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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World Cancer Day: 10 +3 Simple Ways to Reduce Your Cancer Risk

Fact: In 2012, there were 14 million new cancer cases worldwide, and 8.2 million cancer related deaths.

Fact: About 70% of all cancer deaths occur in low- and middle-income countries.

Fact: The number of global cancer cases is expected to rise by 70% in the coming 2 decades.

Fact: More than 30% of cancers can be prevented.

Cancer is a very scary beast. Conjuring some pretty frightening thoughts, the term comes from Latin word for ‘crab’, in part, because of the creeping, spreading nature of the disease. Many of us think of cancers as a single ailment, but in fact they’re a very mixed bag and result from multiple cellular-level changes caused by a range of distinct factors. These vary from infections (one fifth of all cancers worldwide are caused by a chronic infection) through to radiation (for example the sun), food and even alcohol.

Today is World Cancer Day and to raise awareness around cancer, the World Cancer Research Fund International has released a short video outlining some simple ways to reduce your cancer risk.

Based on up-to-date evidence, their advice is pretty simple.

So what is it?

  1. Maintain a healthy weight. What this means this will vary depending on your height, race and age, but it is generally regarded as a BMI between 20 and 25.
  2. Move more. Getting exercise is good for your heart, but also your cancer risk. It’s recommended that we are all active for at least 30 minutes each day.
  3. Eat more fruit, vegetables and whole grains. Forget super foods, these are simple, cheap and easy to find. In fact, some of these foods, rich in fibre, are known to reduce your chances of colon cancer.
  4. Reduce your fat and sugar intake. Less is more when it comes to this group.
  5. Limit red meat in your diet. For many in the developing world, and some youngsters in wealthier nations, more meat is still a good thing. But for the vast majority of Europeans, Americans and Australians, follow the rules of eating less and eating better quality.
  6. Cut down on alcohol. A risk factor for some cancers of the mouth and throat, drinking less is a smart way to reduce your risk.
  7. Eat less salt. Be mindful of what you add yourself, but also of the salt content of staples like bread, spreads and meat products. Hidden salt is a major source in our diet.
  8. Avoid supplements. The WCRF says it’s best to use diet alone and see a nutritionist or your local GP if you’re concerned.
  9. Breastfeeding is best, if you can. Breastfeeding reduces your risks of some cancer types and is in line with the public health recommendations of most nations.
  10. Cancer survivors have special recommendations and should develop and follow these in conjunction with their healthcare providers.

In addition to the ten above, most doctors would also recommend:

  1. For those in the hotter parts of the globe – remembering to cover up in the sun, apply and reapply sunscreen and wear a hat. Protection against melanoma risk is particularly important for kids, who’s skin is especially sensitive.
  2. Quit the habit. Tobacco use is still the most important risk factor for cancer, causing around 20% of global cancer deaths. Leaving the smokes and supporting those around you to do the same, can have lasting health benefits for your entire community.
  3. As mentioned, a large number of global cancer cases are caused by infections – many of which are preventable through vaccination. The final piece in the cancer-prevention puzzle is to check your local or national vaccination guidelines and always be vaccinated against cancer-causing infections like HPV.
World Cancer Research Fund International

What’s the take home?

At the end of the day, there is actually a lot we can all do to reduce our cancer risk. Taking a moment to think and act on World Cancer Day might just lend a lifetime of protection to you and to those around.

Follow Sandro on Twitter via @SandroDemaio

For more information, head to WCRF International.

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Rising Wealth Inequality and NCDs – What’s the Link?

This week, Maja Pleic writes on the connections between economic inequality and non-communicable disease. A timely article, in time for the latest triennial Global Status Report on NCDs.

 

On January 19th, Oxfam released a report which shows that global wealth inequality, already alarmingly high, is set to continue its rise and by next year, the richest 1% of the global population will hold as much wealth as the remaining 99% of the population. This trend is not only worrisome from the perspective of social equity, but represents a real danger for almost all aspects of human and social development and poses a serious threat to the health of our economies, democracies, education systems, health systems and the very health of all individuals on this planet.

Flickr /  US Mission GenevaThe same day, the WHO launched the Global Status Report on Noncommunicable Diseases 2014, urging governments to take immediate action to address the epidemic of noncommunicable diseases (NCDs). According to the WHO, of the 38 million deaths due to NCDs in 2012, a staggering 42% were premature and could have been avoided with appropriate policies and responsive health systems. These two seemingly unrelated reports reflect different aspects of the same global challenge: systemic inequities in the global distribution of power and wealth and as such – access to the mechanisms for human development: education, employment, healthcare, and the very right to life itself.

