This week on PLOS Translational Global Health, we continue our podcast series in Global Health with medical doctor and human rights lawyer, Fiona Lander. Coming from Melbourne, in South-East Australia, Alessandro asks Fiona about her time with the United Nations, in medical practice and travelling the globe.
Dr Fiona Lander holds degrees with dual honours in Medicine/Surgery and Laws from Monash University. She works in the areas of intellectual property and pro bono law, alongside her medical practice in the field of emergency medicine. Fiona previously worked in India as Senior Officer assisting the United Nations Special Rapporteur on the right to health, and has also worked with the Health and Human Rights team of the World Health Organisation in Geneva, Switzerland. She is the founder of the Global Health and Medicine working group at the Henley Club, Melbourne.
This week on Translational Global Health, regular blogger Jo Jewell - recently of the World Cancer Research Fund (WCRF) - offers an important reflection and summary on the progress thus far, in the global prevention and mitigation of NCDs.
In September 2011, public health NGOs were gearing up for the High-Level Meeting of the United Nations on Non-Communicable Diseases (NCDs). This was only the second time that the UN General Assembly had met on a health issue. As such it was both a landmark occasion and an unprecedented opportunity to raise political awareness of the catastrophic impact of NCDs around the world.
Public health advocates wanted the meeting to bring a similar level of political attention and sense of urgency to NCDs as had previously been achieved for the HIV/AIDS epidemic. Critically, it was hoped that the Political Declaration that was to be agreed would secure much greater action worldwide on the prevention and control of NCDs. In so doing, all governments would set in stone their political ambition, commitment and accountability to addressing NCDs.
It was in this optimistic context that I joined the policy department at World Cancer Research Fund International. Thankfully, the Political Declaration was universally adopted by governments from around the world. In it they agreed a roadmap for international action. As such, my work at WCRF International has been influenced by the outcomes of this meeting. As I sadly prepare to leave WCRF International to take on a new career challenge, it seems like a good moment to reflect on the impact of that High-Level Meeting and what has happened during this exciting period for NCD policy worldwide.
Action since the UN Declaration on NCDs.
The UN Political Declaration has been instrumental in galvanising global action on NCDs. It has mandated international agencies such as the World Health Organization (WHO), Food and Agriculture Organization and the UN Development Programme to expand their work programmes on NCDs and to collaborate on this issue more than ever before. While there is still a need to ensure that NCDs are truly integrated in all the relevant areas – such as the ongoing discussions around the post-2015 global development agenda, it is undeniable that the profile of NCDs has risen as a result.
In the years since the Political Declaration, the WHO has successfully adopted a global policy architecture for NCDs, including a Global Action Plan, a set of global targets (designed to incentivise and drive action), a framework for monitoring progress, and a voluntary global target to reduce premature deaths from NCDs by 25% by 2025.
As a result, NCDs are well and truly established on the health policy map, and the WHO – as the lead agency on health – has articulated what it would like to see national governments do in terms of developing and implementing policies.
What has this meant for our work?
For World Cancer Research Fund International the new global policy architecture on NCDs galvanised our work advocating the wider implementation of effective policies for the prevention of cancer and other NCDs. We developed the NOURISHING Framework to bring together key areas where governments need to take policy actions to promote healthier eating and ultimately to help achieve the 25 by 25 goal. Having an agreed policy framework is critical because it allows the political discussion to move from the “what” to the “how”, which is where there is most potential to support national governments in developing policies.
As part of NOURISHING we pulled together the policy actions that countries are taking around the world (e.g. on nutrition labelling) so we could see – and share with others – what countries are doing to implement these global agreements. What are other countries doing”? is a question we heard often from government officials. Even more, I used to hear “what is the evidence that policy is effective?” So we developed a plan to collate, review and interpret the evidence base. This is work I will be excited to see WCRF International develop into the future, and which I look forward to using in my new role at the WHO’s Regional Office for Europe.
Working internationally is different to working at the national level. Nationally, policy actions have to be tailored to contexts and populations; internationally, it’s about identifying the core elements of well-designed policy that are transferable globally. One of those elements inevitably involves the law, which is why we explored the role of law in obesity prevention in our first working paper, and collaborated with the McCabe Centre for Law and Cancer.
Where are we going next and what are the challenges?
By its very nature, public health evidence is complex. This is particularly the case for multi-factorial issues such as obesity. As I leave World Cancer Research Fund International my hope is that it ultimately does for policy what it has always done so well in its science programmes (notably for Second Expert Report and now with the Continuous Update Project). That is, to ensure that all the evidence is brought together in a way that we can learn from it and take action. Communicating what has been learned to governments, including analysis of the real-world effects of innovative policies, should enable even more policy action on NCDs and a greater confidence in our understanding of the “how” part of the equation. This will be the true legacy of the Political Declaration.
