be scaled up nationally to affect sustainable change. Additionally, the many people currently struggling with cancer, and those to be diagnosed with the disease in the coming years, should not be deprived of cancer care due to their geography or inability to pay. These patients have a right to receive treatment, and it is time that this right is recognized with investment in better cancer care in Kenya.
Progress is on the horizon
In 2012, Kenya established a National Cancer Prevention and Control Act, making it one of the few countries in Africa with legislation for cancer . The Act, which stipulates the establishment of a National Cancer Institute among other important advances to counter this disease in Kenya, has yet to be operationalized .
During a launch of 2013 breast cancer awareness and screening month (October), the Kenyan Ministry of Health called for revenue allocation for cancer control in the government budget. The presence of the First Lady, Margaret Kenyatta, and other government officials at the cancer-screening launch ignited hope for high-level commitment in reducing the cancer burden. The First Lady declared that she and President Uhuru Kenyatta had been screened for cancer, encouraging the public to follow suit – potentially lifting some of the public’s stigmatization of cancer.
Kenya is currently undergoing decentralization of government functions, including healthcare, which means that there is a renewed opportunity to integrate cancer care into other regions of the country and build an overall healthier Kenya. As 47 counties of Kenya absorb the healthcare mandate, it is expected that greater community involvement will result in tailored healthcare for each region. Devolution will facilitate more straightforward avenues for advocacy on NCDs at the county-level, as the decision-makers in government will be more localized and have so far demonstrated themselves as easier to communicate with. County health policymakers are usually also native to the communities that they serve and have a more vested interest in improved health outcomes in their designated regions, than the previous national level decision-makers.
For both healthcare devolution and expanded care for cancer, there is a push to build private-public partnerships. Both public and private healthcare providers must have a seat at the policy table and work together, as multi-sectoral action will have the biggest impact within communities. Yet, the need to safeguard public health must be emphasized and the terms of such partnerships critically evaluated and monitored.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095128.
Jordan Jarvis, is a Global Public Health Researcher based in Kenya’s office of African Medical and Research Foundation (AMREF), and a member of the Young Professionals Chronic Disease Network in Kenya.
Duncan M. Matheka, is a Kenyan Medical Doctor and Public Health Researcher, and the African Representative of Young Professionals Chronic Disease Network
It’s that time again – ‘zero one, zero one’. The new year begins and the old slips away. A time for celebrating, enjoying and reflecting. A time to think about the important things in our lives and how we can prioritise them.
As 2014 starts, many of us will be making resolutions. Promises, big and small, for the year ahead. But this year, let’s not just think of the local – or the ‘me’ – when contemplating our New Year’s commitment.
Thinking beyond the horizon, what small but important actions can each of us do to help the wider community achieve happier, healthier lives?
Here are seven simple suggestions…
1. Donate some time and get back much more
Volunteers are a crucial part of our modern economy and a functioning society. Donating a small amount of time and an enormous repertoire of skills, unpaid workers who choose to give some hours each week or month can make the world of difference for organisations and people doing great things. Find something that you love to do anyway or find a group that you enjoy hanging out with – it is a rich and meaningful way to give back, have fun and catalyse a better world.
2. Forego a meal out, to feed those in need
Christmas is an expensive time and most of us are under some financial pressures, but making a small contribution to a charity or community group not only makes us warm and fuzzy – but keeps them running. Every dollar counts.
Put aside a small amount each week and very quickly this adds up to a substantial donation. A great idea is to forego a meal out at a restaurant or cafe each week. This $10 becomes $500 over the 12 months ahead, and can feed a small crowd in-need.
3. Lend your voice to a campaign that matters to you
Very often, your greatest asset is not in your hip pocket, but in your throat. Lending your voice to a worthy cause, or throwing your vocal support behind a campaign or community group can make the world of difference. You can even do it online.
It doesn’t take long, but can make a lasting impact.
4. Ditch the car to give legs to the environment
I’ve said it before and I will again, for every kilometre you walk or ride instead of drive your car, you not only improve your health and the health of those around you – but you also save the community a small fortune. Why not start the year by walking to get the milk, taking the kids to school by foot or jogging into work?
5. Don’t hesitate to ask why
Some conversations are hard to have. No-one likes to talk about the state of politics, or climate change mitigation. Even a chat about the health of our most marginalise populations seems to be a social faux pas nowadays.
We can change this by starting 2014 with a conversation. How about “why isn’t Australia doing enough about climate change?“ or “why are we building roads faster than we build railways” or “why are alcohol and fast food companies still allowed to sponsor sport?“…
Talking and engaging others is the first step to solving these bigger challenges.
6. Buy consciously
For most of us, Santa was generous and we rarely go without the things we really desire. But being in this position – in a nation with little want – we also have an opportunity (read responsibility) to think before we buy. Every dollar we spend is a vote for the company that made the product we purchase, a vote for the way they produced it and even the marketing tactics they used to lure us in.
Vote with your dollars and show you support local business, ethical companies, responsible advertising and sustainable corporate practice.
7. Break a habit, for a better life
Finally, sometimes giving something up can actually make your life richer.This New Year, move from ‘contemplation’ to ‘action’ in one or more of three domains. Improve your health and the health of others simply by not doing something.
Cut down your alcohol drinking and consider a few non-alcoholic days per week. Quit smoking or support someone you know to quit – smoking is so 2013. Finally, break your sugar-drink habit. With increasing scientific evidence that soft drink (aka soda) contributes an enormous burden to society, maybe January is time to replace the juice, lemonade and cola with simple H2O – water.
As a new year dawns, there are so many simple ways to help build a healthier, more cohesive world through personal action. Going into 2014, let’s all jump in and take our own small resolution to ensure the 12 months ahead are a wonderful time for all.
Translational Global Health facilitates the translation of findings from basic science to practical applications in Global Health practice and, thus, meaningful health outcomes for diverse populations and societies.
“Millions of families are pushed into poverty each year when one of their members have become too weak to work. Or when the costs of medicines and treatments overwhelm the family budget. Or when the main breadwinner has to stay home to care for someone else who is sick.” - Ban Ki-moon, Secretary-General of the UN on NCDs.
“If countries are serious about combating NCDs, an exponential increase in the scale and scope of these measures is needed to incentivize the production, trade, and consumption of healthy food… and to ensure a whole-of-government approach to public health.” - Helen Clark, UNDP
About the Bloggers
Lead Blogger Dr Alessandro Demaio is an Australian Medical Doctor with a Masters in Public Health and a PhD in Global Health. Since 2013, Sandro has been a Postdoctoral Fellow at the Harvard Global Equity Initiative, Harvard Medical School and an Assistant Professor at the Copenhagen School of Global Health. He is also Co-Founder of NCDFREE.
Sandro is joined by a sensational team of Guest Bloggers from around the globe.
Global Health & Classical Music, Imperial College London
Research Fellow, Harvard University
Assistant Clinical Professor of Emergency Medicine, Columbia University College of Physicians and Surgeons