My journey from civil war to global health

Dr Jibril Handuleh (centre) is physician, researcher and lecturer with dual nationality in Somalia and Djibouti. After training as a general practitioner in his homeland, he overcame multiple challenges to publish 15 papers over the course of two years, in some of the world’s most widely-read medical journals. This is his story.

Somalia’s wars, droughts and famines are well known, but less attention is paid to how these problems undermine the nation’s mental health. Aside from the damage wrought to bodies and property, many Somalian minds bear scars from a two-decade civil war that ended in 1991, and continuing economic precarity. This situation has been exacerbated by the disruption of healthcare services, with hospitals destroyed and doctors fleeing for safer countries.

I was born and grew up in exile in Saudi Arabia, eventually returning to study medicine once stability had returned. During my training, the university in my hometown of Borama had no local teaching staff or exams in psychiatry, despite the fact that two out of every five Somalians are estimated to suffer from mental health problems.

Somalians with psychiatric disorders are often stigmatized, abused and literally imprisoned in their homes. Mentally ill people can become a huge burden, as families don’t know how to deal with severely disturbed or violent relatives. Many are therefore chained up or put into prison in order to control them. Traditional healing methods can be just as repressive, with patients having their heads dunked repeatedly into water almost to the point of drowning, in an attempt to force out harmful jinns (magical spirits).

Moreover, even when they receive medical help, patients are often misdiagnosed with exclusively physical rather than psychiatric conditions. Bipolar and schizophrenic Somalians are commonly presumed to have typhoid fever, and therefore mistakenly prescribed antibiotics that are both expensive and ineffective.

These challenges prompted the Somalian diaspora in Europe to collaborate with the Borama community to establish our first psychiatric unit. Central to the project was the hiring of 10 female healthcare workers, who have run individual and group therapy sessions, and encouraged local community leaders to reduce mental health stigma.

The clinic opened in 2012 – the same year I was introduced to AuthorAID, a website that supports academics in developing countries. Following registration, the platform quickly became part of my daily writing process. It was a key resource in my attempts to communicate the challenges and successes of African healthcare provision. While beginning to publish my first paper, this platform helped me secure access to online literature and research funding – crucial in a country like Somalia where academic infrastructure and the internet itself is weak.

I learnt how to draft and edit a paper, submit it to a journal, and get it published. Within two years, I had papers accepted at three conferences and was able to publish over 15 articles in academic journals, two of which were accepted by leading international mental health journals. The American Journal of Psychiatry published my article on psychiatry hospital practice and The Lancet Psychiatry published my article on mental health services in Somaliland, a territory in Northern Somalia.

Apart from psychiatry, my research has also covered e-health in fragile states, chronic diseases and conflict-health interactions, taking Somalia as a case study. I have worked with researchers from Tulane University, Oxford University, Harvard, the Karolinska Institute and King’s College London. After becoming the first academic to publish from post-conflict Somalia, I was chosen as a Research Fellow at the Centre for Global Health at King’s College London, funded by the King’s THET Somaliland Partnership (KTSP).

In addition to my own research, I have shared my learning experiences with my students and peers. I have run two workshops on research communication for my colleagues, and also set up a newsletter at Amoud University’s College of Health Sciences, where I lecture and practice medicine. The newsletter raises medical students’ awareness of and interest in scientific writing, which helps deepen their training.

Learning from peers in other countries has also been very important for my career development. Through the resources and expertise provided by other Southern academics, I increased my chances of winning a master’s degree scholarship. Motivation letters became easier to write and more compelling and I recently won admission to an MSc in International Health at Germany’s Heidelberg University. My studies will focus on public health training in low- and middle-income countries that receive aid from the German government. Somalia has the world’s highest maternal mortality in the world, and among the highest infant mortality. I hope to use the MSc as a platform for making lasting changes to these inequalities, as Heidelberg is one of the leading centres of global health research.

My plan is to become a researcher, academic and science communication mentor for my students and academics in my country and across Africa. I want to encourage those who come from a similar background to also join the scientific world. By collaborating with peers in African universities, I hope to build the continent’s academic publishing capacity, fighting against academic fraud and raising our reputation in the global publication arena.

Dr Jibril Handuleh is physician, researcher and lecturer with dual nationality in Somalia and Djibouti.

AuthorAID is a free international research network that provides support, mentoring, resources and training for researchers in developing countries. The AuthorAID community, which includes over 10,000 researchers from around the world, helps researchers in developing countries to publish and otherwise communicate their work. It also serves as a wider global forum to discuss and disseminate research. AuthorAID is based at INASP and supported by the UK Department for International Development (DFID) and the Swedish International Development Cooperation Agency (SIDA).

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Healthcare In Danger: what happens when it all goes wrong?

This week on PLOS Translational Global Health, emergency physician and humanitarian & global health doctor, Jenny Jamieson, writes about some of the tacit dangers of delivering healthcare in low-resource settings.

As healthcare workers, some of us travel to resource-limited settings to deliver care where needs are the greatest. Due to various factors, which range from economic inequality among citizens, political instability, natural disasters, conflict or warfare, many of these places are also some of the most dangerous. As a result, healthcare workers can find themselves working side-by-side to crime; and even becoming the target of directed threats or violence. Those who are willing to put themselves on the front line in order to help others, can themselves end up being actively targeted. Aside from a stint in Afghanistan in 2013 and a few fleeting visits to some of the more dangerous regions within the African continent, I never truly considered being at risk from doing my job.

As a doctor I’ve been guilty of feeling like I have immunity. As if there is some fluorescent sign above my head saying “I’m an emergency doctor – don’t harm me. I’m here to help.” Risk perception is entirely subjective, and the degree to which that risk is perceived and then individual decisions are based upon this risk, differ. Familiarity with known risks can, at times, breed complacency.

Any illusions about my “doctor immunity” were recently crushed when I was kidnapped in broad daylight in Dar es Salaam, where I am currently living. While I was held captive for three hours and not physically hurt, critical incidents such as these are rarely factored into plans and preparations for working abroad. Yet violence against health workers is a key and overlooked humanitarian issue in our current global climate. Doctors and health workers may be seen as targets as they treat anyone, regardless of their political affiliation.

An International Committee of the Red Cross (ICRC) study found that there were 1800 incidents involving serious acts or threats of violence to healthcare workers across 23 countries between 2012 – 2013; and it is likely that many more incidents go unreported. In response to growing concerns surrounding the safety of healthworkers,, the ICRC launched the “Health Care in Danger” initiative, which aims “to address the widespread and severe impact of illegal and sometimes violent acts which obstruct the delivery of healthcare.” (Durham). Since then, there has been renewed attention on this issue. During a recent World Health Assembly, WHO Director-General Margaret Chan stated that health workers are under attack like never before. Indeed, health care workers are at greater risk today than than they were when the Geneva Conventions were originally being drawn up. The intensity of threats and attacks to doctors have increased.