Jo Jewell has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network.
The aims of Universal Health Coverage (UHC), as defined by the World Health Organization, are: “to provide all people with access to needed health services (including prevention, promotion, treatment and rehabilitation) of sufficient quality to be effective; and ensure that the use of these services does not expose the user to financial hardship.” Yet as I studied cancer care and control policies in Andhra Pradesh, India, I realized that I did not fully grasp what this definition of UHC actually entails. I particularly took issue with the phrase “to provide all people with access.” When we say that a country or a state has achieved universal coverage – or in the case of the Rajiv Aarogyasri Scheme (RAS), 87% coverage of the state’s population – what does that mean in practice? At first, I assumed that the expansive reach of RAS ensured that 87% of the population could access free tertiary care. But my conversations with state government officials and health care providers suggested otherwise.
As I delved deeper into the state’s policies, I discovered that the widely lauded statistic actually signifies that 87% of the state’s population is simply eligible for RAS, by way of possessing a white ration card. And I came to understand that there is a huge difference between eligibility and accessibility. The focus of my last two posts was the fundamental barriers to care, both on the supply and demand sides. But these posts merely highlighted few of the multitude challenges faced by patients in seeking health services. It is therefore highly unlikely that all those who are technically eligible to benefit from RAS when sick actually do.
Perhaps the most fundamental barrier to care, I realized, was one that is seldom discussed – the linkage between services. Even if the state removes the financial barriers to each service along the cancer care and control continuum, from primary prevention to survivorship and palliation, patients may remain unable to access comprehensive care if referral networks are inadequate. In fact, one oncologist I spoke with admitted that he discontinued screening efforts for cervical cancer because he had no way of reaching the patient after testing was complete. Despite obtaining Pap smear results, he could not find the patients for further diagnostics, counseling, and treatment.
Certainly, other government-funded programs attempt to mitigate these challenges and improve access. In 2010, for example, the Government of India approved the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases & Stroke (NPCDCS). The broad objectives of the NPCDCS are to: prevent NCDs through behavioral changes, promote early diagnosis of NCDs, train doctors and other health staff to monitor and treat NCDs, and establish and strengthen palliative and rehabilitative care facilities. Notably, the program strengthens existing public health infrastructure established through the National Rural Health Mission to reach even those populations residing in remote areas. The central government aims to scale up the NPCDCS, which has thus far been implemented in only 100 districts, to cover the whole country by 2017.
But whether or not even this program will facilitate UHC depends on how it links to existing state-funded insurance schemes. From my conversations, it became clear that at the moment, the NCPCDS and RAS seem entirely disconnected.
Because cancer is a chronic disease that requires preventative, screening, diagnostic, treatment, palliative, and rehabilitative services, investigation of cancer control policies provides some insight into the extent to which states have achieved UHC in practice. RAS has certainly improved the poor’s access to inpatient care, but we must be critical of such health financing mechanisms in order to improve their efficiency. The point of this series of posts is that pouring money solely into tertiary care may not be sufficient to improve financial protection, let alone increase quality and quantity of life, reduce the disease burden, and ultimately achieve UHC. We must aim to design programs that truly minimize supply side barriers to all health services and innovate to address such demand side barriers as cultural stigmas. Only then can we truly realize universal health coverage as defined by access rather than merely eligibility.
Pooja Yerramilli completed her B.A. at Yale University and MSc. at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health and is currently collaborating with the Harvard Global Equity Initiative to research the financing of cancer care and control in low and middle income countries.
This week on PLOS TGH, we continue exploring the medium of Global Health podcasts. Coming from central Melbourne, in South-East Australia, Alessandro interviews the globally recognised and respected Professor in Nutrition and Public Health – Kerin O’Dea.
Professor Kerin O’Dea is Professor: Nutrition and Public Health in the Health Sciences Division of the University of South Australia. Professor O’Dea is currently engaged in research on an NHMRC Program Grant titled ‘Improving Chronic Disease outcomes for Indigenous Australians: Causes, Interventions, System Change.’ Professor O’Dea is interested in the therapeutic potential of traditional diets and lifestyles of numerous populations, including Indigenous Australians.
Key previous senior academic and research leadership positions include: Director of the Sansom Institute for Health Research, UniSA (2009-2012), Professorial Fellow, University of Melbourne, Department of Medicine, St Vincent’s Hospital (2006-2009); Director, Menzies School of Health Research, Darwin NT (2000-2005); Deakin University (1988-1997) as Professor of Human Nutrition, Dean of Health & Behavioural Sciences (1993-1994) and Pro Vice Chancellor Research (1995-1996).
She has been an active part of numerous national committees over many years advising government on health and medical research, Indigenous health, nutrition, and diabetes.
