Arquivo de etiquetas: Saúde Global

Non-Communicable Diseases IV

Diet and Physical Activity-II

Nutrition requires not just diet, it also requires physical activity. Regular, moderate to vigorous physical activity, which can make use of the nutrition in an appropriate manner without excess calorie or fat accumulation in the body. Physical activity has been clearly shown to be beneficial for reducing all-cause mortality, increasing life expectancy and certainly most of it is through the cardiovascular benefits.

541It protects the heart and blood vessels. But it also protects against cancer. Some of the cancers, especially bowel cancer are much less likely to occur in people who are regularly physically active. Mental health improves in people who are physically active. Bone and joint disease is much less in people who are physically active. So physical activity has multiple health benefits. And we are really looking at particular benefits for heart disease and where we find that in terms of the risk of coronary heart disease or heart attacks, 31% of the current disability adjusted life year lost due to heart attacks is because of physical inactivity. And therefore you can derive a huge benefit of averted disease and disability if we are actually physically active on a regular basis. But the social conditions in terms of current modernity are now militating against regular physical activity. As development occurs in low and middle income countries we see people becoming more sedentary. In China for example, we have seen that occupational physical activity, domestic physical activity and travel related physical activity have declined markedly over the last 20 years, whereas there has been a slight increase in active leisure time physical activity, but that does not compensate for lack of physical activity in the other major domains. Indeed, it is a paradox of modernity that previously people used to be paid for doing physical work, now we are to pay for doing physical work by registering for a gym membership.

542And now we see that we are spending most of our time sitting at a desk or watching television and that has a price to pay. Even independent of physical activity we see that sitting or being sedentary for several hours a day has independent risk of increasing heart attacks and lowering life. So if people sit for a long time, then you’re likely to have increased risk of heart attacks. But we ought to limit that as well and start moving around. Even fidgeting in the chair is fine. This of course means that we need societal responses, not just individual behavior change. And we are seeing several factors that are actually acting as negative influences. We are seeing a shift from pre-industrial agrarian economy to industrialization, changing dietary habits and physical activity habits, profound changes in households technology with labor-saving devices and dramatic shift in leisure activities for adults and children. We ought to do some social reconditioning to counter these effects. And most of what we do will also be good for sustainable development.

543So if we look at the kind of interventions that we need, first of all we must understand the role of the market. Market is aggressively sometimes promoting unhealthy foods as well as devices which reduce leisure time activity and also the kind of avocations that actually make you a couch potato. So we ought to be able to mold the market much more effectively by increasing consumer consciousness, by providing financial incentives and disincentives, better incentives for healthy foods, disincentives for unhealthy foods and so on and alter the industry practices towards producing healthier products. In terms of policy, there has been a tremendous amount of evidence showing how policy can be remarkably effective in bringing about change. And Finland has been the poster child of prevention. It had the highest ischemic heart disease and cardiovascular mortality rates in the ’60s, but by deliberately bringing about policy change to reduce the amount of unhealthy fat intake in food products as well as altering the individual behaviors by health education, in 20 years they brought down the heart attack rates to much lower levels than elsewhere in Europe. Now we are also seeing other interventions like food labeling, reduced salt in processed food. We’re seeing ban on Trans fats and advertising restrictions, all of them being implemented in Europe and elsewhere, in United States. So there are market interventions which are sometimes needed in order to ensure that consumers are provided with healthier options. In Mauritius for example, a mere shifting of the ration oil in the public distribution system from palm oil to soy oil the healthier oil became the cheaper option and which in five years the mean plasma cholesterol concentrations in the population came down by 15%, just by changing the pricing structure.

544And similarly, in Poland, after the fall of the Soviet Union, there was a greater import of vegetable oils and withdrawal of subsidies on animal fats, along with an opportunity to import more fruit and vegetables into the country. And this within a few years brought down cardiovascular mortality rates quite dramatically in comparison with the neighboring central and eastern European countries. So this is what policy can do sometimes. And of course we have both the individual approach as well as the public health approach when it comes to behavior change.

545There are of course individual behavior change prompts that are required for people to adopt healthier practices. But we must also create a conducive environment through policies for enabling people to make and maintain healthy living choices across the lifespan. And there, urban design and planning for example becomes very important for physical activity and even for diet. Protected pedestrian paths, designated cycling lanes, community recreational spaces, integrated transport systems, reducing vehicular density and emissions, insuring traffic flow and regulation are quite smooth and also permit good physical activity, Land use and housing, Accessible food markets. Having fruit and vegetable availability closer home for example. All of these are measures which can improve not only the quality of life but certainly can improve people’s health. Quite often it is said that you know all these are matters of individual choice, why does the state have to intervene? We don’t want a nanny state telling people what to do. Whether to smoke or to, what kind of food to eat or how much to work, should be entirely a matter of individual choice. Yes, individual choices do matter. But choice can be conscious condition or compelled. A conscious choice can be on the basis of correct information or incorrect information. But choice is often conditioned by aggressive marketing and promotion by the industry for example of unhealthy foods and also the cultural factors in the community. It can also be compelled by lack of availability and affordability. If fruit and vegetables are extraordinarily expensive, if salmon is very expensive compared to beef or red meat, then clearly poor people can’t make that choice. So we ought to create conditions in which choice becomes easy for people. And that is where we need to really look at how best we can actually bring about a social environment which is conducive to healthy individual choices as well as sustainable development which enables people to lead healthy lives free from non-communicable diseases but also protect the environment at the same time. Because the determinants of non-communicable diseases and environmental degradation are very similar. The foods we eat and produce, the kind of cities we live in or pollute all of these are linked both to non-communicable diseases and the environment. So we ought to be looking at diet and physical activity, not merely as individual preoccupations, but as societal concerns. And then only we’ll be able to provide a holistic response to this major cause and contributor to non-communicable diseases.

Non-Communicable Diseases III

Diet and Physical Activity-I

Two of the most important risk factors that have been identified for non-communicable disease are diet and physical activity. Indeed, they feature very prominently among the goals set by the World Health Organization and the United Nations for reducing NCD related premature mortality. We recognize of course that the world today sees two faces of malnutrition.