ICRC

Photo v ICRC.

In the last few weeks, we have seen hospitals in Syria being deliberately targeted by violence and crime, reaching the highest levels in a single month since the start of the conflict. A bomb blast on June 10 in Aleppo resulted in damage to medical equipment, pharmacy stores and the post-operative room, resulting in compromised delivery of much-needed health services. A hospital in Busra was hit by 10 barrel bombs on June 15, destroying the only facilty in the province providing dialysis and neonatal care. Médecins Sans Frontières (MSF) have repeatedly called for respect of international humanitarian law and respect for medical staff, medical facilities and civilians accessing these.

It must also be recognised that there is a multiplier force at work here. When violence prevents health care workers from reaching those who are in greatest need of attention, people continue to suffer illness and injury without adequate treatment. This knock-on effect may be in the form of physical injury or a mental health issue, such as post-traumatic stress. Violence may also directly affect the health facilities that are providing treatment; hence violence and crime may undermine the already fragile health infrastructure. Hence a vicious cycle ensues with violence and crime contributing to health care needs being even greater in these settings.

So what can be done to address insecurity in the field? Coupland, who spearheaded the Health Care in Danger project, states that the healthcare community “must recognise this issue and be able to communicate about it.” Proper security training is essential for anyone working in a conflict area and many of the large medical humanitarian organisations will ensure all their employees receive this. Having been a recipient of MSF’s security training, I was able to employ many aspects of this whilst being held captive. Strong government policies to prevent violence and crime, including upholding international humanitarian law and human rights law, is essential, but often difficult in settings where governments may be weakened, destabilised or corrupt. The global health community has taken awhile to recognise that conflict, violence and insecurity are not just constraints to health care delivery – as Coupland states:: “they can be showstoppers.” 

So when it all goes wrong, what do you do?

Despite all this, when things go wrong, humans usually find a way of rebuilding the things that have been stripped away from them. You find a way of rebuilding the bubble of security that was once wrapped around you and has since been brutally torn away. You find a way of restoring your optimism for life and work. You remember why you traveled abroad and the reasons why as a healthcare provider, you are willing to put yourselves at risk in order to help others.

The important thing to remember when embarking on global health work is that things can go wrong. We don’t have absolute immunity. But with adequate training, awareness and precautions, it is possible to make them go right again, too and prevent a dangerous experience from being a showstopper.

 

AAEAAQAAAAAAAANAAAAAJDJhMDA4NTY1LTg5YzEtNDE5OS1hNTRmLWI1MzRjOTA3ZTY3MQDr Jennifer Jamieson is an emergency doctor from Australia who is currently based in Dar es Salaam, Tanzania. She has previously worked for Médecins Sans Frontières (MSF) in northern Afghanistan. She is a cofounder of the Global Health Gateway, an organisation dedicated to keeping young health professionals engaged in global health activities and work.  

 

 

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A Slow Burning Natural Disaster

This week on TGH, Assistant Professor Christopher Tedeschi, MD, MA, FAWM explores heat stroke deaths in India, as they approach record numbers–and as most of the casualties may be avoidable.  

Sometime in the next several days, monsoon rains will begin to sweep across India and gradually move northward, offering drenching relief to thousands caught in this year’s relentless heat wave. Andhra Pradesh, one of the hardest hit states, has reported over 1600 deaths in the past week alone. As of Tuesday morning, more than 2300 people had died nationwide as a direct result of the extreme heat.

flickr / Vinoth ChandarRecent reports describe modest efforts to mitigate this disastrous outcome. The government has encouraged people to stay home and keep hydrated, and established a distribution network for drinking water and buttermilk. Yet many news stories speculate that relief can come only in the form of the coming rains, and imply that other efforts to curb the death toll may be futile.

“These deaths are easily avoidable. All they need to do is follow basic precautions like avoiding working in the sun. Not many listen. What can we do? It’s a problem of poverty,” M. Sudhir Kumar, a civil assistant surgeon at Dakkili Primary Healthcare Centre, told the Times of India.

But local leaders and academics alike need to come up with better ways to reduce the damage rather than throw up their hands.

The heat wave is a slow-burn natural disaster representing the sort of environmental emergency we should expect more frequently in coming years. The UN’s Intergovernmental Panel on Climate Change reports that extreme weather events will likely become more common, and that “it is very likely that heat waves will occur more often and last longer, and that extreme precipitation events will become more intense and frequent in many regions.”

Many of these events will disproportionally affect populations with fewer resources to protect themselves, more to lose when extreme events happen, and longer recovery times.

Flickr / Bryan LedgardHere’s where the global health community, NGOs, and community organizations come in. As we concentrate on the increasing prevalence of non communicable diseases—especially in rapidly developing nations like India—we need to include environmental emergencies and climate driven events in our planning.

Those of us devoted to wilderness and environmental medicine should pay special attention. This ongoing disaster represents an opportunity for the wilderness medicine community to influence public health in remote, austere locations like the ones most affected yearly by blistering heat.

The Wilderness Medical Society guidelines for the treatment of heat-related illness provide an outline for medical care required for different stages of heat illness. With that foundation, local knowledge should take over: what is the best way to alert communities when extreme heat is predicted? Where should towns and villages establish cooling stations?  Can cool mist devices be improvised to serve large numbers of people? 

Heat emergencies are predictable—and amenable to locally devised action plans, which should aim to reduce the morbidity due to heat illness on all levels: by distributing increasingly urgent warnings when high temperatures are predicted, encouraging individuals to change their behavior when temperatures rise (alteration of work hours, frequent breaks for laborers and checks on the elderly), implementing community relief measures like cooling centers and provision of adequate drinking water, and enacting standardized protocols for emergency personnel to treat heat stroke quickly both in the field and at health centers and hospitals.

The Gujarati city of Ahmedabad has had such a system for the past few years. A plan to mitigate heat deaths seems to have paid off—the protocol includes cooling stations, a public health awareness campaign, and social messaging apps to convey updated information. The Ahmedabad Heat Action Plan, an impressive document created by a variety of international organizations including the Natural Resources Defense Council, provides an elaborate blueprint outlining what constitutes a heat emergency and what stepwise responses should be taken. Hopefully the implementation of this plan has already led to measurable decreases in morbidity due to heat stress.

But it’s difficult to tell if similar measures have been enacted in more remote areas, like Andhra Pradesh and neighboring Telangana, which remain perilously exposed. In these primarily rural districts, at-risk groups like laborers and older individuals have little access to cooling measures.

What will it take to implement a campaign like the Ahmedabad plan in the hardest hit regions? In these districts, populations are more spread out and less apt to be the beneficiaries of such a prestigious international academic collaboration. 