Prof O’Dea in The Lancet:
Having contributed to the explosion in nutrition-related research in the past few decades, O’Dea says it’s now time for concerted action. “One of the things that characterises much public health research is that we describe how bad things are but don’t do enough intervention,” she says. “Today, taking no action can be more expensive than the interventions themselves.”
This week on PLOS blog Translational Global Health, two emerging health leaders from Kenya lend their voices on the topic of cancer control and care.
Meet Mary, a 43 year-old mother of 5 children and a poor peasant farmer from rural Kenya, who has been battling breast cancer for 7 years. In denial of her condition, Mary has held the firm belief that her breast lump is a result of witchcraft against her. She received her initial diagnosis at a rural health facility 7 years ago, but declined the advised mastectomy.
After her diagnosis, Mary went 5 years without any medical follow-up until she finally visited the health facility again. At this time her breast was ulcerated and oozing, but she still did not agree to a mastectomy. Earlier this year, Mary was sent to Kenya’s main public referral hospital in Nairobi, Kenyatta National Hospital, where specialists found that her breast cancer had metastasized to her spinal cord. An aggressive treatment regimen was initiated, but radiotherapy could not reverse the complications. Unfortunately, the only remaining option is to manage her pain, although her breast cancer could have been manageable had it been detected sooner. Sadly, Mary is a prime example of the many people struggling with cancer in Kenya.
The issues and barriers to cancer control
Cancer accounts for approximately 18,000 deaths annually in Kenya, with up to 60% of fatalities occurring among people who are in the most productive years of their life [1, 2]. Men are most commonly diagnosed with prostate or esophageal cancer, and women are most frequently affected by breast and cervical cancer .
A huge disparity exists in patient outcomes between low-income countries like Kenya and high-income countries like Canada. Take cervical cancer as an example: due to pap testing, cervical cancer is rare in Canada or the US; however, it is the number one cause of cancer deaths in Kenyan women . Prevention and screening has just not been available or accessible to most people in Kenya. Most cases are often undiagnosed or misdiagnosed, which is partly due to inadequate healthcare infrastructure.
The issue is exacerbated further by a faulty national health insurance plan that doesn’t allow patients to afford medical services . The health system is inadequately designed and resourced – particularly for people with cancer – with poorly equipped hospitals, a low doctor to patient ratio, and a lack of access to affordable drugs. These factors lead to late presentation, complications and meager patient follow-up .
Widespread lack of awareness and accurate information about cancer is another reason why screening is rare and many cancers are detected when it is too late to treat effectively. Several cultural myths exist regarding cancer, which are critical obstacles to expanded cancer control and care in Kenya, especially when it comes to early detection . One popular myth, as demonstrated by Mary’s case, is that cancer is caused by curses from ancestors and elders. In such cases, people even believe that you can ‘catch’ the disease from those who have it.
Although developing countries bear 80% of the cancer burden, only about 5% of global resources devoted to cancer are found in these countries . Most cancer care services in Kenya are concentrated within a 5 km radius of each other in Nairobi, making it difficult for most Kenyans to access necessary care. The public national hospital hosts most of Kenya’s oncology expertise and technology. About 78% of Kenyans live in rural areas, which mean that many patients requiring care may travel up to 600 km to access cancer services . The wait time for treatment at Kenyatta National Hospital is extremely long, and this is a problem, as there is a narrow window of opportunity to treat cancer effectively.
The other option of private cancer care, is not actually an option for the majority of Kenyans, as treatment costs in these hospitals are so astronomical that many patients travel to India for cancer treatment instead. More effort and resources are needed to make treatment more widely available and accessible.
Action required to reduce barriers to cancer prevention and care
Prevention efforts, both on a personal and policy level, must be scaled up for cancers that are amenable to prevention such as cervical cancer.
Non-communicable diseases (NCDs), which include cancer and other chronic conditions, share common behavioural risk factors that must be reduced to facilitate disease prevention: physical inactivity, tobacco use, harmful use of alcohol, and unhealthy diet [1, 2]. Smoking and alcohol abuse are on the rise in Kenya, air pollution is potent in urban areas, schools do not prioritize physical activity, obesity is on the rise, and the list goes on .
Reduction of these NCD risk factors is not addressed sufficiently by the Ministry of Health and other policymakers. Only 5% of the Kenyan budget is spent on health – instead of the recommended 15%, and much of the cost is on treatment rather than prevention . Robust prevention policies will result not only in lives saved in the long term, but also in long-term economic gains.
Some community awareness campaigns are happening at the grassroots level, but these must be scaled up nationally to affect sustainable change. Additionally, the many people currently struggling with cancer, and those to be diagnosed with the disease in the coming years, should not be deprived of cancer care due to their geography or inability to pay. These patients have a right to receive treatment, and it is time that this right is recognized with investment in better cancer care in Kenya.