531 532 533 534 535First is the huge problem of undernourishment where we find a large number of children and young women in the developing countries having low body weight or anemia or even both. At the same time we are also see a rising burden of overweight and obesity across the world. Not just in the developed countries, but also in the developing countries. Interestingly, both of these problems while perceived as quite different from each other, have a profound impact on the risk of non-communicable diseases which can arise even from underweight or overweight. The whole idea that children are born small for size and underweight are much more susceptible to adult cardiovascular disease, diabetes, and some cancers was first proposed by Forstal and David Barker then in U.K. And this hypothesis known as the Barker hypothesis as acquireda great deal of evidence over the last 30 years. We know that children who are born with low birth weight, if they acquire what’s called rebound adiposity, that if they start gaining weight, even within the normal range, between the age of 2 to 12 years, especially between 2 to 6 years, they are much more likely to put on fat rather than muscle. And this is likely to result in early onset of adult diabetes, heart disease and even some cancers and reduce lung function. So we now recognize that there is a link even between under-nutrition and non-communicable disease. But when we look at the larger picture of what are the risk factors for disease and disability across the world according to the global burden of disease study and we take all diseases and all causes of death and all causes of disability into account we find that there are ten leading causes, almost all of them are related to non-communicable diseases, but the vast majority of them are related to diet and physical inactivity. Indeed, when you cluster all the risk factors responsible for death and disease which is avoidable across the world, then the diet and physical inactivity cluster is the largest cluster. So the good news is that we can actually modify much of this by altering the dietary patterns of people across the world and making them more physically active. Now when we look particularly at non-communicable diseases we recognize that apart from smoking and certain other risk factors like high blood pressure and cholesterol which of course are also related to diet and physical activity we find low intake of fruit and vegetables, high intake of unhealthy fats, low intake of nuts, low intake of fish, all of these have been recognized to be important risk factors for non-communicable diseases. And when we look at how diet can best prevent non-communicable diseases we can think of it in terms of what’s called primordial prevention. Preventing the acquisition of risk factors whether it is diabetes, high blood pressure, high cholesterol, or overweight. So if you prevent it in the first place by having a healthy diet across the life course, there can be nothing better. But even when risk factors have been acquired, a person has developed high blood pressure or diabetes or overweight or high cholesterol for that matter, we can actually reduce those risk factors substantially by what’s called primary prevention, effectively using diet and physical activity. But even people who have had a heart attack or a stroke can actually get much benefit from diet and physical activity and prevent a recurrence of heart attack or early death. So whether it is primordial prevention of risk factors or primary prevention by reducing risk factors before they get into disease, or secondary prevention of preventing recurrence of events, diet and physical activity have a potent influence in protecting us against non-communicable diseases. Now clearly we are looking at various elements of nutrition. Diet is what we eat, but nutrition is what we get out of it. Unfortunately most of nutrition science so far has focused on individual nutrients and occasionally on food items. So we have been talking about either saturated fat or monounsaturated fat or trans-fat or refined carbohydrate or we have been talking about other elements like antioxidants. All of them as though they were isolated in terms of their action on health. All of these need to be taken together, not merely as nutrients or food items, but as composite dietary patterns. But even for that, let’s look at the science behind it. Among the various types of fats we have the good fats, what have been called the good fats, the omega 3 fatty acids and the unsaturated fatty acids called monounsaturated and polyunsaturated fatty acids. Then there are the fats which have been considered bad, the saturated fatty acids as well as dietary cholesterol. Though the current evidence suggests that this may not be entirely true. Taken in moderation, these are actually helpful for building some of the essential body structures like cell membranes and hormones and so on. But taken in excess, they can also contribute excess calories. But the real ugly fats are the trans fats, or the partially hydrogenated fats which are not naturally produced, but are usually industrially hydrogenated fatty acids. Now the industrial hydrogenation is done in order to prolong the shelf life of these fats. But anything that lengthens shelf life unfortunately shortens human life. And this is very true of Trans fatty acids where a 2% increase in energy intake from trans fatty acids is associated with a 23% increase in the incidence of coronary heart disease or heart attacks. You can’t have a worse fat than that. Now there’s been a huge amount of debate about which type of fat and how much of fat and so on. But I think there is a reasonable consensus that has been built up now which says, it is not so much the quantity of fat that matters, it is the quality of fat that matters. Quantity does matter to the extent that you don’t want to take too many calories. But within that caloric limit it is the quality of fat that is much more important. You need more of monounsaturated and polyunsaturated fatty acids, less of saturated fats and certainly very little or none at  all of Trans fats. And there is that kind of consensus that’s been built up. One of the problems of course has been in trying to reduce the total amount of fat in the diet. Many people have advocated the introduction of high carbohydrates as a substitute for fat. That’s been a big mistake because introduction of carbohydrates to substitute fat actually increases certain types of abnormal fat patterns in the blood and also increases the risk of diabetes. So we can actually take fat, but prefer to take healthy fats rather than unhealthy fats. We recognize of course that omega 3 fatty acids are principally derived from fish, though they can also be produced from certain other fats that we can take in from some of the vegetables as well, particularly certain types of nuts and so on. And of course flax seed and others are sources. But mainly they’re derived from fish oils. Even as we are trying to increase the amount of healthy fats, we ought to pay attention to the carbohydrates, which have assumed a lot of importance recently, not only in the causation of diabetes, or increase in overweight but also in coronary heart disease. That refined carbohydrates are particularly dangerous and we need to take a lot more fiber through unrefined carbohydrates in our diet. Indeed, what’s called the glycemic load of the food has become very important. The carbohydrates in your diet, how quickly do they release sugar and how quickly does the sugar peak? That is what’s called the glycemic load. How much of sugar is released and how quickly? And that is the glycemic load which can actually cause overweight, obesity and increase the risk of heart attacks apart from the risk of diabetes. Now this can be offset of course by taking more of fruit and vegetables. Now salt is also a major issue that has been debated considerably. We don’t want to take too much excess salt in our diet and somewhere between five to six grams appears to be the optimal as recommended by the World Health Organization. But one of the things that people don’t seem to recognize very clearly is dietary sodium, the effect of which is on blood pressure and of course on stroke and heart attacks can be substantially countered by dietary potassium, which comes through fruit and vegetables, the natural sources.Therefore if you take more fruit and vegetables you are preventing high blood pressure, you are preventing stroke, you are preventing heart attacks. You are preventing a variety of cancers. And this is now emerging as one of the very protective elements in our diet and that’s what the global burden of disease studies says, that low intake of fruit and low intake of nuts, all of these protective elements in the diet is now a major cause of disease burden, especially through non-communicable diseases. Now we recognize that taking fruit and vegetables in a fair amount, particularly more than three times a day, preferably five times a day  can substantially reduce the incidence of stroke by 27% and lower the mortality due to stroke by 42%, reduce coronary mortality that’s due to heart attacks by 24%. Reduce overall cardiovascular mortality by 27% and lower all-cause mortality by 15%. Now if a single dietary item can change the disease burden so profoundly then there are public health implications that we have to make sure there is access to it. However we ought to be really looking at dietary patterns rather than looking at individual food items. And there have been several diets that have been studied like the Mediterranean diet, which has been quite celebrated now as being very protective against heart attacks and being very good for health. The DASH diet which looks at low sodium and a balanced diet with better fats and which reduces blood pressure. Then the Okinawa diet in Japan which has been attributed to be responsible for the high longevity in those populations. Again, a strong fruit and vegetable based diet. Low in unhealthy fats, high in fish. But the Mediterranean diet for example has a composite character. It’s rich in grains, fruit, vegetables, herbs, spices, nuts, beans, dairy food, seafood and healthy oils. Now even when you’re a non-vegetarian, for example, there is a simple rule to remember, fish is better than fowl and fowl is better than flesh. And if there’s a lot of red meat consumption, you’re in danger, but on the other hand, fish consumption is protective. Now we have seen that in a major secondary prevention trial of coronary heart disease in France that the risk of a second heart attack and sudden cardiac death was substantially reduced by a modification of the Mediterranean diet. But that led to further studies on primary prevention. Can we prevent the first heart attack with the Mediterranean diet? And it has been very clearly shown that in women, and, as well as in men, that the risk of getting a heart attack can be substantially reduced at the composite nature of the diet moves towards the full Mediterranean diet. More of the elements in your diet resemble that of the Mediterranean diet, the greater the protection from a heart attack. There has been a major study called the PREDIMED trial which has actually shown very clearly in Spain that if you have the Mediterranean diet with extra virgin olive oil, then the risk of heart attack and death actually substantially decrease and similarly we also see that if you actually add nuts, then also there is a substantial benefit. So the composite diet really matters in terms of protection. But we don’t have to borrow the Mediterranean diet everywhere in the world. What we are really aiming for is a prudent diet which resembles the Mediterranean diet but can be culturally and contextually adapted. For example, it’s been shown, even in the United States in large cohort studies that those who have a prudent pattern of diet will have a higher amount of vegetables, fruit, legumes, whole grains, fish and poultry. On the other hand the western pattern of diet classically consists of higher red meat, processed meat, refined grains, sweets and dessert, French fries, high fat dairy products. It has been shown, again, as I said, within large American cohorts that as you move towards a higher level of prudent diet from a very low level of prudent diet, you get a 30% lower risk of getting a heart attack or a cardiovascular death. And similarly if you move to a higher pattern of western diet from a low pattern of western diet, then you get a 64% higher risk of getting a heart attack or a cardiovascular death. So the dietary pattern matters very much and in each country we ought to be able to provide the population with dietary choices which will enable them to get their culturally appropriate fruit and diet. But this is becoming increasingly difficult. We are seeing vegetable oil consumption rising across the world. Now this may not be a bad thing in terms of providing energy to populations which are poor, but if the oils are unhealthy rather than healthy oils, if they´re mostly rich in trans fats and saturated fat, then actually they’re compounding the problem by creating non-communicable disease. And that’s where we ought to insure that the oils that are available are the healthier oils. Similarly, fruit and vegetable consumption across the world is fairly low, especially in low and middle income countries. In India for example, the per capita consumption of fruit and vegetables is a 130 grams per day as opposed to the WHO recommendation of 500 grams per day. So we need to correct this situation as well. And unfortunately when we look at the global production patterns we are seeing a fall in the availability of fruit and vegetables, now from a 22% shortage of supply of fruit and vegetables as compared to the need, by 2025, we will see a 34% shortage and by 2050 we will see a 43% shortage. So when we are looking at sustainable development we ought to be able to look at how best we can produce enough fruit and vegetables to meet the population needs and protect health. At the same time we are seeing a huge explosion in meat consumption and meat production. Red meat certainly is problematic from point of view of heart disease, obesity, cancers, but it also consumes a huge amount of grain because the animals are grain fed. And that also causes environmental problems in terms of a huge release of greenhouse gases from these grain fed cattle. But we ought to be able to really look at how we can balance our dietary patterns  by looking at agricultural livestock systems so that the healthier food options are available which are also environmentally friendly, rather than unhealthy options which are bad for health and bad for environment.

Non-Communicable Diseases II

Impact of Tobacco abuse

Now I want to introduce you to the number one mass killer in the world, tobacco. In the 20th Century tobacco killed 100 million people. And this was more than all the wars of that very violent century put together. But in the 21st Century, it is estimated by the World Health Organization that tobacco could kill one billion people if we do not take measures to stop it. The problem about tobacco is that it is killing people all over the world, especially poor people.