To understand how disparities in health and disparities in income are related, it is necessary to debunk the myth of individual human decisions as the main determinant of both economic prosperity and ill health. Instead, individual capabilities must be understood within a system that is defined by the distribution of wealth and division of labour, which in turn determines who has access to the mechanisms of human development, including nutritious food, safe drinking water, quality health care and medicine, and education.

In the case of wealth distribution, the neoliberal viewpoint, with its roots in the Protestant work ethic, has long held that skills and hard work are justly rewarded through the economic system. Thus, anyone who wants to improve their lot in life can climb the socio-economic ladder by making the right decisions: investing in their health and education, working long hours and developing unique skills that are richly rewarded in the market place. This is the American Dream of social mobility aspired to by billions around the world. The implicit conclusion is that those with wealth and power are reaping the rewards of their hard work or the hard work of their ancestors, and those stuck in poverty have simply made the wrong decision or have not worked hard enough.

While it is alluring, especially for those in power, to view the distribution of wealth as the socio-economic equivalent of Darwin’s survival of the fittest, the reality is that humans are less like lions and gazelles, competing for survival relying only on their individual strength and wits, and more like bees and ants working collectively in a system of inter-dependant survival. In fact, our success as a species and the rise of civilization itself is based on systems of division of labour[i]. The systems we have created throughout history have divided the labour and the spoils of labour to varying degrees of equity. Importantly, access to information, education, health care and medicine, food and water go hand in hand, with the division of labour and distribution of wealth.

On one end of the spectrum, slavery and conquest were systems based on an exploitative division of labour and resources, such that one group, the slaves, did all of the work; and another group, the slave-owners, reaped all of the wealth created by that work through violent oppression. Similarly, the conquests of colonial Europe appropriated wealth for the elite few in the capitals of Europe from the labour and resources of the colonized masses, again through violent oppression. In these rigid systems of exploitation, one’s socio-economic position and share of the wealth were determined at birth, with no room for individual agency over one’s life, health or prosperity. There is little doubt that the most exploitative systems in history created the greatest concentrations of wealth. What is also clear is that by necessity, these systems could only be developed and maintained through the violent oppression of the human capabilities of the masses, which required denying access to education, health care, and skills development to the majority of the population.

On the other end of the spectrum are the socio-economic systems embodied by the ‘welfare state’ that emerged in post-WWII Europe and North America. From the ravages of war sprang forth unprecedented social solidarity and the idealization on a global scale of the rights of man –to life, liberty, security of the person, justly remunerated work, and social security, among others.[ii] National health systems, social security, universal education, unemployment insurance, heavy state investment in infrastructure, and strict banking regulations imposed during the Great Recession all worked together to create an economic system that fostered social mobility and gave large segments of the population access to the mechanisms of human development: education, health care, skills development, and financially rewarding employment.

As a result, global and national wealth inequality declined and the middle classes in North America and Europe swelled as taxes were levied on the rich, and opportunities made available for the masses through the welfare state. The period 1950 to 1970 was accompanied by the greatest growth rates in per capita income seen since as far back as we can estimate (0 A.C).[iii] Unsurprisingly, this economic boom went hand in hand with a rise in living standards, life expectancy and health status. It is not that individuals all of a sudden were making better choices about their health, it is that for the first time, large segments of the population had access to nutritious food, decent health care and medicines, health education, and to justly remunerated employment. This era is now fondly remembered as the ‘golden age’ of capitalism.

Flickr / Seattle Municipal ArchivesThe 1970s can be seen as marking the beginnings of a new global system of neoliberal globalization defined by financial deregulation, declines in effective tax rates on capital gains and the richest 1% in North America and Europe, the decline of the welfare state and the globalization of the production process. As the effective tax rates on the wealthy declined so too did the welfare state with consequences for accessibility to health, education, and rewarding employment. The new division of labour was represented by a ‘race to the bottom’ as Western companies took advantage of lower wages and lax labour and environmental standards in low and middle-income countries (LMICs), forcing LMICs to compete against one another to attract much-needed capital, and resulting in the steep decline of unions and labour shares in high-income countries. As the bulk of production shifted to the global periphery where wages are lowest and exploitation is permissible, labourers in Western countries have seen their wages stagnate or decline, labour unions disbanded, and the middle class shrink. At the same time, we have seen the rise of ‘fast food’ – high-calorie, low nutrition, highly-processed cheap food aimed at low-income populations.

The decline of the welfare state and the rise of exploitative global production practices have resulted in a higher concentration of wealth in the hands of the few, and the decline of the middle class and opportunities for social mobility for the masses. In Western Europe and Canada, the commitment to universal health insurance and universally accessible education remains strong, although threatened. Meanwhile, in the US, the costs of a post-secondary education have soared and despite the passing of the Affordable Care Act, access to quality healthcare remains a function of income.