Progress is on the horizon
In 2012, Kenya established a National Cancer Prevention and Control Act, making it one of the few countries in Africa with legislation for cancer . The Act, which stipulates the establishment of a National Cancer Institute among other important advances to counter this disease in Kenya, has yet to be operationalized .
During a launch of 2013 breast cancer awareness and screening month (October), the Kenyan Ministry of Health called for revenue allocation for cancer control in the government budget. The presence of the First Lady, Margaret Kenyatta, and other government officials at the cancer-screening launch ignited hope for high-level commitment in reducing the cancer burden. The First Lady declared that she and President Uhuru Kenyatta had been screened for cancer, encouraging the public to follow suit – potentially lifting some of the public’s stigmatization of cancer.
Kenya is currently undergoing decentralization of government functions, including healthcare, which means that there is a renewed opportunity to integrate cancer care into other regions of the country and build an overall healthier Kenya. As 47 counties of Kenya absorb the healthcare mandate, it is expected that greater community involvement will result in tailored healthcare for each region. Devolution will facilitate more straightforward avenues for advocacy on NCDs at the county-level, as the decision-makers in government will be more localized and have so far demonstrated themselves as easier to communicate with. County health policymakers are usually also native to the communities that they serve and have a more vested interest in improved health outcomes in their designated regions, than the previous national level decision-makers.
For both healthcare devolution and expanded care for cancer, there is a push to build private-public partnerships. Both public and private healthcare providers must have a seat at the policy table and work together, as multi-sectoral action will have the biggest impact within communities. Yet, the need to safeguard public health must be emphasized and the terms of such partnerships critically evaluated and monitored.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095128.
Jordan Jarvis, is a Global Public Health Researcher based in Kenya’s office of African Medical and Research Foundation (AMREF), and a member of the Young Professionals Chronic Disease Network in Kenya.
Duncan M. Matheka, is a Kenyan Medical Doctor and Public Health Researcher, and the African Representative of Young Professionals Chronic Disease Network
It’s that time again – ‘zero one, zero one’. The new year begins and the old slips away. A time for celebrating, enjoying and reflecting. A time to think about the important things in our lives and how we can prioritise them.
As 2014 starts, many of us will be making resolutions. Promises, big and small, for the year ahead. But this year, let’s not just think of the local – or the ‘me’ – when contemplating our New Year’s commitment.
Thinking beyond the horizon, what small but important actions can each of us do to help the wider community achieve happier, healthier lives?
Here are seven simple suggestions…
1. Donate some time and get back much more
Volunteers are a crucial part of our modern economy and a functioning society. Donating a small amount of time and an enormous repertoire of skills, unpaid workers who choose to give some hours each week or month can make the world of difference for organisations and people doing great things. Find something that you love to do anyway or find a group that you enjoy hanging out with – it is a rich and meaningful way to give back, have fun and catalyse a better world.
2. Forego a meal out, to feed those in need
Christmas is an expensive time and most of us are under some financial pressures, but making a small contribution to a charity or community group not only makes us warm and fuzzy – but keeps them running. Every dollar counts.
Put aside a small amount each week and very quickly this adds up to a substantial donation. A great idea is to forego a meal out at a restaurant or cafe each week. This $10 becomes $500 over the 12 months ahead, and can feed a small crowd in-need.
3. Lend your voice to a campaign that matters to you
Very often, your greatest asset is not in your hip pocket, but in your throat. Lending your voice to a worthy cause, or throwing your vocal support behind a campaign or community group can make the world of difference. You can even do it online.
It doesn’t take long, but can make a lasting impact.
4. Ditch the car to give legs to the environment
I’ve said it before and I will again, for every kilometre you walk or ride instead of drive your car, you not only improve your health and the health of those around you – but you also save the community a small fortune. Why not start the year by walking to get the milk, taking the kids to school by foot or jogging into work?
5. Don’t hesitate to ask why
Some conversations are hard to have. No-one likes to talk about the state of politics, or climate change mitigation. Even a chat about the health of our most marginalise populations seems to be a social faux pas nowadays.
We can change this by starting 2014 with a conversation. How about “why isn’t Australia doing enough about climate change?“ or “why are we building roads faster than we build railways” or “why are alcohol and fast food companies still allowed to sponsor sport?“…
Talking and engaging others is the first step to solving these bigger challenges.
6. Buy consciously
For most of us, Santa was generous and we rarely go without the things we really desire. But being in this position – in a nation with little want – we also have an opportunity (read responsibility) to think before we buy. Every dollar we spend is a vote for the company that made the product we purchase, a vote for the way they produced it and even the marketing tactics they used to lure us in.
Vote with your dollars and show you support local business, ethical companies, responsible advertising and sustainable corporate practice.
7. Break a habit, for a better life
Finally, sometimes giving something up can actually make your life richer.This New Year, move from ‘contemplation’ to ‘action’ in one or more of three domains. Improve your health and the health of others simply by not doing something.