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Even as of now, about six million people die each year because of tobacco and about 70% of them are in the developing countries. By year 2030, tobacco will be killing at least eight million people each year and about 80% of them will be in the developing countries. It is the largest preventable cause of death in the world today. Tobacco is consumed in many forms across the world, mostly in the form of cigarettes in the western world and in many of the developing countries. But there are other forms of tobacco consumption, whether it is the hand-rolled beedi in India or the shisha in the Middle East, or even oral tobacco, because tobacco is chewed in many forms in South Asia and now increasingly in Africa and the Middle East. Indeed, you would find that deaths due to oral cancer are much higher in the South Asian countries because of the habit of chewing tobacco which is now the leading form of tobacco consumption in India. Tobacco steals away about eight years of a person’s life on an average. And the British Physicians Study which first brought this to light showed that people who smoke even small numbers of cigarettes stand to lose some part of their life expectancy compared to those who do not smoke at all. And those who smoke in large quantities are likely to die much younger because of the effects of tobacco which are far reaching in terms of more than 25 diseases. You have cardiovascular diseases which are the number one killer because of tobacco, followed closely by cancers and then by respiratory diseases. And all of these serve to take people away prematurely into death or disability. But the good news is that if people stop consuming tobacco, especially before the age of 35 years, then much of this risk can be reversed. Most of the risk of cardiovascular disease can be reversed within three years. Some of the risk of cancer can continue up to 20 years. But if you want to ensure that your life expectancy is almost similar to that of a nonsmoker, better give up tobacco consumption early on, especially before 35 years where there’s a huge gain because of cessation. Tobacco steals not only health, but also steals income and an opportunity for development. For example in most households where tobacco is consumed in poor families you find that education as well as children’s nutrition suffer. In the Philippines, the poorest households were spending more on tobacco than on education, health and clothing combined. In fact about 20% of the household income in a smoker’s family was going to tobacco. And similarly in China, India and Thailand, everywhere we find that there is a developmental cost to tobacco in terms of lost educational opportunities for children, for nutrition, and many other ways in which tobacco affects household welfare. And we recognize that as tobacco is increasingly becoming a global threat, there are very many ways we can prevent the harm from tobacco and reduce the consumption of tobacco, especially among the poor and the young and the women who are being targeted by the tobacco industry. There is evidence available from a number of countries, particularly from the high income countries, but also from the low income countries that measures such as taxation, advertising bans, smoke-free policies which ensure smoke-free public places and indoor work places as well as effective health warnings, especially pictorial health warnings are very effective in reducing tobacco consumption. Indeed, in the United Kingdom in the 20-year period between 1981 and 2000, 48.1% off all deaths averted, the entire mortality reduction in the U.K., 48% of that was because of reduced smoking. You can’t have a more effective public health intervention than that. And much of this has now been codified into what’s called the MPOWER Package developed together by the World Health Organization as well as the CDC in the United States. In year 2003, about 178 countries subscribed to the Framework Convention on Tobacco Control which was developed by the WHO as the first public health treaty in the world. And the measures that are advocated for implementation of that treaty and which are captured in the MPOWER package are effective surveillance and monitoring, protection against secondhand smoke, that is, ban on public and indoor smoking in workplaces and cessation support, that is offer of help to quit, effective health warnings on tobacco product packaging, enforcement of comprehensive advertising bans and raising tobacco taxes. Of these, tobacco taxes have been identified both by the World Health Organization and the World Bank to be the most effective way of reducing tobacco consumption because raising taxes raises prices and those with low disposable incomes like the poor, the young, and others who have low incomes like women in many developing countries are less likely to consume tobacco or are more likely to give up tobacco if that happens And this has been shown to be quite effective in many countries. For example, in France as well as in South Africa it has been shown that if you raise tobacco prices threefold, then you halve the consumption and double the income that the government earns from tax revenue. And in the Philippines now, they have not only raised the taxes but are using 70% of that to finance universal health coverage. So much good can come not only by lowering consumption, but by also using the revenue for improving public health. Also we recognize that banning of smoking in public places and indoor work places can have tremendous health benefits. For example, it has been shown in a number of countries that if you ban smoking in public places, hospital admissions due to heart attacks come down within six months. In fact, it has been shown by combining all the data from many studies in many countries that at least 17% reduction in hospitalization due to acute heart attacks can happen. Within months, if you ban smoking in public places. So there can be tremendous benefit from some of these policies. But we also know that effective pictorial health warnings, especially showing the harm in terms of cancer, heart attacks and effects on children, small babies who are born to smoking mothers, all of these can motivate smokers to give up smoking and these health warnings are now being implemented across the world. Started in Canada, went onto Brazil, Thailand, now the European Union, United Kingdom and even in developing countries like Thailand and India, you see these pictorial warnings. But we cannot merely content ourselves by warning people against tobacco and expecting them that they would give up gradually. We have to accelerate the movement towards a tobacco-free century. And for this, we have been looking at what goals the WHO has set. And the WHO say it’s between 2010 and 2025 there should be a 30% reduction in tobacco consumption the world over. But some of the countries have been more ambitious. They’ve been looking at a 40% reduction and a 50% reduction. Some countries like Norway, New Zealand and others have said, between 2025 and 2040, they will bring down the consumption to less than 5%. They call it, the endgame for tobacco. So really we are looking at trying to accelerate the decline in tobacco consumption to levels lower than 5% when it ceases to be a norm and it is possible to regulate it away from society. So we can actually achieve a tobacco-free society by an endgame for tobacco, we just need to be more ambitious in our goals as well as more effective in our tobacco control measures. But we ought to not, not, not only look at tobacco as a threat to health; we now recognize tobacco is a threat to sustainable development. We have talked about one billion deaths like to happen in the 21st Century, but tobacco kills trees too. In order to cure tobacco leaf you have to burn wood. And for 300 cigarettes smoked anywhere someone, somewhere has killed a tree, because you have to burn wood. Also a modern cigarette manufacturing machine consumes about four miles of paper per hour because of the wrapping of cigarettes. So trees are harmed. We have air pollution because of secondhand smoke. Tobacco is a water intensive crop and can accentuate water insecurity. Four million hectares of arable land which could and should have been used for growing nutritious crops are now being wasted on a killer crop. So it’s a threat to food insecurity. Tobacco lands families in poverty because they’re consuming the resources that should have been used for economic welfare of their family on tobacco and they’re actually pushed into poverty each year because of that. So in a number of ways, tobacco is a threat to both health and sustainable development and that is why the United Nations is identifying it as an important component for action under the health goal, but also is looking at it under the sustainable development goals framework. So we recognize that tobacco is the number one public health threat as well as a major threat to economic and sustainable development in the 21st Century. If we do nothing, about one billion lives will be lost in the century because of tobacco. But if we act effectively, especially through tobacco taxes, through ban on smoking in public places and indoor work places, effective health warnings and then promote cessation among people who are already addicted to the habit, we can substantially bring down the number of deaths. And the world is now responding by not only setting goals of 30% reduction in tobacco consumption by 2030, or 2025, but is looking to a tobacco-free century by asking for an endgame for tobacco. And indeed, sustainable development in the 21st Century cannot become a reality unless we eliminate tobacco from the world within this century

Non-Communicable Diseases I

Introduction to NCDs

In this lecture we will be discussing the most important public health challenge of the 21st Century in terms of the global burden of death and disability, that is, non-communicable diseases. In September 2011, the United Nations convened a high level meeting of heads of state to discuss the response to this growing global threat. The second time ever that heads of state met to discuss a health issue under the United Nations. The first one being a meeting on HIVAIDS in 2001. This is because the four major non-communicable diseases, cardiovascular diseases, cancer, respiratory diseases and diabetes together account for the largest number of deaths as well as the highest burden of disability in the world. Of course there are other non-communicable diseases that are chronic diseases like for example cirrhosis of the liver or kidney diseases and of course mental health which is a very major chronic disease. And we also have other problems like oral health, or eye health, which also qualify for non-communicable diseases. But if you take these four major disorders, that is heart diseases and blood vessel diseases, cancers, respiratory diseases and diabetes, they’re linked by four common risk factors. That is, unhealthy dietary patterns, physical inactivity, tobacco and alcohol consumption. And that’s why these were clumped together in that high level meeting which the United Nations and the WHO convened. If we look at how this has become a major global threat from 57% of all deaths occurring in the world in 1990, it has grown to contribute to over 65% of deaths in the world by 2010. But that’s not the only problem.

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512 513 514The problem is that a large majority of these deaths are occurring in the developing countries and are occurring in very young people. If you look at the deaths that occurred in 2008, about 60% of all deaths in the world were because of non-communicable diseases. But 80% of them occurred in the developing countries. A quarter of all NCD related deaths occurred below the age of 60 years. And 90% of them occurred in the developing countries, the low and middle income countries. So it is the question of prematurity of these deaths in the productive prime of midlife which is a major threat to development and sustainable development. And the pattern of these diseases also has been changing. In the developed countries heart attacks or ischemic heart disease and stroke or brain attacks due to blood vessel disease of the brain have been the dominant killers over the last 20-25 years and have remained so. However, in the developing countries, infections, particularly among children used to be the major cause of death in 1990, but now both stroke or brain attacks and ischemic heart disease or heart attacks have risen to the top, even among the developing countries. And this is a major threat to development. And we find that because people are dying young in the developing countries, what we call the age standardized mortality rates are much higher in the low and middle income countries. Even though, at the proportion of deaths occurring in the population, the high income countries still have NCDs as the major killer. But even the proportional mortality is rising in the developing countries and the problem of premature death continues to haunt them. And this is a major consequence for development, because we do recognize that as health transition occur, the poor among countries and the poor within countries are increasingly becoming vulnerable. This has been so in the high income countries for the last 30 years. But even in the developing countries, we are now finding that the poorer socioeconomic groups are much more affected by chronic diseases because of the risk factors are becoming much more common among them. And even deaths due to non-communicable diseases are occurring much more frequently among the poor than among the rich who now know how to protect themselves. So this is a huge directed development and sustainable development. And the economic impact of this is tremendous. NCDs by themselves have been estimated by a study of the Harvard School of Public Health to lead to a cumulative loss of $30 trillion dollars globally between 2011 and 2030. And if you add the loss due to mental illness, this loss rises to $47 trillion dollars. And many of the developing countries are going to be experiencing a serious threat to their economic and social development if we do not stem this epidemic with concerted global response. And we recognize also that this is a threat to health equity because the poor are suffering much more, because of lack of knowledge, lack of access to health services, and inability to obtain timely and efficient care. But it’s also a threat to the sustainable development because many of the determinants of NCDs are also linked to the determinants of environmental degradation. And we need to look at this as a common problem in the context of what we are attempting for sustainable development over the next 15 years. As NCDs rise year by year, between 2010 and ’25, we will see a rise of NCD related deaths by 10.5 million per year. And 9.5 million of these additional 10.5 million deaths in 2025 will be in the low and middle income countries. But fortunately we have the knowledge to act and save many of these. It has been estimated that about 37 million lives can be saved in these 15 years if we act on six risk factors of non-communicable diseases, which have been identified as targets for action by the United Nations and the World Health Organization. And if we act even more effectively on tobacco we will be able to reduce it even further in terms of the total number of deaths that can be prevented. And if we add effective treatments which are available but become, need to become more accessible, then we are likely to save even more lives. So we do have the knowledge and tools to bring about a substantial reduction in the total burden of non-communicable diseases if we act effectively. And in order to help us do that, the United Nations has now set up a goal globally for 25 by ’25, which means that we need to try and reduce the number of premature deaths in the age group of 30 to 70 years which are occurring because of non-communicable diseases, by 25% by the year 2025 compare to the baseline year of 2010. So 25 by 25 means we are preventing premature deaths by utilizing effective interventions against risk factors as well as effective treatments. So now we recognize that non-communicable diseases are the major public health challenge of this century affecting not only the developed countries, but sweeping across the low and middle income countries, where it is particularly a threat because of the age at which these diseases kill. Cardiovascular diseases or heart and blood vessel diseases, cancers, diabetes and chronic respiratory diseases are now accounting for the largest number of deaths in the world, but are also killing a large fraction of them in the developing countries below the age of 60 years. And this is a major threat to economic development, particularly in these countries and is a threat to sustainable development globally. But fortunately we also recognize that these risk factors are modifiable and many of these diseases are treatable. And in that, we can save many valuable lives through effective interventions. We know that by acting on the important modifiable risk factors like tobacco, healthy dietary patterns and alcohol consumption, we can substantially modify the projected disease burden of non-communicable diseases and by coupling it with effective treatments we can save many lives across the world. And that is why the goal of 25 by 25 which asks us to reduce premature mortality due to NCDs by 25% by the year 2025 is not unrealistic. We can do it.