Hence, when the WHO reports that 16 million people die prematurely each year from NCDs, this figure must be understood within the global economic system which is defined by the concentration of wealth and the division of labour, and in turn determines who has access to nutritious foods, safe drinking water, health information and education, quality healthcare and medicines, and a safe working environment. Furthermore, in order to address this global epidemic, we have to decide as nations and as a global community what kind of system we would like to live in.

Unless policies are implemented globally to reverse the rising concentration of wealth, the welfare states in Western countries cannot be sustained, never mind exported to LMICs where they are badly needed. Universal health insurance is not possible without a middle class and the taxes to pay for it, and addressing chronic non-communicable disease in the long-run is not feasible without universal health insurance.

Hence, we are faced with the decision of continuing down the road we are currently on and returning to a time where only the very rich can afford the most nutritious food, quality healthcare and education and where social mobility is restricted; or else, implementing policies to reverse the concentration of wealth, re-investing in the welfare state and reinvigorate the middle class. If the global community collectively increased taxes on the top 1% of earners and capital gains, closed tax loopholes and tax havens, and invested in infrastructure, education, universal health insurance and social programs, we could expand access to the mechanisms of human development globally and usher in a new golden era of human progress. President Obama’s recent proposal to raise taxesfor the wealthiest Americans is a sign of hope and welcome first step in this direction of equal opportunity and shared prosperity.


[i] Diamond J. Collapse. How societies choose to fail or succeed. New York: Penguin Books, 2005.

[ii] United Nations. The Universal Declaration of Human Rights. 1948.http://www.un.org/en/documents/udhr/

[iii] Piketty T. Capital in the Twenty-First Century. Cambridge: Belknap Press of Harvard University, 2014.

This article was originally published on the Young Professionals Chronic Disease Network blog.  

Follow Maja on Twitter here.

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6 New Year’s Resolutions for Your Body and Your Planet.

Another year over, and a new one just begun. Happy New Year and may it be a wonderful one! As 2015 begins, but before it starts to speed away, many of us will be taking a moment to look back. A brief chance to take stock of the past and with this in mind, plan changes for the future.

Many of us will be casting our resolutions.

But this year, going into the countdown to some major hurdles for the human race and the planet – including the framing of the new post-2015 Millennium Development Goal replacements and the major Paris meeting on Climate Change – can our resolutions be more than just about ourselves?

Here are 6 New Year’s Resolutions for your body – but also for your planet.

1. Walk more, drive less

 It’s not always easy and I appreciate how nice it is to take the car on those cold mornings, or a steaming hot afternoon. But leaving the car and walking not only cuts your climate emissions (transportation makes up about 28% of USA’s emissions) but is also great for your heart, your brain and your mind. Exercise, even walking, is protective against heart disease, dementia and helps to reduce stress.

Even driving partway and walking the last few miles! Dropping the car is a great step forward, and a healthy option for you and your surrounds.

2. Eat less meat, eat better quality

It might surprise you, but 30% of Global Greenhouse Gasses come from what we eat – from food production. And a vast amount of this is generated by a small portion of our plate: meat. In fact, beef and lamb are by far the worst at soiling the global and local environments. Each kilogram uses 15,500 litres of water to produce and creates 30-40 kg of carbon dioxide (the same as driving 60-90 miles). Grazing occupies 26% of the earth’s ice-free land, and feed crop production uses about one third of all arable areas.

I’ve said it before and I will say it again. Eating less, for example being a vegetarian during the week and leaving meat for weekends; eating better quality, keeping beef for very special occasions and wherever possible, sourcing it carefully to ensure the animals and the planet are taken care of – is a great start to a healthier future.

3. Buy local, buy in season, buy fresh

In 2015, take on a big challenge – reconnect with food. Take the time to learn what is in season (usually what is cheap, fresh and most tasty) and what is local. It might mean trying some new recipes or swapping things around depending on the time of year. It might also mean a week of leafy greens in summer and a fortnight of broccoli come colder months, but fresh is usually best and local means fewer carbon miles.

4. Reconsider that second drink

Now I know this one might have been a challenge on the 31st, but in the New Year it is a good time to think – or rethink – about the amount of alcohol we drink. Being sure to keep days free of drinking throughout each week and challenge our need to accompany that hard day’s end, an exciting win or a first date with an alcoholic beverage.

And with each glass of beer using up to 75 litres of water to produce, cutting back is a wise move for your liver, your cancer risk and your planet.