Cut down your alcohol drinking and consider a few non-alcoholic days per week. Quit smoking or support someone you know to quit – smoking is so 2013. Finally, break your sugar-drink habit. With increasing scientific evidence that soft drink (aka soda) contributes an enormous burden to society, maybe January is time to replace the juice, lemonade and cola with simple H2O – water.
As a new year dawns, there are so many simple ways to help build a healthier, more cohesive world through personal action. Going into 2014, let’s all jump in and take our own small resolution to ensure the 12 months ahead are a wonderful time for all.
This week on Translational Global Health – we’re experimenting with something new! The first of our PodCast interviews with leading health thinkers. Leading us off, is the inspiring Siri Tellier – of the University of Copenhagen, Denmark, and Renmin University, China.
Talking about life, interests and her incredible work in North Korea, Afghanistan and more…
Siri Tellier holds an Master’s from Harvard School of Public Health, 1970, with a specialization in public health demography.
She has 40 years of experience in international health, including as Director of International Department of Red Cross in Denmark (1992-2001), as well as long term field postings as representative of UNFPA in Afghanistan, China, and the Democratic People’s Republic of Korea, Programme Director for Community Participation in Water and Sanitation with the UNDP, and Chair of the UN Theme Group on HIV/AIDS in China.
Last week in Stockholm, Sweden, I was asked to present an insight into the links between food and global health to the Swedish Medical Society Conference; a brief outline on the parallels and overlap between what we eat, the systems that produce and support that consumption, and the health of our populations.
Now this is no easy task – and not because the overlaps are limited – quite the opposite – but because I had only 10 minutes to do it in!
With this in mind, I proposed just 5 of the reasons why food is, and must be, a Global Health Issue.
Reason number one, we are what we eat.
Put simply, globally, locally and individually – we are what we eat. Improvements in nutrition may have given us enormous health benefits this last century, but food-related disease, including obesity, has now become our greatest health challenge for the current century.
In addition to half a billion people still undernourished worldwide – today diabetes, heart disease, cancers and lung disease, are the leading cause of global deaths. In China, a nation rapidly undergoing nutritional and epidemiological transition, one in two or 500 million people are thought to be prediabetic or diabetic.
Diseases which are both caused and solved, in part, by food.
In Europe, the USA and Australia, obesity rates range from the low teens to mid thirty percent, and obesity-related disease is already crippling populations, health systems and national budgets – concurrently under strain from the economic crisis.
Now this is not to suggest that it is simply a question of calories in versus calories out, but the food we eat, can afford and have access to – and how this is marketed, packaged and served – is a large dictator of our health.
Reason number two: Poverty is not a protector from food-related disease, but a risk factor for it.
In the 20th century, the global health scourges were more likely resulting from under-nutrition. This is no longer. Today – our leading global health challenge results from over-nutrition related malnutrition, with 80% of this disease burden occurring in the world’s low and middle income nations.
The commonly spouted theory that malnutrition resulting from overconsumption is a rich-person’s problem is a dangerous myth.
Risk factors such as obesity and poor diet – as well as diseases such as diabetes, heart disease, lung diseases, cancers and mental illness – are linked with poverty, not affluence. Diseases deeply linked with the quality and quantity of our diets, these are all linked with social and economic derivation.
Reason three: Dietary risks represent profound health opportunities.
The 2010 Global Burden of Disease Study ranked the top causes of global disability and deaths. It is no surprise to many of us, that diet-related diseases topped the charts. But what can surprise some, is that diet itself was named the number one risk factor for morbidity and mortality globally.
The good news though, is that this is a risk factor. This is a disease modifier and amplifier, but if addressed, it is also a disease minimiser and an opportunity for prevention. The quality and quantity of our diets may be an enormous threat to current global health, but inversely it can also become an enormous opportunity for creating a healthier future – if managed appropriately.
The fourth reason: Big Food is a complex, heterogenous and prickly beast.
In 2013, top food companies have more power than some governments, but are unelected and have very different incentives – we must understand this.
The world’s biggest food company alone employs 330,000 people and has an annual revenue of almost 100 billion US dollars – two-thirds the GDP of New Zealand and twice the GDP of Croatia. This company also produces 1 billion products each and every day.
In short, some of these companies have more economic power than some national governments and probably more global political influence than many national governments. Yet, the leaders of these companies are unelected and their driving incentives are market-based and focused on profit, not development, environmental sustainability, social justice or health.
This is a challenge – a huge challenge – and currently there is no clear consensus on how to manage this risk.
Do we work with them? Do we shut the door? Do we regulate or let them regulate? Can they really be trusted to fund governments and elections?
These companies exert an enormous influence on population health and I categorise their behaviours into three groups. The good, the bad and the ugly.
The good companies – those which supply food staples, share the need to create healthy populations and sustainable practices – must be engaged and led by government, but in an independent, mature, arms-length and transparent way.