Maternal and Child Health V

The Long Shadow of Childhood Undernutrition

In some of the previous chapters of this lecture, we’ve spoken of how maternal mortality and child mortality are influence also by the state of nutrition during pregnancy, prior to pregnancy and what happens to children in terms of their own nutritional status and probability of their succumbing to illness before the age of five. So we now recognize that childhood under-nutrition is a very critical element in global health. Not surprisingly it was positioned as one of the millennium development goals to be targeted for a substantial reduction in the prevalence of childhood under-nutrition across the world. Even a report as recent as the global nutrition report of 2014 lists that about two billion people are estimated to be deficient in one or more macronutrients, when we are really talking about macronutrient deficiency, we are really talking about ultimately being under-nourished due to deprivation of calories or energy. But we also now recognize that it’s not just calories or energy, it’s the quality of diet that matters in multiple ways. So we are looking at nutritionally balanced diets as well. And that is where we find the problems are probably even more than this particular estimate. We also know that about more than three billion people are afflicted globally with micronutrient deficiencies, whether it’s iron deficiency, vitamin A deficiency, or iodine deficiency, or a combination of all of these. When we look at the global profile of low birth weight and under-five malnutrition and look at what the magnitude is in different parts of the world in comparison to the standard, conventional, geographical atlas, the picture is really very different. Countries of south Asia, particularly India and its neighboring south Asian countries like Bangladesh and Nepal have a huge burden of under-nutrition, as do some of the countries in sub-Saharan Africa. Whereas in many other parts of the world, childhood under-nutrition is no longer a challenge and indeed, does not figure as a part of their own agenda for implementation of the millennium development goals. Despite all the progress that has been attained because of the millennium development goals and even to some extent the period preceding that, we have seen that there are huge disparities, even among the low and middle income countries in terms of the prevalence of underweight in childhood. While Brazil, China and Thailand have been models of great success with prevalence less than 10%. Indeed in Brazil, about 2%. In the countries of south Asia we find the picture very different. India, even in 2011 in a global nutrition report of the World Health Organization was reported to have 43% underweight below the age of five years. Bangladesh, 41% prevalence. And Nepal, 39% prevalence. Even in sub-Saharan Africa, which is better off than south Asia, there was a 28% prevalence of underweight children under the age of five. And these have profound effects. There is impaired physical growth, particularly linear growth among these children who are underweight and under-nourished. There’s a much greater susceptibility to infections, whether it is measles or respiratory infections or diarrheal diseases. Most of the infections can take a toll and even chronic infections like tuberculosis are far more often in the setting of under-nutrition. At the same time, it has an impact on cognitive and intellectual functions. The brain power of these children is substantially reduced as compared to what their potential would have been if they were well-nourished. And while it is certainly a tragedy for the child, in terms of not being able to obtain their full developmental potential, it’s also a huge problem for the countries in terms of the cumulative loss of brain power which they could have otherwise utilized for productive growth. At the same time, because education is also affected of these children because under-nourished children are sickly. They don’t learn very well. And they do not advance well to higher education; therefore their employment opportunities are also substantially decreased. They have reduced ability to participate in sports and other recreational activities and therefore their ability to really be important members of a large peer group, whether in schools or in society is also decreased over a period of time. But even more importantly this link carries on to pregnancy also. Imagine a girl child who’s under-nourished and anemic, growing on to become an anemic and rather underweight adolescent with a limited pelvic size. And when that adolescent girl then becomes pregnant soon thereafter we find that the small pelvic size also results in a small placental size that creates a problem in terms of the pregnancy outcome for the mother, but in the same time the reduced blood flow also results in under-nourished children, particularly when the baby in the womb is not able to get enough blood flow from the small placenta. So it has an impact on the mother, it has an impact on the child. And you may have maternal mortality or child mortality, particularly neonatal mortality, or you may even have a child who has been born successfully but is small size and then there is a further penalty to be paid thereafter. There are also a fair amount of negative effects on the risk of adult chronic disease like cardiovascular disease, diabetes, and even to some extent, some cancers. There are intergenerational effects not only between the child who becomes the mother and her own child, but sometimes these intergenerational effects can spill over to subsequent generations as well. So there is this intergenerational disadvantage of childhood under-nutrition that can carry on to subsequent generations. And we see this long shadow of childhood under-nutrition being cast into adult life when we look at the impact of rebound adiposity in a child who has been born small in size and low in birth weight, but gains in weight between the ages of two and twelve years. That doesn’t actually translate to an increased muscle mass. It translates much more into body fat, especially fat deposited in the abdomen and around the vital organs in the abdomen. And this sets the stage through metabolic programming for onset of high blood pressure, early onset of diabetes, and heart disease in, in these children as they grow into adulthood. And even in fairly early adulthood, you can find diabetes and heart attacks claiming a huge toll of health on these children. And we have evidence of this from multiple countries, but here is an example from India, from what’s called the New Delhi Birth Cohort. And this cohort that’s been followed up from birth to adult life what was determined was that while in the first two years of life the children in the lowest birth rate range were reasonably well protected against acquiring a lot of body fat, by the time they cross two years of age and started having a compensatory nutritional intake, their percentage of body fat markedly increased. And it is these children who had low birth weight under the age of two, but who had rebound adiposity or relative obesity. It was not actually obesity or overweight, it was relative obesity compared to their low birth weight in the beginning who turned out to have much higher incidence of diabetes by the time they became adults. So it was this problem that set the stage for adult diabetes. And it’s not surprising therefore to see that India, which had such a huge burden of childhood under-nutrition in the earlier pictogram, now in this pictogram also it has one of the highest burdens of diabetes in the world. So these are fairly interlinked, at least in the south Asian subcontinent. But these effects are not only limited to the life of one child or even the offspring of that child. When we look at a woman who is now pregnant and who is carrying the consequences of her own impaired nutrition from childhood, we must recognize that the female fetus that is in the womb also is having eggs which will result in her own children when she becomes a mother later on in life. And those are also affected in terms of their gene expression by the childhood under-nutrition that the mother suffered. So at least three generations are linked by this intergenerational transmission of nutritional disadvantage. And perhaps even more as we understand epigenetics, we recognize that some of these disadvantages can be carried into multiple generations. So we need insure that childhood under-nutrition is corrected, not only because we want to protect the present generation or the immediate next generation, but truly in the spirit of sustainable development we want to prevent some of these disadvantages accruing to as yet unborn generations. There are interventions that we need to adopt in order to insure that childhood under-nutrition can be successfully tackled by countries. And some of these are nutrition-sensitive interventions. They do not lie in the form of nutritional supplementations or specific nutrition related or diet related interventions, but they have a profound effect on nutrition because they impact the level of nutrition both in terms of intake as well as in terms of absorption and utilization. Water for example is absolutely important. Unless you have clean drinking water, you can get diarrheal disease and that can wash out a good part of the nutrition that has been taken in. For the same reason, sanitation and hygiene are absolutely important, because infectious diseases, because of poor sanitation and hygiene, again, can drain away much of the limited nutrition that children in low and middle income countries get. And at least 50% of under-nutrition in India has now been ascribed to lack of sanitation. In terms of agriculture and food security, that becomes absolutely important, because we do need to produce enough dietary diversity through crop diversity as well as healthy food products to ensure that every citizen has calorically adequate but also nutritionally appropriate diet at each stage of life. And therefore these systems are to become better aligned to the need of nutrition of all society but particularly from the point of view of preventing child under-nutrition which is such a crying shame. Now we need social safety nets because if there are huge income disparities and also in terms of access to diets because of poor living conditions in low income communities, then we are going to see under-nutrition being perpetuated. So we do need some social safety nets as well. We need a greater focus on early development of children. We need focus on better schooling. Again, education fosters better nutrition. At the same time, midday meal schemes in different countries are also helping to improve some of the nutritional problems, especially micronutrient deficiencies among children. And we need child protection. We need maternal and mental health to be looked at, because if the mother is mentally stressed, she cannot feel a young infant or even the growing child properly. We need women’s empowerment. Having more income and more social status and political power for women insures that children grow up much better. At the same time we need access to health and family planning services because if you have an early pregnancy in an under-nourished adolescent girl being pushed into early marriage. And of the subsequent spacing of pregnancies also is very small, you are bound to get children who are under-nourished. And that is going to have an adverse influence later on as well. So we do require a large number of nutrition sensitive interventions. But we also need to incorporate nutrition specific interventions such as insuring adequate food and nutrient intake at each stage of life as appropriate to that age. And the specific requirements which may vary based on the level of physical activity, based on whether the person is at that point in time undergoing an illness or not and so on. Now we also particularly need to focus on promotion of exclusive breastfeeding at least for the first six months of life. That is absolutely mandatory for good nutrition as well as building of the immunity of the child. And this is very critical but unfortunately not widely practiced even in low and middle income country settings where one would have considered it to be a traditional cultural norm. But it is not. And we also need to promote the right complimentary feeding practices and responsive feeding practices when the children require food. So all of these actually are built in in earlier infancy and childhood. In fact while exclusive breastfeeding is required up to six months, continual breastfeeding should be carried on as long as possible even up to two years, if it’s possible. At the same time, good feeding practices are very important in the growing child. When we talk about the catch up growth happening because of compensatory nutritional feeding, getting ultimately converted not into real good, linear growth with muscle mass, but into a lot of body fat, we must recognize that high carbohydrate diets with low physical activity may be responsible for that. So we need better diets which also are combined with rigorous physical activity in the children, which can ensure that the catch up linear growth is translating into actually a better physical stature in terms of linear growth, but also more muscle mass rather than just body fat. So we need to pay attention to what kind of food we are giving. At the same time, caregiving and parenting practices are important in the entire area of child nutrition, control of infectious diseases is critical because we said; diarrheal diseases can drain away nutrition. Other infections can also reduce the appetite, reduce the absorptive capacity. So control of those infectious diseases, even treating intestinal worms which actually make the child malnourished, that’s also very important. Now we need to look at multiple micronutrient supplementation as a possible additional element, though that cannot be the sole pathway for good nutrition. We have to depend upon natural foods for good nutrition. The use of ready-to-use therapeutic foods has been recommended, particularly in treatment of severe forms of childhood under-nutrition. This is a little controversial because it appears to be pushed sometimes by the industry. But they may have a limited space in the treatment of the severe forms of malnutrition. In terms of the impact of various programs, we have also seen success stories which we can learn from and other countries can emulate. Thailand has been a poster child for such a success. If you see what has happened in the three Southeast Asian countries of Thailand, Philippines and Indonesia, between 1980 and 1990, Thailand had a marked decrease in the prevalence of underweight children. There was a bit of a spike thereafter when all of these countries were facing economic challenges because of some of the financial crises that their country’s faced but nevertheless we noticed that Thailand’s success continues to be commendable. And this has been a feature ever since thereafter. Indonesia has shown a slower growth, but even there we are finding a considerable amount of success. Philippines on the other hand till recently hasn’t had much success, but now it’s beginning to record some gains. What succeeded in Thailand and what is it that we can learn from there? That Thailand adopted the basic minimum needs approach, which looked at some of the social determinants like housing and environment. They brought in family planning and reproductive health services. They encouraged community participation. They also utilized spiritual and ethical development as a platform for promoting healthy nutrition and good eating habits. So they combined all of this and the effective linkages between services in various sectors with community level action mediated by community mobilizers who were interfacing with families, brought nutrition from the abstract policy level into very much of the home habit. Now when you look at how the Thailand model worked, they looked at services and brought in government, NGO action into health, education, agriculture and other sectors. But they also brought in facilitators who worked with community mobilizers, provided supervision, training, information and support. And these  mobilizers acted with the families and that interface involved counseling, organizations, supplies, referral for prenatal care, child care practices, growth monitoring, supplementation of micronutrients when needed. All of this happened at the community level. And the communities also became active participants in planning, implementation and monitoring. So this has been Thailand’s prescription for a successful program which reduced childhood under-nutrition in a very short space of time. And that is where other countries can actually learn from. What we recognize now is that childhood under-nutrition is not an aberration that comes in because of poor feeding in the limited space between birth and five years of age. It is sometimes a carryover effect of poor nutrition during pregnancy. It sometimes is a carryover effect of the poor nutrition that the mother herself had as a child and as an adolescent. But we also recognize that there are factors in infancy and early childhood which again need better attention, particularly to reduce the risk of various ill health conditions which can affect the child but also trying to prevent some of the later problems of adult chronic disease. And the stage there is set between birth and two years and between two years and twelve years. We also need to look at adolescence as a very important period of life. We don’t want anemic mothers resulting from anemic adolescent girls. We want to make sure that they also have good nutrition so that they can grow up well and bear healthy children later on. Even male adolescents too require healthy nutrition rather than becoming obese or having poor nutrition otherwise. This again needs to be carried over into adult life because again, if nutrition suffers in pregnancy, the child is bound to suffer again. So the idea of building  nutrition into a life course model is absolutely critical. Even if we target childhood under-nutrition and monitor specific metrics related to childhood under-nutrition, when we plan programs and frame policies, we have to have the life course model. And we have to look up, look upon it as a multi-sectorial societal responsibility. And that is where it fits into sustainable development.