5. Drink tap water, lose the soda

There are few things in this world that give us nothing and take a lot – but soft drink, or soda is one. It takes enormous amounts of energy to produce, comes wrapped in a petroleum or aluminium casing, is empty calories that sit on our waistlines and is linked with diseases like obesity and diabetes.

This year, break the habit and swap sweetened drinks for water. Going one better though, if you live in a region with great tap water as I do in Australia, then give away bottled water too and keep the saltzer as a sometimes treat.

Water is almost always best.

6. Practice and preach mindfulness

The final piece in your New Year’s puzzle is the one I find most challenging. Having taken care of your planet and of your body – remember to take care of your mind.

Just a few minutes of mindfulness each day resets the body, centres your focus and allows a moment to reflect. This might be a session in the garden, some yoga with friends, a walk in a local park or a quiet catch up with a close buddy. Whatever it is that rests your mind and helps you unwind.

Connecting with yourself and being mindful of what 2015 has and will bring.

Happy New Year…

As the new year dawns, this is a great opportunity to make small changes in all our lives to better our health, the health of those around us, and the health of the planet.

After all, small changes add up.

Happy New Year.

Follow Sandro on Twitter via @SandroDemaio

The Conversation

 

Dr Alessandro Demaio (MBBS MPH PhD) is Co-Founder of NCDFREE. He is also a Postdoctoral Fellow in Global Health at the Harvard Global Equity Initiative, Harvard Medical School and an Assistant Professor at the University of Copenhagen.

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Payment-by-results in International Development: the elixir or the poison?

This week, Jason Calvert (MPH) – a development and health economist with PwC – explores the benefits limitations of a Payment-by-Results approach to international development.

Flickr / epSos.deAs the concept of Payment-by-Results (PbR) gains momentum in the international development sector, it hasn’t taken long for it to turn into somewhat of a ‘dirty’ word – particularly among not-for-profits. In some ways, its reputation can be justified but not entirely. PbR is a payment mechanism where delivery organisations will only get all or part of their payment upon the delivery of some form of ‘result’. This differs from other payment mechanisms where payments may be made upfront or on the delivery of inputs or intermediate outputs rather than results. As such, it is much more controversial.

Taking the approach of trying to improve value-for-money during times of belt-tightening on government spend makes sense. We’ve seen this in other public sectors such as healthcare and criminal justice – both of which have experimented with forms of PbR. However, in healthcare, this led to a scenario where incentives to focus on preventative care were eroded, as payments would be made based on results in the form of curing illness. To be fair, it’s much easier to measure illness cured as opposed to illness prevented. In criminal justice, PbR was trialled in offender rehabilitation programmes. It was found that this led providers to ‘cherry-pick’ clients that would be easier to rehabilitate – leaving out potentially those most in need of services, but who would be more difficult to rehabilitate.

The provision of core public services such as health, education and justice faces many challenges in a developed-country context. It’s usually even more complex in developing countries. Unwieldy PbR contracts could potentially further complicate matters, and place pressure on implementing organisations to spend more time focussing on reporting burdens as opposed to implementation. This is at odds with using PbR to improve value-for-money by shifting the focus to results. But in order to financially penalise a delivery organisation with the PbR stick it is necessary to have solid evidence underpinning the decision to do so (or risk being sued). Whilst this will (hopefully) drive improvements in the quality of monitoring and evaluation we see in international development projects, some results are much harder to measure than others. The costs of measuring tricky outcomes (like measuring improved community attitudes towards injecting drug users in rural Kenya), and attributing these to one particular programme, could often outweigh the benefits of a PbR contract. However, it could be argued that in the context of poor information and difficult measurement, there is even more risk of money being misspent or results not being achieved.

Other PbR challenges relate to the assumption that not-for-profits respond to financial incentives the same way for-profits would. The potential for cherry-picking and avoiding the most marginalised individuals, and the possibility that by focussing on narrowly-defined results, valuable but hard-to-measure activities might not take place (such as community advocacy).

Flickr / DFID - UK Department for International DevelopmentPbR does have the potential for benefits – but only if implemented in a very careful manner on carefully selected projects. In such cases, it has the potential to align incentives between funders and implementers to focus on core results rather than inputs, incentivise greater focus on refining theories of change to suit clear goals, improve transparency and accountability, weed out wasteful activities, and drive greater professionalism in the sector. But as a sector, we need to stop thinking that PbR is a panacea or that it’s going to solve many of the inherent problems in the aid sector. PbR isn’t going to disappear, but I’m convinced that over time we will realise that it is only suited to certain development sectors where measurement of results is not overly contentious (such as infrastructure projects). Rather than thinking PbR will solve all our issues, we should be focussing on improving the way we undertake evaluations and make use of the results: shifting them away from being ‘tick-box’ exercises, to making them true lesson-learning tools that don’t end up gathering dust on a shelf at the donor office.