Flickr / Dr EG An effective strategy seems to require few resources besides community engagement, the ability to deliver public health messages, and simple technology like electric fans and misted water. Yet despite the escalating—and oftentimes tragically avoidable—death rate, it remains difficult to convince people to comply with solutions offered by the government.

Frustrating, but not hopeless. Academics and local officials like those behind the Ahmedabad plan need to devise more persuasive ways to nudge the population to alter their behavior safely. Rewards for employers to change work requirements? Incentives to persuade people to hydrate appropriately or visit cooling centers? We can probably do better—if experts in public health and environmental medicine effectively join with community innovators with fresh ideas about changing behavior and providing accessible relief.

As the monsoon reaches the south of India in the coming weeks, we’ll likely see a dramatic drop in heat related deaths as the rains provide some much needed cooling, and the specter of heat related deaths will fade from the headlines until next year.

And then the floods will come.

Christopher Tedeschi, MD, MA, FAWM is Assistant Professor of Medicine at Columbia University Medical Center and an emergency physician at NY Presbyterian Hospital. He is a member of the core teaching faculty of the NYP Emergency Medicine Residency and clerkship director of the sub-internship in Emergency Medicine.  Dr. Tedeschi 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 and education in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during global health emergencies.  His other interests include nonfiction media production, especially as related to medicine.

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Three important things you didn’t know about diabetes

This week, lead blogger Dr Alessandro Demaio of the Harvard Global Equity Initiative returns to lay things straight on a leading cause of global deaths.

When we think of diabetes, we tend to think of rich people with poor lifestyles. A chronic disease linked with obesity, heart disease and worse outcomes for some infectious diseases, diabetes tends to be associated in our minds with wealth, excess and over-consumption.

But it’s not.

Diabetes is a disease that results in higher-than-healthy sugar levels in the blood and can lead to some disastrous outcomes – including blindness, kidney disease and heart disease. In Turkey last week, working with Rotary to deliver workshops on diabetes prevention and care, three important messages emerged that shouldn’t be overlooked when it comes to this massive health challenge.

1. The burden is hitting our poorest, hardest

Globally and locally, the poorest two-thirds are hardest hit, when it comes to the burden of diabetes. To give this concept some shape, in China today, one in two of the population is estimated to be diabetic or at risk – in 1980, one in one hundred had the disease. In fact Latin America, The Middle East and parts of Africa have some of the highest rates of diabetes in the world.

The natural next question, is why – and there’s no simple answer. In part, it is because of the dramatic changes in diet and behaviours observed today across the world – including the globalisation and ‘Westernisation’ of our food and lifestyle patterns. In part, it is because of a lower baseline level of health literacy, as well as under-resourced education and health systems, and prevention mechanisms. In part, it is due to poverty restricting access to increasingly more expensive healthy foods and diabetes medications. And finally, we know that some populations are even at higher biological risk from the disease, developing health problems at an earlier stage and at lower body weights – such as populations from the South Asian continent. Risk that stems from as early as ‘in utero’ conditions and the nutritional status of the mother to those now at risk.

Even within nations like Australia, poorer neighbourhoods and socio-demographic groups are at higher risk from disease, disease progression and poorer outcomes – largely due to the same risks above.

Finally, and sadly, diabetes and poverty is not just a one-way street. With treatment costing as much as 70% of a family income in countries like Malawi and Vietnam, many now see chronic diseases like diabetes, as ‘poverty cycle catalysts – entrenching families in poverty, removing younger generations from work and educational opportunities to care for those affected, and in some cases reversing economic development.

2. It’s not one disease

The second take home from the week just past, is that while diabetes as a single name might seem simple – it’s actually not one disease.

In simplest terms, diabetes can be divided into three main groups based on those it affects. Type 1 Diabetes is a disease where the body attacks its own insulin-producing cells and has an onset earlier in life. Those living with the disease are often young and normal weight when diagnosed – and there is no known prevention method. Nor is it reversible. Type 2 Diabetes (once known as ‘adult onset diabetes’) is associated with overweightedness. The extra weight causes the body to produce more insulin and eventually the organs and cells that produce it, become overwhelmed, exhausted and even fail. It is usually associated with factors like physical inactivity and obesity, but not always. It can be prevented and in the early stages, it can even sometimes be reversed. The third distinct type of diabetes is Gestational Diabetes – which affects women when they are pregnant and usually resolves following birth. It does not often pose the same long-term risks to those affected, but can cause larger babies and problems during birth itself.

There are other types of diabetes, and even some categories and definitions for ‘pre-diabetes’ – those almost, but not quite diabetic. The important message is that all are not the same and the most common type is preventable – so having a conversation with your doctor or nurse can be a wise move, if you’re concerned you’re at risk.

3. Funding is falling between the gap

Crucially for those who work in policy or public health, diabetes at a macro level is being largely forgotten. In short, whether it is at the national or international policy level, or when looking at major donors like Bill Gates and others – diabetes is being left off the map and with serious consequences for those affected. In 2011, the wider group of related NCDs (of which diabetes is one) caused around two in three global deaths yet received only 1.5% of all health aid.

In Australia, it is a similar story. We have an efficient healthcare system, but sadly we spend less than 2% of our health budget on preventing disease – a third of the level spent by Canada and 50% less than the USA. All in a time when we are facing enormous burden of preventable diseases, including diabetes.

Money doesn’t solve everything, but it would go a long way to reducing this burden with many evidence-backed and cost-effective options available.

The final word

Diabetes might cause some confusion, but at the end of an important week of learning and sharing ideas, some things became very clear. Whether to avoid the pain and suffering or the economic fallout, diabetes is truly a global, health issue.

Connect with Sandro on Twitter.

For those on Twitter and interested in Global Health, the Sixty-eighth World Health Assembly of the World Health Organization is happening this week. Follow live via #WHA68.

This article is dedicated to Rotary International, for their efforts in reducing the global burden of diabetes.

The Conversation

 

 

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Emerging doctors call for action on global epidemic: non-communicable disease

twentytwelve_bannerThis week, special guest-bloggers and Australian doctors-in-training, Rebecca Kelly and Tim Martin of the Australian Medical Students’ Association, call for greater focus, discussion and action on the world’s leading causes of death.

In March this year, the Australian government released the 2015 Intergenerational report revealing a prediction of the economic and social trends over the next 40 years. There’s some fantastic news; children born in the middle of this century are projected to live greater than 95 years. Importantly, this increase in life expectancy will involve an improved quality of life and Australians will be more prosperous in real terms.