Maternal and Child Health IV

The Sexual and Reproductive Health Agenda

Maternal health shall be always a core health priority in any nation. It shall always be part and parcel of the universal health coverage, whatever the model. Indeed, MDG V also had a sub-target which espoused ensuring universal access to reproductive health as its horizon. And we still have to achieve this. Maternal mortality is an indicator of how well health systems are functioning. In well-functioning health systems, maternal mortality is extremely low, as low as less 20. Negligible.

443 And in ensuring universal coverage for mothers and women would require access to quality reproductive health services, but not just that, it would also require financial protection without which this access is not possible without impoverishment. When we move toward examining challenges post-2015, then one of the bottlenecks is the problem of poor quality and poor access to data, in the context of maternal health. Only 11 of the 75 countries have information, good enough information on maternal health indicators. And 85% of the global population lives in areas where cause of death data, as basic as the cause of death data are of poor quality and therefore one of the endeavors as we move towards post-2015 framework says, to set up maternal morbidity indicator frameworks and capacity worldwide. And such an initiative has been launched by the World Health Organization. We must remember that maternal mortality, the death of a woman related, occurring as a result of, or a complication of pregnancy is just the tip of the iceberg. For every maternal death, there are 20 to 30 other women, other pregnant women who experience acute or chronic morbidity. And this emanates from a near death that they just managed to avert. Or, non-severe obstetric complication, but can be very devastating, such as uterine prolapse or a fistulae. So we move from reduction in mortality, that’s one aspect, but we also have to take care of this part of obstetric morbidity and the near misses that continue to occur in a very large number of women, even now. sexual and reproductive health continues to need greater attention in the development agenda.451It’s a fundamental pillar of core development of a nation and a society. Unsafe sex is among the top ten causes of disability and death globally. It’s a key toward bad outcomes. And addressing this is the pathway to overall better health, overall sustainable health and sustainable communities. More than 120 million couples continue to have unmet need for contraception. More than 120 million couples. And even today 80 million pregnancies are unintended each year on the globe. This has to be addressed. We’re still far away from an optimum reproductive health scenario in the world today.

452Our efforts to intensify this and in particular to address the younger women, the adolescent girls and women and mothers in marginalized societies. Poor households, poor communities, rural or urban, has to be an important endeavor even in the post-2015 scenario. Family planning promotion has the potential to reduce poverty and hunger and avert almost a third of all maternal deaths, because the number of pregnancies comes down, the mother is able to cope with pregnancies much better. And also family planning can reduce childhood deaths by 10%. Women’s health cannot be optimally addressed without addressing the social determinants such as the status of women in the society and the level of their empowerment, education, and connectivity with the environmental sustainability. In the post-2015 frameworks an important priority for women’s health shall be addressing the problem of unsafe abortions. Each year there are 19 to 20 million unsafe abortions in the world. Almost all of them take place in countries that are low or middle income. And they are particularly so in countries with restrictive, conservative abortion laws. Very disturbingly each year there are 40,000 deaths of adolescent girls and women each year in the world who do unsafe abortions. We have the overarching picture of the abortion laws. The green color depicts liberal abortion laws where the choice is offered to the woman, to under…undertake an abortion.

453The red colors indicate those countries where the abortion laws are restricted and there are conditionalities to undergo abortion. In the second map that how appears on the screen, you would see that areas where there are restrictive abortion laws the burden of unsafe abortions is high. Thus, in Latin America and in sub-Saharan Africa, where the laws related to abortion are restrictive, conservative, the prevalence of unsafe abortions is very high. The take is that if you wish to curb unsafe abortions, the abortion laws should be liberal and pro-choice as far the women and the girls are concerned. I’d like to move toward the unfinished agenda of sexually transmitted illnesses in the context of post-2015 priorities. The STI, the sexually transmitted illnesses are the second most common cause of healthy lives lost in women after the pregnancy resolves. Our focus has been on gonorrhea, chlamydia, syphilis and trichomonas and it remains a challenge.

454HIV is also a sexually transmitted illness and it could be put here as a part of STIs. But we also have human papillomavirus infection, herpes simplex virus infection, hepatitis B infections. And somewhat less troublesome, problems such as scabies and pubic lice that need to be addressed. You will see that the Americas in the developed parts of the world have a huge challenge of sexually transmitted illnesses. So that’s one major area is the Americas, then Asian countries are the other major hub of STIs. And this needs to be put on the high priority agenda in the post-2015 scenario. STIs have a huge impact on not only women, but also on the fetus and the child. STIs cause premature delivery, newborn deaths, birth defects, infections in children. They are contributing toward infertility in women. And they also of course are associated very importantly with rejection of the women by the families and disempowerment. STIs must be addressed optimally and among all women in the world as we move on. Then we look at other challenges in women’s health post-2015. One problem stands out very clearly and that is the issue of violence against women. Not fully understood, often hidden, but we now know from large studies and one particular one done by WHO that the prevalence of violence against women, often by the intimate partner, the husband or the partner is extremely high. Non-sexual as well as sexual violence.Sexual abuse before the age of 15 is quite significantly prevalent across nations. Across societies. At times, transactional sex is common in some regions. And pays for education among the girls. Women who experience violence lose their sexual and reproductive choices because they are forced. They lose their rights. Intimate partner violence is common cause of unintended pregnancies. And this happens in the confines of the home. Thus there are multifarious impacts of this…this problem, affecting a large number of women in the world today. And this must be addressed as a health problem, this must be addressed as a social problem. One form of violence against women is the practice of female genital mutilation, which occurs as a traditional practice in some parts of the world, particularly Africa and some Asian countries.