As a sector, we’ve catapulted ourselves high in our ambitions regarding PbR and value-for-money. Only time will tell where we land.

 

jason-calvertJason Calvert is a development and health economist with PwC, experienced in the monitoring, evaluation, and assessment of value-for-money in international development programmes, with a particular focus on human development projects. He has experience with payment-by-results mechanisms, both in international development contexts and broader contexts such as domestic health and social welfare.


Jason currently leads the monitoring and evaluation workstream on DFID’s Girls’ Education Challenge – a £300m fund of 38 projects across 18 countries aiming to educate up to a million girls. He has previously worked with the World Health Organization’s Regional Office for Europe on strengthening their evaluation and appraisal methods.

This article was co-blogged with PwC.

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A quick experiment: removing barriers to fruit in the retail environment, will more of us buy them?

This week on PLOS Blog Translational Global Health, a short post from our colleagues in Peru on the role and effects of the retail environment in behaviour change for NCDs.

Everybody knows that eating fresh vegetables and fruits is good for you. At least, let’s assume, the majority of people do. But does this translate into action? We also know that knowledge is not enough. More importantly, does everybody react in the same manner to the same information? Who is more likely to make more concrete moves towards action? All these questions are relevant, because in practice, it will determine “how it works and under what context” for many interventions.

Nourishing Framework from WCRF International.

Nourishing Framework from WCRF International.

Fruit and vegetable intake is essential in a healthy diet and this has been translated into ‘5 servings per day, 7 days a week’ campaigns worldwide. On the scoping and wider policy side, WCRF’s has developed the NOURISHING framework, a policy framework to promote healthy diets & reduce obesity. But, given our human nature, as behavioural economist Dan Ariely  points out, there is certain irrationality in not doing the ‘right thing’.

Despite being an agrarian country, an Andean study in Peru showed that approximately one-third of the population had low fruit and vegetable intake (defined as less than 3 days per week). Insufficient local data at an individual level impedes to monitor the patterns of diet in this population as well as the consumption of healthy and unhealthy food. Moreover, little is known about the personal reasons that lead someone to prefer fruit over an unhealthy snack, and what changes —i.e. an intervention to promote a healthy diet— may be effective in influencing peoples’ decisions.

A research team led by members of the CRONICAS Center of Excellence in Chronic Diseases at Universidad Peruana Cayetano Heredia, based in Lima, Peru, made a quick, on-the-go, hypothesis-driven, unfunded —as usual, fun studies are the unfunded ones— experiment to test if some strategies are more effective to increase fresh fruit purchasing at a university cafeteria.

Here is the experiment.

Three different scenarios were established sequentially, each stage lasted 3 weeks. In a first stage, fruit was positioned over 3 meters away from the point of purchase and price was PEN 1.50 ($US 0.57) per fruit unit with no advertisement. In the second stage, the price remained the same but fruit was positioned next to the point of purchase with an advertisement promoting fruit consumption. The advertisement was displayed in Spanish and showed the unit price and the following message: “Consuming five fruits and vegetables per day prevents many illnesses” as stated by the World Health Organization. Finally, for the third stage, fruit price lowered to PEN 1.00 ($US 0.38) and all the other changes remained as the previous stage. Cafeteria staff participated with daily recording of indicators. A simple approach, using pen, paper and eyes: we needed to know age group (above/under 20), gender and number of fruits sold.

So what was the outcome?

Flickr / Denim Dave

Flickr / Denim Dave

The analyses of the registered information showed an increase in fruit purchasing when comparing fruit sales from the first and the last stage. This is good news, but it is not all. Take home message one: break accessibility barriers for healthier products, and consumption increases. A study, published in Public Health Nutrition  journal, showed that simple marketing strategies such as enhancing visibility, adding information and lowering price do also work for increasing fruit consumption. Interestingly, by the third phase, people reacted to it and more fruits were sold.

However, besides the most salient (and significant) results, here is the beauty of being able to disclose your weaknesses, which makes it much more interesting. For context, this cafeteria caters for approximately 200 students per day and most of them have just completed high school and are preparing to enter into university.

Interestingly, the baseline scenario is so challenging: median sales of fruit at the cafeteria are remarkably low, just 1 to 2 fruits per day over each of the 3-week period tested. This is a huge challenge! Second, the human factor is not constant, females do better than males, they buy more fruits, as did the ‘older’-adults —just to be clear, our own research team was banned from buying fruits. Third, as usual — although we would like to claim this, but technically we can’t— we do not know if it was the change of place (availability) or the lowering of price (costs) the biggest driver in increasing sales, because of our ‘bundled’ intervention. Fourth, a further challenge, was that we were not able to explore if fruit sales reduced expenditures in junk-food or if unhealthy sales remained constant.