The bad must be recognised, called out, improved and, when necessary, regulated.
The ugly are the most dangerous. We must recognise that selfish and deliberate decisions by food multi-nationals have caused enormous public health costs in the past decades. These Big Food corporations and their practices must be controlled, even limited – this is essential for global health.
The final reason, there is a growing disconnect between food, cooking and people.
Food is essential to global health, right down to the individual level. As food systems become more processed, supply-chains become longer, and our diets are characterised by a long list of chemicals rather than ingredients – we are losing our personal connection to food. Our understanding of how to choose it, cook it and consume it. And this is occurring almost ubiquitously.
Understanding food and where it comes from, is an essential knowledge nugget for a healthy society – and crucial for those working in health. As the Journal of the American Medical Association recently published, the old medical adage of “see one, do one, teach one” must also become “see one, taste one, cook one, teach one”.
Engaging with the education and political sectors to ensure this is understood, would be time and energy well spent for any global health enthusiast or doctor. Food must become a more accepted part of the clinical mandate.
To conclude, Food is an essential part of health and wellbeing – chosen, prepared, cooked and consumed correctly, food is medicine – it can and has been an enormous catalyst to gains in life expectancy and quality of life to populations around the globe.
But – and this is an important ‘but’ – mismanaged, unregulated, recklessly advertised, poorly produced and over consumed, food can have dire public health consequences. And those consequences are currently playing out around the world.
Food companies, governments, the medical community, the food supply, what we eat, how we eat, food policies and what we subsidise, how much we eat and what we waste will all dictate whether, in the next century, food can once again be a catalyst of health – or continues as a risk to it.
One thing is clear – food is, and must be, a Global Health Issue.
Since typhoon Haiyan ravaged the Philippines last month, some predictable patterns of disaster news coverage have begun to emerge – including evidence of a sometimes contentious relationship between the press and aid organizations. This week on PLOS TGH, Columbia University’s Chris Tedeschi explores.
Stories about the acute phase of the disaster—sudden chaos and unprecedented destruction—have given way to a secondary wave of intermittent criticism, stories of corruption, and even debate about why we still can’t get it right when the international aid machine groans into action.
On time.com, John Crowley argued that a disproportionate number of stories ask why disaster responders have not yet repaired a system rife with inefficiency. He notes that reports from the field indicate that the problems are not as pronounced as news reports make them out to be.
Crowley argues that some of the overblown coverage reflects the moment when journalists witness the inevitable chaos before roads are cleared and medicines are delivered. He blames the media for exaggerating this disparity of supply and demand in the early phase of a crisis, and for “scaremongering” security issues, ultimately delaying aid.
But even the scaremongering is part of an awkward symbiotic relationship between aid groups and the press. Reporters depend on NGOs for access, and in turn, aid organizations survive on dollars donated by individuals and groups moved by dramatic news reports.
The secondary wave of reporting usually focuses on something gone awry—fuel line brawls after Sandy, cholera in Haiti, everything in Katrina—and helps to maintain viewership while postponing crisis fatigue, thus generating more support for agencies on the ground. Oftentimes, financial contributions from this phase can pad the budget of NGOs for months to come.
In Linda Polman’s The Crisis Caravan: What’s Wrong with Humanitarian Aid, journalist Richard Dowden describes the relationship between NGOs and the media in Goma following the 1994 Rwandan genocide: “Each [NGO representative] would give a higher death toll, because each one would know that the man with the highest death toll would get on the nine o’clock news that night. And being on the nine o’clock news meant you got money….”
To some degree, the media does focus disproportionately on what’s gone wrong, partly because journalists fall into a trap of propagating classic disaster myths: all aid comes from far away, countless people and resources are required, and locals often can’t help themselves.
Few reporters cover humanitarian crisis full time. A 2004 study by the Fritz Institute and Reuters Foundation found that of 265 reporters surveyed, only 27 said that crisis stories were more than half their output. Reporters who do specialize in humanitarian emergencies often lack resources or the specialist knowledge to understand complex issues, and make poor use of available resources such as the UN OCHA website and reliefweb.
Ultimately, Crowley’s conclusion is on target. Information is aid. Stories should focus on building capacity and empowering responders, and describing the experiences of those impacted by the disaster. Less congratulatory stories should focus not on the unalterable realities of disaster response, but on the need for organizations to operate efficiently and transparently.
“It is time to look at how effectively international organizations are supporting a normally well-oiled (but now struggling) domestic response capacity,” Crowley argues, “not how international aid shipments are arriving late.” Sadly, it’s not that simple. Stories about how everything is going well would fail to paint the real picture, and would deny a critical role of the press: to expose injustice, highlight inefficiency, and serve the public.