455Female mutilation, female circumcision has no medical benefit or value. This is an unacceptable practice. There are problems related to psychological trauma and the impact it has in future reproductive live. But there are also acute problems such as infections and hemorrhage, which can potentially kill the woman. And there is also likelihood of chronic morbidity, obstetric problems, fistulae, which can ruin the life of, of the girl, of the woman. Female genital mutilation has to be curbed in the post-2015 frameworks. If required there has to be laws against this depraving practice and if required, there has to be a major social movement to, to address this menace. We must also remember that women’s health is not just about reproductive health or pregnancy or maternal health, there is also a huge importance of mental health in the context of healthy women, healthy mothers. Suicides are among top causes of deaths in peri-natal period in the developed world. And this would happen increasingly so in developing countries as we move toward better, so-called better care. Often the conversation around the mental health is focused on post-natal depression and that’s fortunately getting new attention. But other psychiatric illnesses in peri-natal period also need to be paid attention to. So peri-natal mental health is an important emerging agenda for the global community to address. Other priorities that await focus, are the breast cancer and cervical cancer. And infertility in its own right, not only are we concerned about excess fertility, but we are also concerned about women’s choice and the families or the couple’s choice to have children. And infertility is equally devastating to individuals and families. So this is waiting attention and this should be a priority in the post-2015 agenda. My key messages in this lecture are the following. First, we have made progress in regard to reduction in maternal mortality. And we are proud of it, even though we would miss the MDG V but the, the progress made is remarkable. Maternal mortality has declined by 50% since 1990 and this is the effect of the MDG initiative. Although the current burden, as we have stated earlier is unacceptable and we need to take care of this unfinished agenda, we must always remember that 99% of all maternal deaths are really in the developing countries. It’s the agenda of the poor. It’s the agenda of the developing nations and emerging economies. Maternal health is at the heart of development agenda and it’s at the heart of our quest toward universal health coverage. As we move beyond 2015, we have to take care of the unfinished task of averting all preventable maternal deaths. But we also need to focus clearly on the near misses and the obstetric morbidity that may not result in mortality. We have a huge unfinished reproductive health agenda, huge unmet family planning and need has to be addressed. Unsafe abortions have to be tackled. These are needless deaths and needless morbidity and needless risk to the women. Sexually transmitted illnesses have to be a focus for us to eliminate them, bring them down to a negligible level in years to come. The new agendas on the table are violence against women, peri-natal mental health, and other conditions such as cancer and infertility that affect women and mothers of the world.

Maternal and Child Health III

The Global Maternal Health Scenario

We now turn our attention to global maternal health. We will examine the progress made in reducing maternal mortality and also look at the issues which will be the focus beyond 2015. 421Let me first define two terms. Maternal death and maternal mortality ratio because these two terms would be used repeatedly in this particular lecture. Maternal death is defined as the death of a woman while pregnant or within 40 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management. Thus, maternal death is a death of a woman related to pregnancy and its complications. Maternal mortality ratio is defined as number of maternal deaths per 100,000 live births. Please note that this is a ratio where maternal deaths are the numerator and live births, babies born live after pregnancy are in the denominator. Where do we stand in regard to the status of maternal mortality? Maternal mortality has been the focus of our endeavors, worldwide. It used to be extremely high and it continues to be high, at an unacceptable level. Although we have made progress and we’ll come to that in a moment. Even today however, approximately 800 women die from preventable causes related to pregnancy and childbirth. In 2013, 289,000 women died during and following pregnancy and childbirth. More remarkably almost all of these deaths, 99% of them occurred in developing countries. There are hardly any maternal deaths in the developed world. This is the quantum of preventable mortality among women who go through pregnancy in the natural course of their lifetime. This map shows the distribution of maternal mortality ratio in various parts of the world in the year 2013. The reds and the oranges are high MMR where are the blues and the light blues are the lower maternal mortality rates. The deepest blue is just a rate of less than 10 per 100,000 maternal mortality ratio and you can see that that color is present only in the best of the, of the developed world. The deep red is a maternal mortality ratio of 500 per 100,000 live births.

422Extremely high. Fifty times that in the blue zones that you notice. It’s also obvious from this map that the highest rates of MMR prevail in sub-Saharan Africa. Indian subcontinent and other parts of Africa are somewhere in the middle where the rates are between 200 to 300 per 100,000 live births. So the agenda of maternal mortality reduction is the agenda of poor nations of sub-Saharan Africa and relatively poor nations of Asian subcontinent. The Millennium Development Goal number V relates to improving maternal health. And its specific focus is reduction in maternal mortality. And the target of MDG V is reduction in MMR or maternal mortality ratio by three-quarters, 75% from the 1990 baseline, to 2015 as the timeline. So MDG V is about reducing maternal mortality ratio by 75%, between 1990 and 2015. Let’s see what progress has been made in the context of MDG V since 1990. Between 1990 and 2013, and 2013 is a year for which we have the most updated data, maternal mortality worldwide has dropped by 50%. So if you notice, the number of maternal deaths on the right side, 1990, 523,000 and in 2013 maternal deaths are down to 289,000. It’s about 50% reduction. If you look at the ratio, the maternal mortality ratio, it declined from 380 per 100,000 live births as we defined shortly ago, from 210 globally in the year 2013. It’s again, an outstanding reduction, close to about 50%. More importantly the MDG initiatives have been a trigger for faster reduction in maternal mortality ratio. Between the year 1990 and 2005, the average annual percent change in MMR was the reduction of 2.2% each year. And this accelerated to 1.5 times in the time period of 2005 to 2013 to 3.3%.

441There is no doubt that the political commitment, increased resources, better monitoring and better and higher scale up of effective interventions triggered by the Millennium Development Goals, has resulted in saving additional lives of mothers. However, only 10 high burden countries of the 75 will achieve the MDG V. The rest of the world and the world as a whole would unfortunately still fail to achieve MDG V. And that’s the unfinished agenda that we carry beyond 2015. But let’s look at the regional progress and inequities in maternal mortality ratio. As you would see from this graph, the global community as a whole reduced MMR from 380 to 210 between 1990 and 2013. A decline of 45%. This decline was greater in South Asia, the middle two bars, from 530 to 190. The sub-Saharan Africa, where we see the highest rates also made a significant reduction, the blue is much bigger than the red. And this decline was 48%. So there has been progress all across the world, including the tough places like the African continent and the Indian subcontinent. The progress has been uneven and this needs to be corrected. So there are inequities where we need to invest in order to make sure that there is more even progress and faster progress in time to come. When we look at the causes of maternal deaths and try to derive lessons for averting maternal deaths, something very clear emerges. Thirty-five percent, more than one-third of maternal deaths occur because of hemorrhage or bleeding, triggered by childbirth. High blood pressure, eclampsia accounts for 18% of maternal mortality. Infections, 8%. Unsafe abortion, unsafe abortions account for 9% of maternal deaths.

 

442This is the global scenario. How do the mothers survive the period of pregnancy and childbirth? One of the key things that we know that works is conducting delivery in safe hands. Providing care during labor and childbirth by a skilled health professional, a doctor or a nurse or a midwife. Therefore for MDG V, a key indicator is births attended by skilled health personnel. And if you look at the coverage of this, you will note that in high income countries, and even in upper middle income countries, the two bars on the right side, almost every birth is being attended by skilled personnel or skilled professionals. Every mother. On the other hand, on the extreme left, in low income countries, this proportion is less than 50%. And low and middle income countries are somewhere in the middle. You can see that further reduction in maternal mortality is related to how best we ensure that the labor and delivery is in the hands of skilled people. And, this inequity between the low income countries and the better off countries has to be bridged. This is the centerpiece of our strategies to improve maternal mortality. Skill care at delivery coupled with the emergency obstetric care which would involve emergency caesarian section and blood transfusion and manual evacuation of placenta. These interventions are at the heart of our efforts to reduce maternal mortality. Then unsafe abortion need to be addressed through legalization of abortion services and abortion as a, as a, as a domain and its acceptability in the society coupled with expertise to undertake safe abortion. These are the key approaches to addressing maternal deaths. In the context of maternal health MDG, namely the MDG V. This MDG is linked to very interestingly many other MDGs. It’s related to eradication of poverty, access to basic services. It is linked to improving the status of gender and empowering women and empowering communities. It’s linked to its impact on child mortality and child survival. The MDG IV, it is linked to universal education because educated women are less likely to, to have adverse pregnancy outcomes and maternal deaths. It’s also linked to the HIV related MDG because a part of mortality of mothers is linked to HIV. In some ways, it is at the heart of the entire MDG effort and we also view MDG V as a final common pathway and an indicator of overall development. And of course global partnerships, environmental sustainability are linked in ensuring empowerment of women, good health of mothers, and above all very, very low levels of maternal mortality.