Last but not least, we were excited to figure out more about the complexities of human nature. We know that this is a small study from “darkest Peru.” Now, when we hear that the target of “5 servings per day” is a simple one to aim for, we will say, it ain’t that simple.

J. Jaime Miranda is Research Professor at the Department of Medicine, School of Medicine and Director of the CRONICAS Center of Excellence in Chronic Diseases, both at Universidad  Peruana Cayetano Heredia (UPCH) in Lima, Peru. 

Maria Kathia Cárdenas works as health economist at CRONICAS Center of Excellence in Chronic Diseases. She studied a Master in Epidemiological Research at Universidad Peruana Cayetano Heredia (UPCH) through a Fellowship supported by The National Heart, Lung and Blood Institute.

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Podcast Interview with Young Cancer Survivor and Advocate, Mexico City

abishThis week, the latest in our series of podcasts from around the world. Sandro interviews Abish Romero, a young cancer survivor and advocate living and studying in Mexico City. 

 

 

 

 

 

 

 

 

Abish Romero is an MPH student at the National Institute of Public Health of Mexico. She became a cancer advocate after being diagnosed with breast cancer when she was 24 years old. Her experience with the disease made her realize how important social protection is in developing countries; and how governments can strengthen health systems by improving the quality of multidisciplinary care and treatment. As she has seen, these actions are key in avoiding impoverishment in families caused by catastrophic expenditures.

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Human rights and Ebola: the issue of quarantine

The Ebola virus is posing challenging questions around the human rights of patients and health workers alike – and this isn’t the first time such questions have arisen. This week on PLOS TGH, Doctor/Lawyer and Harvard MPH Candidate Fiona Lander explores the issues that have arisen around quarantine.

When Kaci Hickox, a nurse working in Sierra Leone, returned home to the United States on Friday October 24, she clearly anticipated being screened for Ebola. After all, she had just returned from an area of the world where the virus is currently spreading out of control.

Having no symptoms suggestive of infection, however, she evidently did not expect to be put into compulsory quarantine. CNN reported that Ms Hickox was put into an isolation tent inside University Hospital in Newark, although she had twice tested negative for the virus.

As reported this week in the New England Journal of Medicine, the virus is generally not detectable prior to the onset of symptoms, so Ms Hickox’s negative tests were far from an ‘all clear’. However, as was also reported, the virus is not contagious prior to the onset of symptoms. The NEJM and the U.S. Center for Disease Control both conclude that asymptomatic healthcare workers can safely monitor their own temperature and other parameters upon their return home, provided they alert officials immediately if they develop symptoms.

Accordingly, the utility of mandatory hospital-based quarantine in Ms Hickox’s case was limited, and represented a curtailment of her rights; in particular, her right to freedom of movement. Ms Hickox was ultimately released from quarantine in New Jersey on Monday 27 October, and having travelled to Maine, continued to defy requests by the Governor of that State to voluntarily quarantine herself. A Maine court subsequently issued orders (in compliance with CDC protocols) that allow Ms Hickox to go outside, but which stipulate that she must stay away from public transit and workplaces, and that she must not to leave the town of Fort Kent without informing public health authorities.

Following a storm of criticism, New York’s Governor Andrew Cuomo relaxed the strict quarantining protocols that had previously been announced jointly with Governor Christie. However, Governor Christie has insisted on retaining the protocols in New Jersey on the basis that a voluntary system of quarantine is not reliable, apparently because of how serious this outbreak is. Some might argue, alongside Mr Christie, that the nature of the Ebola epidemic demands such stringent action, even if such protocols result in breaches of individual healthcare workers’ rights. However, this ignores the lessons of the recent past.  

Learning from history: a human rights-based approach to epidemicsHIV ribbon
This is not the first time that quarantine requirements have been imposed without evidence to support their imposition. A classic example is that of the AIDS epidemic in the 1980s, where quarantine was utilized in an attempt to stop the spread of the virus, but ended up causing greater stigma, subsequently fuelling spread of the disease.

It is for this reason that the Ebola quarantine policies announced in the U.S. have drawn opposition from HIV activists, who have seen the pernicious effects of imposing quarantine when evidence suggests it is unnecessary. There is no doubt that Ebola is more readily transmissible than HIV, but the same legal principles in relation to compulsory quarantine apply in both cases.