However, the report comes with a warning. Changing economic forecasts flag some potentially tumultuous decades, and an ageing population comes with its own set of challenges. Firstly, there will be a reduction in the number of active participants in the workforce. To make matters worse, Australian government health expenditure per person is expected to more than double, from $2,800 to $6,500 per year in real terms. Finally, with the unavoidable demographic change comes an increase in the rate of non-communicable diseases (NCDs); cardiovascular diseases, cancers, chronic respiratory diseases and diabetes mellitus representing the big four.

Flickr / Brad FlickingerDifficult times lie ahead, and we need to be smart if we want to maintain the health status quo, let alone improve. We already know that the NCD risk factors often start in childhood and adolescence. For instance, greater than 90% of adults who smoke tobacco started in childhood or adolescence and 1 in 4 Australian children are overweight or obese, up from 5% in the 1960s. Subsequently, overweight and obese children are far more likely to be one of the 60% of Australian adults who are overweight or obese. People with risk factors such as obesity, smoking, excessive alcohol consumption, high blood pressure, diabetes, poor diet and sedentary lifestyle are far more likely to develop an NCD.

These figures are striking and extremely worrying. Further, Australian is not immune as NCD rates are skyrocketing around the world. Thus it is timely that the Australian Medical Students’ Association (AMSA), the peak representative body of Australia’s 17,000 medical students, last month passed a policy calling on the Australian Government to prioritise the prevention in NCDs in youth. Medical students are in the unique position of having exposure to the health system whilst also being the targets of youth advertising relating to alcohol and tobacco et cetera. It is an unforgettable experience having a night out with friends, observing binge drinking and smoking, then heading to the Intensive Care Unit the next morning to find a 40 year old, obese man breathing artificially through a tube to his lungs after a lifetime of smoking and drinking. Incidents such as these are all too real and all too common.

Now we are not economists, but it would make sense to think that preventing obesity upstream in children will have a much greater, lifelong impact downstream. If we were policy makers, the question that springs to mind is “what can be done earlier in life to decrease the incidence of NCDs in adulthood?” And if one asks, one finds; there is a rich tapestry of evidence painting the road to NCD prevention.

Flickr / AlessandraWe need to get serious nipping NCD risk factors in the bud with more action and less talk. The McDonalds restaurant on the premises of a children’s hospital in Melbourne is a notable example of nonsensical and counterintuitive policy. Another example is the proposed free trade agreement, the Transpacific Partnership Agreement. Clauses in leaked drafts of the agreement could allow big tobacco, big alcohol or big food to sue sovereign governments over public health legislation. This is no fairy conspiracy; Phillip Morris Asia (the Tobacco company) is suing the Australian Government right now over cigarette plain packaging laws through an existing free trade agreement.

Fortunately, there are (relatively) easy solutions to these problems. The evidence overwhelmingly suggests that the cost of inaction in the prevention sphere is far greater than the cost of action. Earlier intervention equates to better long-term outcomes thus childhood and adolescence are critical points to target. Furthermore, the collective Australian governmental spending on prevention is only around 2%; a pitiful amount. If we spent just that little bit extra on primary prevention rather than expensive new gadgets, and seriously looked at tackling the big tobacco, alcohol and food industries which prioritise profits over wellbeing, Australia might find that we don’t end up with a doubling of health expenditure.

With Government reports such as the Intergenerational report clearly outlining the challenges our health system will face into the future, it is a form of negligence that Australia isn’t doing more to tackle the NCD epidemic. If the Australian Government was fair dinkum about NCD prevention they would be thinking twice about dodgy deals with fast food giants or undercover clauses in secret trade agreements. The medical students of Australia have spoken out in a collective voice; policy settings need to be based in evidence, not ideology. The facts are clear and the yellow brick road has been laid out. We just need to leadership to walk it.

Rebecca is a currently a fourth year medical student at the University of Tasmania. She recently graduated from a Bachelor of Medical Science and her research relates to risk prediction modelling in early life by discovering modifiable risk factors in childhood. Rebecca has become increasingly involved in her local global health network and is also completing a Masters in Public Health. She is looking forward to her a clinical elective at the end of this year in in Cusco, Peru.

Tim Martin is a final year medical student at Monash University with research interests in vaccine safety, hospital acquired infections and healthcare evaluation. He is an aspiring paediatrician passionate about the intersection between health equity and politics. Tim has been involved with various health advocacy organisations such as the Australian Medical Students’ Association and Doctors for the Environment Australia in campaigns, policies and projects involving refugee and asylum seeker health, climate change and health, gender equity, Indigenous health and non-communicable diseases. He is a Diploma of Child Health candidate and is currently studying a Masters of Public Health.

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Hacking human health and behaviour #wiredhealth

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

The stage is set for the 22 Main Stage talks, hosted by Editor David Rowan

The stage is set at the RCGP for 22 Main Stage talks, hosted by Editor David Rowan

Following last year’s successful inaugural event, WIRED Health returned to the Royal College of General Practitioners (RCGP) in Euston Square, London, on the 24th of April, for a programme of exciting innovations in medicine.

From augmenting our bodies to decoding the brain, the desire to have greater control over human health and behaviour seemed to be the overarching theme at WIRED Health 2015.

Changing the body

One of the most dramatic and noticeable changes to the human body is amputation. The loss of a limb can have a profound effect on individuals, both physically and psychologically, but more than 20 million amputees around the world currently have no access to any sort of prosthetics.

One of my favourite talks of the day came from prosthetics pioneer Nigel Ackland – the man with the bionic hand – who showed us the difference a good prosthetic can make, not only in terms of function, but also self-esteem. People still stare at Nigel in the street, but with his bionic limb, it’s now a look of awe and curiosity.

Modelling bebionic, the world’s most advanced prosthetic, Nigel gave us a demonstration of the different grips his hand can accomplish. He went on to explain that his phantom limb and bionic one seem to be connected in his brain now, because when he is about to move his bionic hand, he feels his phantom limb move first. This must be a very peculiar sensation.

“I’m not The Terminator. I’m just an ordinary bloke who can tie his shoes.” – Nigel Ackland

Having an expert patient tell his story in his own words was a refreshing addition to the WIRED line up, and having met Nigel during the breaks, I don’t think they could have found a nicer man for the job.

Sophie's works of art on display in the WIRED clinic. The crystal leg was worn by Viktoria Modesta at the paralympic closing ceremony.

Sophie’s world: prosthetic creations on display at WIRED. The crystal leg was worn by Viktoria Modesta at the Paralympic closing ceremony.

Prosthetics designer Sophie de Oliveira Barata came to tell the other side of the story. Sophie founded The Alternative Limb Project a few years ago after being inspired by a two-year-old girl who lost her leg and wanted an out-of-the-ordinary replacement. She now makes many of these wonderful bespoke creations, turning replacing limbs into a work of art – something to be worn with pride.