Maternal and Child Health II

Child Health Post- 2015

Why do children die? First and foremost, about 50% of children’s deaths are related to complications that occur in newborn period. And these are preterm birth complications. Complication during the intra-partum period. We also call them as birth asphyxia, as a composite cause of death. That infections of newborn babies such as sepsis, meningitis and pneumonia and malformations, birth defects. In post-neonatal period the predominant causes are three: pneumonia, diarrhea and malaria. And they account for about a third of global child mortality burden. It’s also important to know that nutrition plays a very important part in determining the child survival. Under-nutritional state, whether in the form of wasting, stunting or low birth weight has a bearing on at least half of under-five child mortality. And we need to correct under-nutrition in a significant way to make an overall progress towards better child survival. We have well established evidence based affordable effective interventions to save lives of children. Neonatal life can be saved with good care of the mother in ante-natal period. Skilled care at birth. Skilled care in labor and at and soon after birth will save many child lives. Resuscitation of the baby who doesn’t breathe at birth. Kangaroo mother care for a small baby who needs warmth and access to breastfeeding. Antibiotics. Supportive care. Beyond the newborn period, immunization. We talked about measles, but we also have haemophilus influenzae and pneumococcal vaccine and rotavirus vaccine which avoid pneumonia and diarrhea. And if diarrhea does occur, effective treatment is possible through the use of oral rehydration solution and the zinc. And for pneumonia, if it does indeed occur, antibiotic therapy will save most children. In the recent times we have been able to package these interventions into programs. So integrated management of childhood illness combines these interventions into a package which is delivered by the health workers after training and insuring that there is a supply chain of treatments out there in the field where the babies and children are. Home based newborn care. Facility based care of sick newborns and children. These packages of services will save most lives. It must also be stated that safe water, sanitation and hygiene are also crucial in improving the health outcomes of children, particularly in preventing illnesses. And nutrition is fundamental to child survival. Exclusive breastfeeding in the first six months of life. Timely and appropriate introduction of complimentary food. Addressing moderate under-nutrition and addressing severe, acute malnutrition aggressively are the building blocks of a good nutrition program in a nation. If we have interventions they must reach children, women and households. If they do not reach, these interventions cannot save children. So when we examine the coverage of various interventions we find that there are gaps. For instance, breastfeeding which does so much good to children is, covered to only about 40% of the global population. Exclusive breastfeeding rates in the first six months of life at just about 40% globally. This should be 90%-plus. Oral rehydration solution should be accessible to every child with diarrhea,100% coverage. But what we have is 30%. And antibiotics for pneumonia which should be accessible to any child with pneumonia, is at the present rate is only 50% coverage. The gap amounts to deaths. And this gap has to be bridged therefore. The interventions must be taken to scale and every child should receive the intervention that he or she deserves. It’s not just about access to interventions alone. Interventions to be delivered through an efficient, and a quality mechanism. So quality of services is also extremely important. For instance if you just close the quality gap and newborn care, we can save additional two million newborn lives. So it’s not only about reaching, but reaching effectively, reaching with quality, that will lead to optimum survival of children. Access to intervention is also linked to mechanisms that connected the babies, that target children, target mothers, target infants to the intervention. In Rwanda performance based payment to community workers led to a better connect of this nature, that children accessed care and services. In Bangladesh engagement with NGOs and commercial partners led to disconnectivity of increasing access by the, the children, by the families to the live-saving interventions. And in India, conditional cash transfers to families and to health workers led to a phenomenal increase in facility births from 40% to 80% in a span of five to seven years. There are drivers of change that lead increased uptick of interventions on scale that we should learn from, adapt them, and implement them if appropriate contextually. What is the agenda of child health beyond 2015? First and foremost we still have to end all preventable child deaths. There are still too many child deaths happening, particularly among newborn babies as we stated. For this, the global community has now set 2035 as the horizon, by which time we all as a global community end all preventable child deaths. And this translates to bringing down under-five mortality rate to 20 per 1000 or less by this timeline. Just to remind you, the current rate is 46 per 1000 live births. So our endeavor is to reduce it by more than half beyond 2015 and up to 2035, a span of about two decades. Likewise, global newborn mortality rate is now targeted to be brought down to single digit by 2035. Current rate being 20 per 1000 live births. So this is the new set of goals and targets that the global community has set for itself and that’s the direction that 2015 onwards we will take as a global community. There are other priorities beyond survival for children. Over-nutrition is looming large. Too many children are becoming obese because of changes in lifestyle. In some ways the ill effects of so-called development. Diabetes, childhood cancer, childhood kidney diseases, birth defects that requires surgical corrections. And very importantly, psycho-social issues, autism, abuse and disabilities are increasingly important to be tackled even in the lesser resource settings and nations. There is also an area of insuring intact survival that is the expectation of the society of today. There’s another important area which is calling for attention, now and beyond 2015. And this is the domain of developmental origins of health and disease. We now know very well that the physiology prevailing in fetal life, distresses and the well-being as fetus has a profound implication in regard to growth, development, health, ill health, abnormal physiology in adolescence and adulthood. The nine months within the womb of the mother have profound programming that determines how the life goals of individual is as an adult. We now know very clearly that if the fetus is constrained, restricted in growth and in terms of well-being in utero, that this baby is predisposed to obesity, hypertension, heart disease, diabetes and so on. So we have an interesting situation here that we have a baby who was deprived in utero. If he survives, comes out as a small baby. And then if he does well and moves into adulthood, he has a second jeopardy and that is the risk of diseases such as the heart disease, hypertension, dyslipidemia, stroke and so on. Can this be modified? Can this be changed? Can this be averted? That babies not only are healthy in utero, not only they are healthy as fetuses, but also as children, also as adult. This is a Holy Grail in child health and adult health in…and in the context of non-communicable disease today. And post-2015, as it is now, this will be a major area of attention for all of us by way of research, by way of intervention design and by way of scaling up these interventions to, to avert this catastrophic pathway that you…that we now know operates in a very significant way in our lives. Health we believe is a driver of development. And that’s at the heart of the global and the national agendas beyond 2015. But healthy children of today are healthy adults of tomorrow. So if adults will drive development, then they have to be healthy. And healthy adults, the beginning is made by being healthy children. So beyond 2015, we have one part of the agenda of ending preventable deaths. And in this context we have summarized the, the…the trend and the situation by making a statement that child mortality has been halved since 1990. Further progress is linked to acceleration in newborn survival in particular and we offered reasons for it. Universal coverage of interventions with quality is the key to end preventable child mortality that stands today. Birth defects will need attention. Their prevention and correction should be a priority. As we move beyond survival, in post-MDG IV scenario we have to ensure that babies not only survive, but they’re intact in terms of their potential for growth and in terms of their neuro-development abilities. Childhood disability, autism, neuro-developmental problems will be an important priority in this period. Under-nutrition will continue to plague us for quite some time, but we now have an epidemic of over-nutrition in children looming large. And we need to apply our attention to both these areas of nutrition. Chronic pediatric diseases such as cancer and systemic iseases will require attention. And a huge effort will be required to find ways of insuring that fetal origins of adult disease could be averted or could be modified. So that children who survive the fetal life and early neonatal life eventually do…do not pick up non-communicable diseases such as heart disease, hypertension and diabetes. And this would be a very major challenge that we will have to put our heads together to energize the science and epidemiology and operations research to, to tackle this emerging area of a huge problem which will be a very important focus post-2015.

Maternal and Child Health I

Trends and Progress in Child Health

In this lecture we shall examine the trends in child survival and look at the priorities beyond 2015. The Millennium Development Goal IV relates to reducing child mortality. And the indicator for child mortality is the under-five mortality rate which is the number of deaths under the age of five per 1000 live births. So the target for MDG IV is to reduce by two-thirds the level of under-five mortality rate between the year 1990 as the base and 2015 as the timeline.

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This is MDG IV which has triggered a great deal of action in saving children. And we made remarkable progress in reducing child deaths in recent times. Although the challenge continues to be huge, but there are successes that we can celebrate. Under-five deaths worldwide have declined by 50%.They have been halved between the year 1990 and the year 2013. In the year 1990 there were 12.7 million under-five child deaths. And this number now stands at 6.3 million in the year 2013. And we must be proud to, to appreciate the fact that despite population growth, there are 17,000 fewer children dying every day in today’s time.

But the other side of the challenge is that another 17,000 children under the age of five continue to die every day till this date. When we examine the progress in the context of MDG IV we also note that there are huge inequalities. Most child deaths occur in sub-Saharan Africa and South Asia. Children from poor families are twice as likely to die as those from rich families. And social determinants such as mothers’ education influence child mortality in a very, very big way. And diarrhea and pneumonia, two causes of child death which are eminently amenable to prevention and treatment continue to kill as many as two million under-five children in the world today.

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Let’s examine the effect of the Millennium Development Goals on child mortality, which is truly phenomenal because global under-five mortality rate is falling faster than at any other time in the history of humankind during the last two decades. Since the year 1990, the under-five mortality rate worldwide has dropped by 49%. There were 90 deaths per 1000 live births in 1990 which is down to 46 per 1000 live births in the year 2013. And all regions except sub-Saharan Africa and Oceania have reduced the under-five mortality rate by 52% or more.

That’s very remarkable. And if you examine the global annual rate of decline in under-five mortality rate it is notable that there has been more than tripling in the annual rate of reduction in the under-five mortality rate. It was 1.2% annual decline between 1990 and ’95. It has now risen to 4% decline in the time segment of 2005 to 2013. And this has happened because the Millennium Development Goals triggered political commitment, greater resources for child health enabling research and evidence and above all a monitoring framework which drove action.413

We can see in this graph that there has been progress post-MDG in reduction in child mortality in all the regions of the world. But overall, despite these gains we as a global community shall not be able to reach the intended MDG IV goal. Only eight of the 60 burden countries would achieve the MDG IV goal in 2015 and that’s the unfinished agenda which will be now carried over to post-2015 scenario. This picture shows the distribution of under-five mortality rate worldwide. The blues are the regions with low under-five mortality rate, typically below 20. And the orange and red indicate areas where under-five mortality rate is very high. The red indeed is an under-five mortality rate of 100 per 1000 live births which is extremely high. You would see that globally areas with high under-five mortality rate are located in sub-Saharan Africa. And then there are intermediate areas in South Asia, the India subcontinent and parts of Africa. And the developed nations have much lower under-five mortality rate as you would expect. It’s also important to know that about half of under-five deaths occur in just five countries: India, Nigeria, Pakistan, DR Congo and China. And India and Nigeria put together account for one-third of the entire global burden. Clearly in order to address the unfinished agenda of child mortality there has to be a focus in five nations and in particular, India and Nigeria. It must be stated that immunization has had a vital role in bringing down child mortality in recent times.

414It’s estimated that since 2000 measles vaccine alone has averted as many as 14 million under-five child deaths. There is an important issue within the child health survival paradigm and that relates to the complexity of tackling neonatal mortality. Neonatal period is the period of infancy less than 28 days of life. The first four weeks of life are the newborn period or neonatal period. Neonatal mortality is the number of deaths per 1000 live births in the first four weeks of life. And this as you would note is a part of the overall under-five mortality as a sub-segment of that. Now neonatal mortality is tougher to tackle because it is influenced a great deal by maternal health and the care that the mother and the baby receive at childbirth,which is quite different from the care that is required for a child with diarrhea or pneumonia. Neonatal mortality has also declined in all parts of the world, as is obvious on this graph. The neonatal mortality rate in the year 1990 was 33 per 1000 live births, which is down to 20 in the year 2013. The absolute number of newborn deaths in the year 1990 was 4.7 million. It’s down to 2.8 million. That’s remarkable. So we have made progress in this regard. However when we see the progress in neonatal period vis-a-vis progress in reducing mortality after the neonatal period, the post-neonatal period something very significant stands out. That the progress in post-neonatal mortality reduction has been more remarkable, faster than that in the neonatal period. So it’s notable that the decline in neonatal mortality is lower than that in post-natal period. That means we have made less progress in reducing deaths occurring in the first four weeks of life. And that is therefore important for us to focus on as we move beyond 2015 agenda. We also note an epidemiological phenomenon that neonatal mortality component of under-five mortality has risen with time. Therefore future progress in child survival is linked to our progress in saving lives of infants in the earliest period of life, which is the riskiest period in humankind.