The Siracusa principles outline the circumstances within which restriction of human rights are justified. In order for a restriction like compulsory quarantine to accord with the Siracusa principles:

  1. It must be provided for, and carried out, in accordance with the law;
  2. It must be in the interest of a legitimate objective of general interest;
  3. It must be strictly necessary to achieve the objective, in a democratic society;
  4. There should be no less restrictive/intrusive means through which the same objective can be achieved;
  5. The restriction must be based on scientific evidence, and not imposed arbitrarily or in a discriminatory way.

It is also vital that such restrictions be of limited duration, and subject to appeal and/or review.

Clearly, containment of the Ebola virus is a legitimate objective, and for a confirmed case, quarantine within a health facility is justified. The arguments for compulsory quarantining of asymptomatic health workers, however, are dubious.

The quarantine protocols put in place by Governor Christie appear to be unnecessary and discordant with scientific evidence. It is likely that the objective of the protocols can be achieved in a less restrictive manner, as borne out by the U.S Center for Disease Control guidelines referenced above; it is also likely that the protocols are also not strictly necessary to achieve the stated objective.

There are other compelling arguments against compulsory quarantine. As well as being of little utility and imposing on their right to freedom of movement, compulsory quarantining of asymptomatic health care workers has the potential to create stigma and fear around the very people whose skills are essential in the fight against Ebola. In addition, it would seem reasonable to assume that healthcare workers returning from East Africa are acutely aware of the risks that they pose to a community, should they be infected with the virus, and are likely to report to authorities promptly if they experience a fever or any other symptoms.

Freedom of movement is a human right and can only be legally curtailed in extreme circumstances. Compulsory quarantine of a patient suspected to have an infectious illness should be a measure of last resort, and only after voluntary measures to isolate the patient have failed.  

The rights of patients

Different circumstances exist in relation to quarantine within West African countries where the epidemic continues to spread. Amongst the media storm concerning quarantine of healthcare workers in the U.S., it can be easy to forget that all three of the countries that have been worst hit by the virus – Liberia, Guinea and Sierra Leone – have imposed quarantines at various points in time, in an attempt to control further spread of the virus.

For example, Sierra Leone imposed a three-day quarantine in late September, confining individuals to their homes while healthcare workers toured affected areas searching for infected individuals who had not yet been identified as having the virus. The New York Times reported that the Sierra Leone quarantine met with mixed responses – some deeming the measures harsh but necessary, others (including representatives of Médecins Sans Frontières) expressing concerns that such quarantines could jeopardize trust between patients and healthcare practitioners.

The Siracusa Principles clearly anticipate the restriction of certain human rights, through measures such as quarantine, in situations such as the current Ebola outbreak in West Africa, where there is an enormous threat to health and security. However, such measures still need to be proportionate and adherent to international standards.

Human Rights Watch has expressed concern that quarantines imposed during the Ebola epidemic have not met these standards, noting that they have “not been based on scientific evidence, have been applied arbitrarily, and been overly broad in implementation”.

Keep calm…and don’t unnecessarily restrict human rights
As the epidemic continues, it will be increasingly necessary for human rights advocates to closely monitor the measures imposed to control spread of the virus, to ensure that the rights of individuals are not unnecessarily restricted.

The hysteria around the Ebola virus is, to some extent, understandable. We currently lack a vaccine or specific treatment for this virus. The mortality rate remains high – estimated at between 50 to 70% – and those who are infected will likely die without appropriate medical treatment. However, this does not mean that there is no treatment. Supportive therapy such as aggressive fluid resuscitation may improve chances of survival.

Moreover, for those outside West Africa, the situation is not as grim as it may seem. The odds of an epidemic occurring in a high-income country such as the U.S. are negligible – the U.S. Center for Disease Control has clearly stated that Ebola poses no substantial risk to the U.S. general population.

Although the West African epidemic demands stringent measures to prevent further spread of the virus – which may include imposition of quarantine protocols that comply with international law – it is fair to say that the quarantine protocols for returning health workers introduced in New Jersey, amongst other States, are not justifiable under international law, and are not supported by scientific evidence. –

Dr Fiona Lander is a medical doctor and lawyer, and a Frank Knox Fellow at Harvard University, where she is currently completing a Masters in Public Health, specializing in Law and Public Health. Dr Lander has previously worked in Mumbai, India, as Senior Officer assisting the United Nations Special Rapporteur on the Right to Health. 

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The greatest health threat you’ve never heard of, but need to know about.

If you have a conversation with someone about the leading cause of global deaths, discussions will usually turn to Ebola, HIV or TB. Even more so, when we think of the biggest killers in the world’s poorer nations, we tend to think of infectious pandemics, under-nutrition or problems resulting from a lack of clean water and sanitation.