Sophie uses the imagination of her clients to inform her designs. For performer Viktoria Modesta, Sophie made three unique creations: a large spike, a luminous limb, and a Swarovski crystal leg. And for a man who wanted an exact replica of his original limb, she modelled a silicone foot and even used hairs from the back of his neck for the toes.

Changing behaviour

What you call things affects how people behave. This was the conclusion of the thoroughly entertaining talk given by Rory Sutherland.

Using a topical example, Rory explained that if you want A&E to become less crowded, just start referring to it by it’s full name again: Accident and Emergency. The original name implies only the medically vital, whereas “A&E”, he said, sounds like your best friend. Another every day example of choice manipulation is that it’d be perfectly possible to manufacture a fly spray that smells nice; but we wouldn’t believe it. It’d be cognitively confusing!

Rory explained that the way choices are presented to us can also affect outcomes. For example, if you want patients to finish their course of antibiotics, don’t just give them 26 white pills; give them 20 white and 6 red and tell them to take the reds when they’ve finished the white.

“I think if we did have free will, we would have got better at exercising it by now.” – Rory Sutherland, Ogilvy & Mather UK.

Russian roulette: in some parts of the world patients are asked to select a used needle from a lukewarm basin of water

Russian roulette: in some parts of the world, patients are asked to select a used needle from a lukewarm basin of water

Another man who recognises the implications of changing choice structure is Marc Koska, founder of the LifeSaver program. Every year, 1.3M people die from the reuse of syringes by medical professionals around the world – a preventable tragedy. Marc explained that it’s easier to make the wrong choice, so he came up with the K1 syringe that is impossible to reuse – a syringe credited with saving ten million lives to date.

If outside forces such as advertising, availability, and even nomenclature and scent weren’t enough, there is a much more unexpected ‘inside’ influence on human behaviour: Microbes!

John Cryan analogises the microbiome's effect on the brain with the story of Geppetto and Pinocchio

John Cryan analogises the microbiome’s effect on the brain with the relationship between Geppetto and Pinocchio

John Cryan from University College Cork found that changing the microbiome of mice altered their social behaviour and response to stress. So our microbiome actually affects our mental health, and John coined the term ‘psychobiotics’ to describe live organisms that can produce benefits in patients with psychiatric illnesses, IBS, and chronic fatigue.

“In terms of DNA, we are 99% microbial.” – John Cryan, UCC

It is quite unnerving to think that, as John says, if microbes are controlling the brain, then microbes are controlling everything.

The Startup Stage

Running alongside the main event was the Bupa Startup Stage, a Dragon’s Den style contest where 17 keen competitors took to the floor to pitch their ideas in 9 minutes or less; and it wasn’t long before we were talking about the dog’s nose for a second year running. Dogs’ incredible ability to detect minute biochemical change in their human companions is the basis for Medical Detection Dogs, a company that provides trained dogs to help, for example, monitor the blood sugar levels of diabetic patients.

A delegate plays Galvanic PIP, visualising his stress response in the form a soaring dragon

A delegate plays Galvanic PIP, visualising his stress response in the form a soaring dragon

The line up of emerging and established entrepreneurs also included stress control platform Galvanic PIP, which measures electrodermal activity and allows you to monitor your stress on screen in the form of say a flying dragon; and Buddy, a mental health app that texts to ask about your day, and collects responses in the form of an online mood diary to supplement ongoing therapy.

“75% of people with mental health problems don’t get any treatment.” – Kitty Cormack, Buddy

And the winner is…

The Startup Stage winner was Ana Maiques from Neuroelectrics, sporting the wireless electrode cap, named Starstim, which uses transcranial direct stimulation (tDCS) to alter brain activity. Ana told us Starstim has been shown to improve stroke recovery speed by an impressive 20%, and the telemedicine platform may also help treat problems such as chronic pain, depression, and addiction.

Fun fact of the day

During his talk about MinION, Oxford Nanopore’s fun sized DNA sequencer, Clive Brown proclaimed, “we can now pretty much sequence the entire genome of a foetus from the blood of the mother”.

It is quite astonishing to think how far genomics has come in its relatively short study span. According to Bradley Perkins of Human Longevity Inc., genomics has changed every aspect of bacteriology; and us humans are next. Bradley assured us that genomics is going to be the biggest data of big data in Healthcare, opening the door to the next steps in synthetic biology and regenerative medicine.

Most inspiring statement

“Life changing doesn’t have to be life ending.” – Nigel Ackland

Until next year

I think the underlying message of the day can be nicely summed up by a quote from Geoff McGrath during his talk on optimising performance in healthcare.

“Breakthroughs in medicine space will come not just from design and technology, but it’ll definitely need a change of mindset.” – Geoff McGrath, McLaren Applied Technologies

This change of mindset might mean the incorporation of biosensor technology into our daily lives; sharing our biomedical secrets with architects of the ever-expanding universe of big data; or the willingness to make innovations accessible and affordable to the people who need them most. One thing is for sure, science and social science must continue to work hand in hand for the good of the planet and it’s increasingly tech savvy inhabitants.

All of the talks from WIRED Health 2015 are now available to watch via this playlist on the WIRED UK YouTube channel.

Many thanks to João Medeiros for inviting me and curating such a wonderful programme. Congratulations to the entire organising team.

Alexandra Abel is currently a first year medical student at Hull York Medical School. She graduated from Imperial College London with a BSc in Biomedical Science and Global Health, before completing a Master’s in Performance Science at the Royal College of Music, where she looked at the implications of teaching older generations to play a new musical instrument from scratch. In her spare time, Alex is learning to play the ukulele. Join her on twitter @alexandraabel

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It’s time we had that talk.

This week, Dr Alessandro Demaio writes from his home country of Australia. A ‘downunder’ perspective with a global relevance – he asks why we aren’t talking more, about the challenges we all face together, and sets you a challenge.

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There are very few things that keep me awake at night, these days.

I manage to sleep even with the growing burden of obesity around us and the nonsensical insistence in our societal and political rhetoric that despite two-thirds of us being now affected in Australia (combined with overweightedness), it is still pushed as a problem born in individual laziness and ignorance. Blind to the broken system we inhabit.

Or the fact that climate change is real (yes, I said it, it is real) and playing out around us – yet the one remaining, vocal, pseudo-scientist who bangs on against its validity gets 50% of the airtime and the media attention.

That we build cities where healthy living is becoming harder and harder, but then wonder why we have a growing burden of heart disease and diabetes.

Despite the fact that we are pulling funding from preventative health in a time when many would argue we have an epidemic of preventable, costly, chronic disease.

I even sleep despite our near-obsession with ‘Americanising’ our education and healthcare systems at the cost of marginal and misguided tax cuts, and when our reference point is an education system heavily backed by a philanthropy culture we do not have, or a healthcare system that costs double and delivers less.