Historically, NGOs and humanitarian organizations have been largely immune from critical coverage, despite an enormous diversity in the quality of the services they provide. In a rare exception after the 2010 Haiti earthquake, a Lancet editorial described the aid machine as “polluted by the internal power politics and unsavoury characteristics seen in many big corporations.”
So maybe the press should be even more critical of what’s going on in the field. What about missed benchmarks and overspending? And why are those aid shipments arriving late after all? We should encourage coverage – for the benefit of donors, readers and affected populations – of poorly coordinated efforts, of groups who cannot provide their own volunteers with basic necessities, of money and resources spent on aid which never reaches its goal, of disaster tourists who take more than they give.
NGOs and reporters alike ought to avoid the trap of addressing inputs rather than outputs, describing how many dollars have been donated or tons of medicine have been shipped, rather than what those dollars purchased or who received the medications.
Several authors have argued for standardization in the practice of humanitarian assistance, but a formal system has yet to emerge. In any emergency, most NGOs and aid groups will demonstrate excellence. But sometimes, there will be confusion, wastefulness, and corruption. And when the dollars at stake have come from governments, private donors, church groups and bake sales, the folks spending the money deserve to know what happens on the ground.
NGOs should take the lead in understanding their role in preventing disaster “catastrophization.” In the Fritz/Reuters study, when journalists were asked, “what do you consider the most difficult barrier to crisis reporting?” the most common answers included “lack of response from groups at the scene,” and “lack of coordination between groups at the scene and their own parent organizations.”
So how can NGOs avoid coverage that makes their skin crawl? Offer press training to field workers. Develop strategies for press relations. Share (don’t hide) information regarding peer organizations, and avoid duplicated effort. Understand that reporters are under pressure to tell dramatic stories that include conflict. And most of all, prepare for greater scrutiny: humanitarian aid workers are professionals spending millions of dollars of other people’s money, and ought to be accountable for it.
Christopher Tedeschi, MD, MA, is Assistant Professor of Medicine at Columbia University and a practicing emergency physician. He is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine. He has worked in disaster preparedness in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during emergencies. He is visiting faculty at the Global Emergency Medicine program at Weill Cornell Medical College. Prior to medical school, he received his master’s from the writing seminars at Johns Hopkins and worked for HBO Documentaries. He lives in NYC.
In time for International Day of People with Disability this week, London School of Economics and Yale graduate Pooja Yerramilli returns to discuss the importance of disability inclusive development and innovative partnerships to empower persons with disabilities worldwide.
“I am very happy. I stand on my own feet – but it was not always this way,” twenty-six year old Mohammad Rafiuddin told me. Rafiuddin is a Hindi language trainer at Tata Business Support Services Ltd (TBSS) in Andhra Pradesh, India. As his family’s sole wage earner, he uses his annual salary of Rs. 180,000 (US$ 3280) to support his elderly parents. Few would guess that only three years ago, this confident young man was unemployed, depressed, and frustrated with a society that defined him not by his personality or skills but by his crutches.
Rafiuddin was only ten months old when he was diagnosed with polio. His family lived below the poverty line and relied on the sole income of his now retired father, an agricultural worker. They could not afford special equipment or assistance to ease Rafiuddin’s physical struggles. Neither did their village have the infrastructure and transportation services to help persons with disabilities (PwDs). So when Rafiuddin reached childhood, he had no option but to crawl one kilometer to and from school. Against all odds, Rafiuddin earned a B.A. and a B.Ed.
Yet, Rafiuddin soon faced a harsh realization that so many other PwDs share – that he was more crippled by society’s attitudes than by the impairment of his legs. He applied for jobs at ninety schools in his district. Even with his academic qualifications, he was turned away from every single one. “They looked at my disability, not my skills,” Rafiuddin says.
Rafiuddin’s story of struggle is not unique; however, his story of ultimate success is. According to the World Bank, India has between 40 and 90 million PwDs. The 2002 National Sample Survey Office estimates that the majority of India’s PwDs are illiterate, and only one in four are employed. Further, the UN Development Programme estimates that 80% of PwDs reside in low and middle-income countries. These statistics reflect the cycle between disability and poverty. Namely, poverty increases susceptibility to such disabling conditions as malnutrition, while the stigma associated with disability precludes access to education and employment.
Ban Ki-Moon, Secretary-General of the United Nations, addresses the General Assembly’s high-level meeting on “The way forward: a disability inclusive development agenda towards 2015 and beyond.”
According to the UN, PwDs constitute the “largest and most disadvantaged group” in the world. Yet the rights and empowerment of PwDs have long been neglected. The Millennium Development Goals make no mention of disability. As a result, according to the International Disability and Development Consortium, PwDs are often left out of development initiatives. Programs to increase school attendance do not accommodate the needs of disabled children, and projects to improve access to water do not consider the physical barriers that PwDs encounter. These challenges are the focus of this year’s International Day of Persons with Disabilities. On December 3, the UN will promote the theme of “Break Barriers, Open Doors: for an inclusive society and development for all.” As Secretary General Ban Ki-moon stressed at the UN High-Level Meeting on Disability and Development in September, “we must not only lift the physical barriers, but also the barriers in attitudes that fuel stigma and discrimination.”