At the same time, when we think of challenges like diabetes, heart disease, obesity and cancers, we tend to think of lazy, aged populations living with too much, in rich communities.

But in reality, both of these statements are completely false – and both insidious yet widespread myths have dire consequences on the health of our populations.

This is where a new conversation around the facts becomes crucially important for Global Health. So what are the facts?

In 2014, three out of five people around the world die from one of a group of diseases called Non-Communicable Diseases (NCDs). Literally meaning a disease one cannot catch from another person, NCDs include diabetes, heart disease, cancers, chronic lung conditions and mental illness. Most people in today’s world don’t and won’t die of too little food, or a virus – but from preventable, chronic illnesses. Half of them will die before they’re 70.

Flickr / epSos.de

Flickr / epSos.de

NCDs are not diseases of the rich either, in fact the poorest at home in the USA – and globally – are among those worst affected. These are not diseases of laziness, or stupidity, or simply the outcomes of poor choices. NCDs are diseases with complex, shared risk factors and deeply linked to the built and social environment around us. The major drivers include poor diet often resulting from a food system geared towards overconsumption of poorer quality foods; the consumption of alcohol; tobacco use, particularly in low and middle-income nations which have become the new target for the global tobacco industry; and a lack of physical exercise, in part resulting from a rapidly urbanising and mechanising world.

In short, this group of diseases is largely a reflection of the technological and economic progresses we have achieved over the past few centuries and yet now kills approximately 36 million people per year – equating to 60% of global deaths. Affecting an individual over a long period, with high levels of suffering and sometimes pain, these diseases cause, result from and entrench poverty – with 80% of deaths occurring in developing nations. “NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty” says Ban Ki-moon, Secretary-General of the United Nations, “More than a quarter of all people who die from NCDs succumb in the prime of their lives. The vast majority live in developing countries. 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.”

So why does this matter to you and I, and why should we care? Well, these myths are not just frustrating for a medical doctor or Global Health academic like myself; they are also dangerous to us all. First, missing the link between NCDs and poverty means that the major killers in our poorest communities are largely left off the development and social security agendas. The Millennium Development Goals heralded a major success for global cooperation on poverty reduction and economic development, but largely failed to recognise and address NCDs. With 15 years passing since these goals were adopted and enacted, this was a major missed opportunity for our global community – with serious life costs. In the dawning of a replacement development agenda looking set to include targets on NCDs, the missing NCD-poverty link has never been more crucial.

Flickr/  Vox Efx

Flickr/ Vox Efx

The second outcome of these myths is that we continue to blame individuals for developing these diseases, rather than seeing the structural and social determinants that cause them. Rhetoric falls to persecution of the sick, rather than their human rights. As Richard Horton, Editor-in-Chief of The Lancet stated, “addressing chronic disease is an issue of human rights – that must be our call to arms.” Instead, we entertain dangerous rhetoric that previously termed ‘adult onset diabetes’ in children is simply an outcome of poor parenting, instead of seeing the pernicious and predatory marketing by soft-drink companies, an urban environment built for cars and not people, and a food system designed to maximise profit and consumption, rather than health and wellbeing. I could go on.

Put simply, Non-Communicable Diseases are the greatest health threat you have never heard of, but need to know about. It’s time we all set the record straight.

With this in mind and together with a group of young designers, communicators and public health thinkers from around the world, this week we launched a new campaign called The Face of NCDs. Focused on a crowd-sourced, online community, #TheFace aims to move the discussion past these myths and put a true narrative to these leading global killers. Led by our Melbourne based global, social movement NCDFREE and partnering with Remedy Healthcare and a host of organisations from around the world, we are crowd-sourcing faces and stories from people affected by an NCD in some way, or working to address them. We believe in the power of people and know that personal narrative is a strong catalyst for new discussion and innovative thinking. So in addition to disseminating information to the public, #TheFace is harnessing the possibilities of social media to encourage people to drive this new conversation themselves.

“If we come together to tackle NCDs, we can do more than heal individuals – we can safeguard our very future” says Ban Ki-moon.

This is a new conversation, long overdue. This is NCDs.

This article was co-published with Australian Health Blog, Croakey. For more on The Face of NCDs and to support those living with, or working in NCDs, head to www.thefaceofncds.org today. This campaign is run by the not-for-profit social movement NCDFREE with no financial gain or conflicts of interest.

Dr Alessandro Demaio (MBBS MPH PhD) is Co-Founder of NCDFREE. He is also a Postdoctoral Fellow in Global Health at the Harvard Global Equity Initiative, Harvard Medical School and an Assistant Professor at the University of Copenhagen.

 

 

The Conversation

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