Or the concerning fact that 20% of Australian households (that’s 1.73 million households) now hold less wealth that the 7 richest people in our nation. And that this divide is widening. And that our politicians seem unconcerned.

I could go on, but I begin to sound like one of those old Muppet men characters.

What I can’t help but wonder about though, as the clock strikes 2 and the city outside sleeps. What keeps me awake at night. What really keeps me awake at night, is not actually these major challenges themselves, or that we largely created these challenges and therefore can fix them… Or the bigger question of where we are heading as a society. Or who we are becoming as a collective.

What really concerns me, is a general lack of concern itself.

Or vocal concern.

Our Crossroads

In 2015, I truly believe our community, our nation and our planet are at crossroads. Now maybe every generation thinks this, but I have some numbers to back it up. This year will see a new global development agenda outlined by the United Nations, replacing the Millennium Development Goals and setting the priorities for investment and focus for the next 15 years. Miss this boat, and important agenda items might be left behind. It will also see a World EXPO focusing on food sustainability and how we feed 9.6 billion people by 2050, without ruining our planet and without taking food from the poorest. It will also see a defining (some say our last chance) climate change conference of global governments and the UN, in Paris this December.

This is a crucial year for us all, and could well set the trajectory of our planet for the coming decades.

So why aren’t we talking more? Why aren’t we having that talk?

Instead, this is a time when our governments seem to be systematically dismantling platforms that allow and promote these very discussions. Opportunities where we can question where we are collectively heading and have a chance to table big issues like climate change, social policy, healthcare financing, societal trust and contract.

Even worse, we seem to be laying down and letting it happen.

I don’t buy the argument that young people are lazy or that older people don’t care. Or that we have just all become selfish, conceited and no longer concerned with the collective. But I often say that we once offered our dinner party guests coffee to give them the hint our night together was coming to an end and that it was time for them to head for the door. Nowadays we just need to bring up climate change or politics and the door is already swinging from the speediest of exits.

When did our biggest conversations, become conversation killers?

Your Challenge

With this in mind and inspired by the discussions I am having with students in Brisbane this week, I am setting you all a challenge. As readers of our blog, I challenge you to start a conversation.

Over the coming week, I want you to begin one conversation about a big issue in your society, that you want to see discussed and addressed. Table those challenges and begin to ask why – and how, who, where and what can we do? Tell me about it through twitter using @SandroDemaio, or via the feedback below.

It’s time we had that talk. Let’s get a conversation started.

This article is dedicated to Marina and the Public Health team at the University of Queensland.

Dr Alessandro Demaio is Principal at kløver, Co-Founder of NCDFREE and festival21 and a Global Health Fellow in NCDs at Harvard Medical School.

The Conversation

 

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BIG SODA plagiarizing the BIG TOBACCO playbook

This week on PLOS TGH is a guest post from Jack Fisher focusing on the plight of Big Soda and the innovative work of Dunk The Junk, the Maine-based NGO aiming to combat childhood consumption of sugar-sweetened beverages, using a unique mixture of hip hop music, street art and basketball. Kevin Strong, MD, community paediatrician, and the Founder of this 21st century approach to health promotion, aims to buckle this concerning trend through his heartfelt passion and innovative community activities.

“The Killer CAN, like the CANCER STICK, will commit millions of unknowing children to a LIFE of chronic disease UNLESS we UNITE in an aggressive OPERATION to #DEFEATSODATRON…. Unite to be #NCDFREE.” – Dr Kevin Strong, Founder of Dunk the Junk.

It’s been 10 days since the World Health Organisation released their revised global sugar recommendations for adults and children to reduce their daily intake of free sugars to less than 10% of their total energy intake, alongside a further desired reduction to below 5% (6 teaspoons) per day providing additional health benefits. This was a positive step forward, however there is still a great need for collective action to tackle the underlying, commercial forces that are at risk of crippling our healthcare systems around the world.

The evidence could not be clearer – an increased consumption of sugars are associated with a poor diet, obesity and a risk of developing non-communicable diseases such as diabetes, cardiovascular disease and some cancers. Furthermore they also contribute to poor dental hygiene among children, which can negatively affect their health and social development in education.

3We are now faced with concerning population lifestyle trends where countries such as the U.S. see half the population consuming sugar beverages on any given day, and where sugary drinks become the greatest calorie source in a teenager’s diet.
In addition, this is not an issue exclusive to the global north, with companies such as Coca Cola exploiting new untouched and unregulated markets in sub Sahara Africa and the developing world.

However how can we blame our children and young adults for these trends when they live in a world where soft drinks are widely visible from the supermarkets to school places to social media? It’s the cheap, convenient, cool choice – at least that is what the crafty marketers want us to think with their billion dollar ploys.

Joe Tripodi, Chief Marketing and Commercial Officer for the Coca-Cola Company, has been quoted last year during a marketing webinar as wishing to double their business by the year 2020 by aggressively targeting young Latino and African-American communities using precision marketing. This is marketing which not only aims on hooking the user onto a product, but increasing the use of said product to new, and in this instance, detrimental, health damaging levels.

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Furthermore if we consider the growing evidence suggesting that sugar consumption mimics the addictive properties of drugs such as cocaine, it only further highlights the similarity and severity of the public and global health challenge we have faced with tobacco in the last century.

WallThe effects of inaction will only result in more adults suffering from cumulative chronic conditions and perpetuate young adults’ risk of premature mortality around the world. This, while big soda executives’ cash in their annual multi-million dollar bonuses, irrespective of their detrimental decisions and morally-dubious marketing ploys.

It will take a collective action all the way at the top with international stakeholders such as the WHO, along with actors on the ground level such as Dunk The Junk, to campaign and call for social change. We should also learn from previous health promotion failures in big tobacco and implement the taxations needed to curb consumption, and educate our youth in a creative captivating manner.

Not to forget, DTJ are achieving this through their dynamic street-art forms that were born out of oppression. The platform may have changed, however the same inequalities of the powers that be, exploiting the vulnerable and most in need for social support to make educated and informed life choices.

grenadeThe next step for DTJ sees their efforts reach the Centre for Main Contemporary Art on the 14th and 15th of March. Combined with this will be the release of their new hiphop track ‘Sodatron Bombs’ which features Bronx rapper, DTJ cipher, General.C-Rayz Walz. The event will also present film & photography from MaineProject., and beatboxing breakdancing with KEA. Find out more about Dunk the Junk by watching the feature NCDFREE have recently released focusing on Kevin and the DTJ Team’s activities below. You can also contact DTJ at learnmore@dunkthejunk.