But how exactly can we go about this complex task? Meera Shenoy, founder of the Center for Persons with Disabilities Livelihoods (CPDL) in Andhra Pradesh, believes that in order to break the poverty cycle, society’s conception of disability must change. “Many disability NGOs,” she argues, “focus on the rehabilitation of persons with disabilities, but do not address the fundamental socioeconomic challenges that persons with disabilities face.” To address this need, Shenoy established the CPDL, a public-private partnership with private companies, a private sector foundation (Youth4Jobs), and the government of Andhra Pradesh.
The generic education that many PwDs receive in school does not adequately prepare them for the realities of a competitive job market. CPDL takes an innovative multisectoral approach and unites NGOs, companies, and the government on a single platform – the education and empowerment of young disabled adults. The organization teaches these youth practical skills to prepare them for specific jobs in service and manufacturing. Such partner companies as McDonalds and TBSS recruit from this pool of workers. In this manner, CPDL secured employment for approximately 70% of the 2800 youth trained through its programs.
Shenoy submits that “these youth transform themselves and their societies when they begin sending money to the same families that previously saw them as burdens. They show their peers that they are not disabled, but merely differently abled.” CPDL’s work has also helped improve perceptions of PwDs among employers. “There are many companies that cannot employ PwDs because the jobs require physical labor,” a partner company’s HR manager concedes. “But where we can take them, where they can work, we should employ them. We have a responsibility to put them in jobs where they can use their skills.”
Disability Rights Advocates rally in Washington DC to urge Senators to ratify the UN’s Convention On The Rights Of Persons With Disabilities
CPDL’s success shows that the world’s “most disadvantaged group” can indeed participate in the global economy. Thus, it is crucial that we prioritize the needs of the disabled particularly in developing countries, both in rhetoric and in action. As a first step, the United States Senate must ratify the UN’s Convention on the Rights of Persons with Disabilities. The treaty does not, as opponents believe, curtail national sovereignty, but merely promotes the international re-conceptualization of PwDs from individuals who require charity to productive members of society entitled to fundamental human rights. The impact that such a revised framework has already made is evident in the hopes and dreams instilled in CPDL’s students. “My ambition is to establish an NGO for the people who are affected by disabilities,” Rafiuddin says. “I want to collect those people and train them – and give them better opportunities, like me.”
Pooja Yerramilli is a Yale graduate and completed the MSc. Health Policy, Planning, and Financing degree at the London School of Hygiene and Tropical Medicine and the London School of Economics. She has been involved in cancer advocacy efforts for several years, and was an active participant in policy discussions regarding smoking behaviors and insurance coverage of smoking cessation treatments at Yale. She recently worked with the Indian Institute of Public Health and is collaborating with the Harvard Global Equity Initiative on research on the Financing of Cancer Care and Control in Low and Middle Income Countries.
Translational Global Health facilitates the translation of findings from basic science to practical applications in Global Health practice and, thus, meaningful health outcomes for diverse populations and societies.
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About the Bloggers
Lead Blogger Dr Alessandro Demaio is an Australian Medical Doctor with a Masters in Public Health. In 2010, Sandro began a PhD in Global Health with the University of Copenhagen, focusing on Non-Communicable Diseases (NCDs). His primary research was based in Mongolia. From 2013 Alessandro is a Postdoctoral Fellow at the Harvard Global Equity Initiative at Harvard Medical School and an Assistant Professor at the Copenhagen School of Global Health; and Co-Founder of NCDFREE.
Sandro is joined by a sensational team of Guest Bloggers from around the globe; specialists in economics, humanitarianism, policy, law, health promotion and more:
Global Health & Classical Music, Imperial College London
Research Fellow, Harvard University
Assistant Clinical Professor of Emergency Medicine, Columbia University College of Physicians and Surgeons
Dr Fred Hersch
MD & Research Fellow, The George Institute for Global Health
Dr Fiona Lander
Lawyer & MD
Health Economist, PricewaterhouseCoopers London
Dr Jenny Jamieson
MD & Humanitarian Specialist, Médecins Sans Frontières
Policy Specialist, World Cancer Research Fund
Dr Kremlin Wickramasinghe
Medical Doctor & Researcher in NCD Epidemiology, University of Oxford
Global Health and Economics, London School of Hygiene and Tropical Medicine and the London School of Economics
Health Researcher, University of Copenhagen
Director of Global Health Communications, American Cancer Society
Global Health and Nutrition Researcher, Menzies Centre for Health Policy, University of Sydney