Jack Profile 2015
Jack Fisher is NCDFREE’s Communications Coordinator and MSc Global Health student at the University of Copenhagen. Follow Jack on Twitter here

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South Africa’s quadruple burden of disease

This week, Pooja Yerramilli returns to explore NCDs and the quadruple burden as barriers to economic and social development with Sandhya Singh – Director of Disease, Disability, and Geriatrics within South Africa’s Department of Health.

Three years ago, I found myself on a bus in South Africa, with fifteen of my college classmates. We were on our way to Kruger National Park, after a week of volunteering and researching in Cape Town. As I stared out the window, appreciating rural South Africa’s beauty, a large billboard, seemingly in the middle of nowhere, caught my attention. “Relay for Life: A Fundraiser for the American Cancer Society.” This poster piqued my curiosity. I had always associated South Africa with HIV/AIDS and tuberculosis. In fact, I had documented a handful of posters in Cape Town that aimed to combat HIV/AIDS by reducing stigma and encouraging testing. Why, then, when the country was clearly facing an HIV/AIDS epidemic, would locals bother to fundraise for cancer research? Surely, they had more pressing public health challenges to deal with.

This mentality and these assumptions are widespread. But the statistics tell a different story. The burden of non-communicable diseases (NCDs), including cardiovascular diseases, diabetes, chronic respiratory conditions, and cancer, is rising globally and in South Africa. In 2008, NCDs accounted for 29% of all deaths in the country. Much of this disease burden is preventable and can be attributed to increasing exposure to risk factors, such as tobacco consumption, physical inactivity, unhealthy diets, and excessive alcohol consumption. Indeed, the 2008 South Africa Youth Risk Behavior Survey found that more than 1/3 of boys and over 40% of girls qualified as “sedentary,” increasing their risk of obesity and resultant complications.

Thus, South Africa, in essence, is facing a quadruple burden of disease: the HIV/AIDS epidemic alongside a high burden of TB; high maternal and child mortality; high levels of violence and injuries; and a growing burden of NCDs. Yet the country does not currently have the infrastructure to cope with chronic diseases.

Why is this important? Because, according to Sandhya Singh (Director of Disease, Disability, and Geriatrics within South Africa’s Department of Health), as South Africa aims to grow its economy, NCDs will pose yet another barrier to development.

World Cancer Leaders Summit 2013, Cape Town

World Cancer Leaders Summit 2013, Cape Town

Several months ago (July, 2014), I was able to speak with Singh about South Africa’s strategies for NCD care and control. In response to the rapidly escalating burden of NCDs, the Government of South Africa has defined three primary approaches required to control these diseases.  As delineated in the country’s Strategic Plan for the Prevention and Control of Non-Communicable Diseases 2013-17, the first is to focus on health promotion and primary prevention at the individual and community levels; the second is to improve NCD control through health systems strengthening; and the last is to expand surveillance of NCDs and associated risk factors and conduct research on these subjects.

Given South Africa’s limited resources and its quadruple burden of disease, the overarching goal which underlies each strategy is cost-effective health systems strengthening. As treatment and control of HIV/AIDS improved, South Africa has seen a shift in the categorization of this disease from acute to chronic. Therefore, according to Singh, “we [the Department of Health] are really serious about learning lessons about the HIV journey and integrating care. If we continue to work in siloes,” she added, “there’s no way we’re going to be able to provide the optimal care we require.”

Accordingly, the Department of Health has identified several means through which NCD services may be integrated with programs and infrastructure already established for HIV/AIDS. The Integrated Chronic Disease Management Model (ICDM), which utilizes community health workers, aims to promote equity and access through community participation, intersectoral strategies, and an emphasis on health promotion. Moreover, the development of the National Health Insurance scheme aims to revitalize and revise primary health care infrastructure, human resources training, and health services integrated with school-based interventions, in a manner which improves NCD control.

The Department of Health aims to identify “best buys” for chronic disease control; for example, integrating NCD screening with the pre-existing HIV counseling and testing campaigns. A priority area currently under development, according to Singh, is drug distribution – specifically, how to deliver prepackaged medications for more than one month at a time, close to patients’ homes. For these projects, Singh suggested that the government can learn from the HIV/AIDS experience and piggyback off of these services. Moreover, Singh emphasized that strengthening primary health care is not sufficient – referral chains between facilities must also be developed and fortified.

Singh attributes much of the recent progress in NCD strategy development and control to political commitment. “I think we would be failing if we did not recognize that South Africa has moved a little further than our neighbors because of political and strategic support. We may not have the resources we need, but we have been able to make important changes, such as salt regulation – something unique to us – because of the political system.” Singh identified the 2009 Lancet article as a turning point and call to arms, because it suggested that “if we don’t do anything about [NCDs], we’ll be faced with the same situation as with the HIV journey.”

Indeed, South Africa’s resulting political commitment is evidenced by its support of the Brazzaville Declaration on NCD Prevention and Control in the WHO African Region (2011) and the UN Political Declaration on NCDs (2011). The government’s words are backed by legislative action, including anti-tobacco regulations, which resulted in a 22% reduction in smoking behaviors between 1995-2009; legislation to reduce trans fatty acids and salt in processed food; and bans on junk food advertisements to children and regulation of foods sold during school hours.

The government of South Africa has also aimed to pursue multisectoral approaches to NCD control. For example, the Department of Health is developing a National Health Commission housed in the presidency, which will bring together the distinct ministries to improve buy in and support for “health in all” policies. Singh suggested that the establishment of an NCD unit within the Department of Health was a crucial step toward catalyzing multisectoral plans, as it may serve as a focal point to advocate for inclusion of aspects of NCD control in all policies – a step that many countries have not yet taken.

Although South Africa has certainly made strides in prioritizing NCDs in its national health agenda, Singh affirmed that there remains inequity in funding across diseases. “Our government has an obligation to look at HIV/AIDS, maternal/child mortality, and MDG-related goals,” she stated. Nevertheless, she continued, “we are cognizant of the rising burden of NCDs and are looking at a range of means to increase internal revenue for NCD control.” The treasury provided funding for the HPV vaccine, out of recognition that “unless something is done now, we cannot afford the cost of cervical cancer,” Singh stated.

Yet Singh expressed concern that international funders continue to solely focus on HIV/AIDS and TB, when the mortality rates associated with NCDs are rising. She further emphasized that “we so often focus on mortality and we ignore the economic impact of morbidity.” The disabilities developed through NCDs often prohibit patients from contributing to the economy.

While political commitment appears key in South Africa’s ability to address NCDs, it is clear that limited resources continue to hamper progress – not only in improving NCD control, but also improving health outcomes for comorbid conditions and ultimately furthering economic progress. Thus, Singh urges international donors to take note of South Africa’s commitment to the cause and devote funds to NCD control.

550530_1808531744377_172581108_n-1Pooja is currently a medical student at the Perelman School of Medicine, University of Pennsylvania and Project Coordinator for the Young Professionals Chronic Disease Network. She graduated from Yale University with a B.A. in Political Science, and holds an MSc. in Health Policy, Planning, and Financing, a joint degree awarded by the London School of Hygiene and Tropical Medicine and the London School of Economics. She has research experience in South Africa and India, where she studied the challenges associated with aging populations and cancer care and control. Pooja previously worked at and is currently collaborating with the Harvard Global Equity Initiative.

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Plain packaging tobacco: a global battle not yet won

This week, we hear from Dr Genevieve Bois, MD and spokesperson for the Québec Coalition for Tobacco Control on the important but unfinished battle that is plain packaging of tobacco products.

Tobacco use is the number one cause of preventable deaths in Canada today, and in the UK, and in the United States – in fact in most countries around the world. Even in low-income countries that still face significant burdens from maternal health issues and infectious diseases, non-communicable diseases are on the rise, with tobacco-use leading the way as an ever-present first risk factor.

We should probably say that tobacco use remains the number one cause of preventable death, and this nuance is important because although the tremendous progress done in certain countries in terms of tobacco control should be applauded, and despite all of it, we still have long way to go. Tobacco remains the number one cause of preventable mortality.

Despite the fact that we may all seem to know that tobacco is dangerous and cigarettes kill, the sheer scale of numbers reminds us that this is not just another vague health issue: tobacco use claimed one hundred million people worldwide in the past century and might very well it will kill one billion people in the 21st century if we don’t seriously alter the current trend. This is a completely man-made and avoidable epidemic. The WHO Framework Convention on Tobacco Control (WHO FCTC) will soon celebrate its 10th anniversary and has catalyzed impressive growth in tobacco control across the world, but what remains to be done dwarfs the progress made.

In 2015, the global population covered
 by at least one effective tobacco control measure (of the 5 main measures identified by the WHO under the acronym POWER) has more than doubled , reaching approximately 2.3 billion people . This means roughly a third of the world is covered by… one of the main measures necessary. Even if this is great progress, most of the world’s population is still not fully protected against tobacco advertising and second-hand smoke (only 10% of the world’s population lives in a nation where an advertising ban was enacted and 16% live somewhere where smoke-free environments have been mandated, 2 of the 5 “POWER” measures). Worst of all, most children and adolescents across the world are still exposed to both advertising and second-hand smoke. That we continue to allow businesses driven by fiscal indicators only, to expose young people to marketing for products we know kill, from an industry that uses billions to hook people on one of the most addictive substance known to man, delivered in a product that will cause death in half its users, should be a source of great shame. If we look at the front runners in tobacco control, the countries where we have seen dramatic declines in smoking rates, those are countries that enforced a series of measures to restrict tobacco use: full advertising bans, smoke-free workplaces, cessation programs, health warnings, health campaigns… not just one, but all.

In 2001, Canada was the first country in the world to introduce graphic health warnings on tobacco packaging, a battle that was hard won and that several politicians and public health advocates had to push hard and long for. The tobacco industry promptly took our federal government to court, and although they lost – as they generally do – this reminded us of the tremendous power of the industry. It is an expensive and exhausting battle for a nation, one that not all politicians are able to undertake. When threats of litigations are made, many countries cannot afford to be tied up in legal challenges and back down on crucial measures. Canada and some of its provinces have been taken to court repeatedly by the tobacco industry, virtually on all effective tobacco control measures. This might have slowed down our progress even if it didn’t halt it, but not all countries are able to withstand that type of pressure. Uruguay is currently being sued by Philip Morris International for an amount of money that dwarfs its GDP. Multiple countries are also being lobbied against moving forward on measures they desperately need, in order to curb health consequences and costs of tobacco use.

One of the latest legal challenges comes for Australia, who had the courage to move forward on what is probably the most important tobacco control measure today: plain packaging. Like in Canada with the introduction of graphic health warnings, it is easy to celebrate the victory after the fact, but it doesn’t show the world the long and hard battle it took to get there. One of the reasons the tobacco industry will fight so hard against such measures is that they tend to snowball: since 2001, when Canada introduced the first graphic health warnings, 77 jurisdictions across the world have followed suit, from India to Nepal and Turkey to Mexico.

If plain packaging snowballs in a similar fashion – and we should all make sure it does – then it could spell the beginning of the end of the tobacco industry.

For those of us who don’t smoke and live in countries where tobacco packs are now hidden in shops (another crucial measure, as large displays of packages are nothing short of blatant advertising), it is hard to know how pretty, glitzy, modern and attractive tobacco packages can be. Bright blue and green like iPods, long and slender packages that look like lipstick boxes, attractive flavouring and shiny packages with alluring names: a package is a mini-billboard, that is still allowed even in nations with comprehensive advertising bans, and that is carried by the smoker, being shown to friends on repeated occasions.

Plain packaging is the logical extension of an advertising ban to protect our youth and our populations, and brings a bit of truth to the world of tobacco. It forces a deadly product to be sold in a box that represents accurately the harm in can create, instead of being in a shiny box that promotes an attractive lifestyle and positive values.

Flickr / Matt TrostlePlain packaging has now been in place for over two years, and we have seen smoking rates dive in Australia, as well as quit line calls rise, the average age of initiation to smoking rise (and crucial indicator, since most smokers start as children and smokers that start early have a harder time quitting) and support for the measure grow. The industry will work hard to mask this success, but it is an obvious victory for public health to anyone willing to look at proper data. Even more promising, a series of countries have are now considering plain packaging or plan to introduce it – Norway very recently, the UK, Ireland, France, New Zealand. While we have yet to see them implement it, such strong statements should give hope and inspire more countries to take steps towards plain packaging. The data from Australia is clear: plain packaging works.

As we enter an important year for global development and health, let’s not forget an important battle – that is far from won. Strong, clear and progressive anti-tobacco policies are the logical thing to do and the right thing to do. The need is great and the evidence is there. But even so, we should not think this will ever be an easy fight.

In the battle against tobacco, advocates have long referred to the scream test: if the industry screams high and loud, then the measure will likely be effective and save lives. For plain packaging, never has the industry screamed louder. We should all take note, remain focused and make sure we continue to make progress in this important global effort.

Dr Genevieve Bois trained as a doctor in Montréal, Canada, and is currently working in tobacco control, as the spokesperson for the Québec Coalition for Tobacco Control, and as YP-CDN Community Director. She spent a one-year with the Copenhagen School of Global Health working on projects for the NCDs unit, but also involved curriculum development for pre-departure training and global health ethics. Geneviève is passionate about NCDs, building healthy cities and using the urban environment to influence health. She is the past Vice-President of Internal Affairs of the world’s largest medical student, the International Federation of Medical Students’ Associations (IFMSA).

Twitter: @GenBois

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