Trends in Public Health III

Globalisation and its Impact on Public Health

We now live in an increasingly interconnected and interdependent world. If industrialization and urbanization constituted the principle propellants of economic growth as well as health transition in the 19th and 20th Centuries, globalization constituted the tailwind that accelerated health transition towards the end of the 20th Century. This we have seen in the way non-communicable diseases have now become a global phenomenon. We have also seen how knowledge as well as technologies have been used to better control infectious diseases across the world. So globalization offers us advantages as well as disadvantages.

So naturally we find enthusiastic supporters as well as very strong skeptics. We need to critically look at how the advantages of globalization can be amplified while curtailing some of the absolute disadvantages that it has brought to global health.

Globalization has been defined as a process of greater integration within the world economy, through movements of goods and services, capital, technology, labor, all of which lead increasingly to economic decisions being influenced by global conditions. We see that the world economy now is increasingly being dominated by the forces of globalization, whether it is the spread of infectious diseases through rapid movement of people, or even the global contagion of economic crisis which affected the banking system in the first decade of the 21st Century. In such an environment you can have the forces of growth fueling production and employment in other parts of the world, but you can also have an increasing vulnerability where financial systems are actually either unstable or inequitable. Globalization affects health in several pathways.

Firstly, in terms of a direct impact on health systems as well as a direct impact on health policies. There is also an increasing exposure to hazards like infections, tobacco and other marketed products. But it also affects indirectly through the impact on national economies. For example, health sector affects the public health expenditure on health in terms of globalization influencing some of the policies related to allocation of resources, both through the health sector overall as well as within health itself, resetting of priorities for expenditure. We also recognize that there can be increasing effects on population risks. For example, on the kind of diets that people now start eating as a result of the global marketing forces and that has an impact on nutrition. And in turn, on health. Living conditions are also substantially altered by the forces of globalization. And all of this cumulatively can decide on whether the impact of globalization on health is positive or negative. For example, we see in the case of Central America the import of snacks from the United States has markedly increased as a result of trade between 1989 and 2006. And we see overweight and obesity rapidly rising in that region of the world, especially in Mexico. And also in other Central American countries. We recognize that we can also have the market liberalization bringing in healthy foods. Like in the case of Poland, where the opening up of the markets brought in much more vegetable oils which were healthier than the animal fats that were being traditionally consumed. And also a greater amount of fruit and vegetables.

And that resulted in a fairly rapid decline of cardiovascular mortality in the mid-1990s in Poland. So globalization in terms of nutrition can be a double-edged sword, depending upon which type of products are being marketed and are being consumed. At the same time we also recognize that trade impacts access to medicines. While this is going to be elaborated much more in a future lecture, we must recognize that lifesaving medicines can now be exported or imported worldwide. But there are barriers which sometimes prevent access to medicines because trade often prioritizes intellectual property over the social contract of making medicines available to everybody who needs them. And therefore trade is a very important area for us to look at when we see the impact of globalization on health, particularly through access to medicines. The whole area of trade liberalization was also accompanied by prescriptions for structural adjustments in the economy. And that had an impact on the way public funds were being utilized for health. During a transition to a market economy in the early 1990s, in Russia, there was a drastic fall in life expectancy, especially of the Russian males, which hit a point which was lower, lowest in a century. About 1.4 to 1.6 million premature deaths occurred during 1990 to 1995. A great proportion of these were among working age men. And there were several factors that were cited as being responsible for this effect.

Firstly the import of a large number of unhealthy foods into the Russian market exacerbated some of the poor diets that they were already having. But one of the most important factors was the deregulation of alcohol consumption which hugely increased alcohol consumption and binge drinking became a norm. And that resulted not only in increased cardiovascular disease, especially sudden cardiac death, but also a huge surge in accidents and injuries. This was also accompanied by reduced public spending on healthcare. And even some of the infectious diseases that were previously very well controlled now started springing up again.

So we saw the destabilization of the Russian health system during this period of economic transition. Again, marketization of health systems became an important feature of the prescription provided by multilateral institutions like the World Bank and the International Monetary Fund, during the late ’80s and early ’90s. And these traditionally worsened public spending on health by reinforcing the market driven approach to healthcare provision. And we are seeing how their emphasis on user fee became counter-productive. Evidence from Kenya, Burkina Faso, Papua New Guinea, all of them showed a clear decline in the utilization of health services with the introduction of user fee. One of the most dramatic impacts was seen in China, where despite the huge advantage that China had derived earlier from wise investments in nutrition, in public health, for water and sanitation, and in general, spending on provisional basic health services to the Chinese people, the introduction of market reforms saw considerable disinvestment of public finance in the health system. The percentage of women with insurance coverage for prenatal delivery, uh, prenatal and delivery services fell from 58.3% in 1989 to 34.7% in 1997. And the overall access to insurance coverage already available to just one in four Chinese in 1989 continued to decline slowly through the 1990s. This led China to review and revise its policy and introduce substantial reforms with infusion of public finance and an increase in the coverage of the insurance system through three programs to more than 95% of the population The fact that market prescriptions may have been unwise has also been acknowledged by the president of the World Bank, Jim Yong Kim, who referred to some of the prescriptions that the World Bank had made to Thailand against some of the reforms that Thailand wanted to undertake in order to launch universal health coverage. He said, “let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution. Thailand’s health leaders were determined to act boldly and provide access for their whole population. Today the world learns from Thailand’s example.” This confession that the World Bank prescription of the ’90s was incorrect came when Jim Kim addressed the World Health assembly in 2013. But the fact remains that many countries did follow the World Bank in name of prescriptions in the ’90s and that may have affected the way health equity grew among those countries. The World Bank has now formally changed its goal to fighting no longer just for the eradication of poverty, but also for shared prosperity, recognizing that mere growth itself is not a guarantor of good health, but you ought to reduce income disparities within countries if you want to gain from growth to the maximum extent. So that again is an important revision of the overall economic philosophy of the World Bank. And that may influence how globalization is perceived in the future.

When we come to the other impacts of globalization and health, we must also consider brain drain of health professionals. More than 20% of physicians working in Australia, Canada and the United States of America come from other countries. WHO estimates that there is a global shortage of about 4.3 million physicians, midwives, nurses and support workers worldwide, and the export of health workers to other countries from countries most in need of them for their own under-resourced health systems adversely affects global health. And this is a problem that we must address. And the WHO has provided a code on human migration of health workers which can offset some of these problems. But we must recognize again, that if there is a global shortage of health workers, we need a global response which provides those resources to all countries, but does not divert them from the less developed countries to the more developed countries. We also must recognize that global funding is now sometimes skewing the priorities both for health research and health programs within countries. While the infusion of a lot of private funding from philanthropic foundations and from the private sector is indeed welcome in terms of raising the overall pie of funds that is available for the health sector, if priorities are principally going to be decided by what the donors choose, then you may actually land up with priorities which are misaligned to the needs of countries as well as that of global health. So we need to build in a greater accountability into the whole system of global funding from nongovernmental sources and say that these are the kind of priorities that have to be determined by countries and by consensus among countries, and any private funding should not distort those priorities. At the same time we see the increased global movement of humans and goods can increase the risk of infectious disease spread. We have seen that for Ebola. We have seen that for SARS. So we need to be very careful about how we actually ensure the movement of people and goods during a period…during an era of accelerated globalization does not cause more of infectious disease spread, resulting in pandemics.

Globalization has also been recognized as one of the drivers of change in ecosystems. For example, agricultural production itself is greatly skewed to meet international demand created by market pressures rather than by addressing local needs. And not even in terms of looking at global health goals or national health goals, but purely looking at the commercial profit line of the crop production that has often resulted in reduced crop diversity with a much greater emphasis on some of the cash crops than  even on staples or protein sources or providing the kind of diversity that’s required for healthy diets. For example we see tobacco, meat, soya and palm oil dominating the agricultural system which are not always to the advantage of good health. Global meat production for example is now going up substantially and is likely to rise from about 310 millions of tons in 2013 to about 518 millions of tons in 2050. While we do require protein sources, this level of meat consumption is not good for health and certainly not good for the environment because of the high level of methane emissions as well as the huge amount of deforestation that is required to produce the grain that goes into feed the animals.

So we must recognize that agricultural systems which are being driven by forces of global commercial compulsions are now sometimes acting to the detriment of good health as well as the environment. And the environmental degradation in turn affects health. We also recognize that shifting of production to low and middle income countries with poor environmental and safety regulations negatively affects the environment in some ways because of increased air pollution levels, because of a number of factories which belch out a lot of carbon dioxide and other greenhouse gases, or contamination of water bodies because of poor environmental regulation. Drainage of water because of soft drink companies draining away a lot of needed water for production of their beverages in the low and middle income countries.

Or even poor living conditions whether it is the garment factory workers in Bangladesh who suffer because of fires breaking out in very poorly regulated conditions of work, or when you’re looking at people working in South African vineyards or people working the tobacco factories of India, we find that while the production forces are now investing much more in low and middle income countries,they’re not ensuring the health and safety of the low paid employees. And this is again, a distortion of globalization that we ought to correct. It has been said that globalization itself is a wonderful opportunity for equalization of opportunity across the world. And by spurring on economic growth, it’ll not only foster better health but also reduce health inequities. Angus Deaton differs and points out that economic growth by itself will not be enough to improve population health, at least in any acceptable time. Clearly we need growth, but we also need inclusive growth in which health inequities which accompany economic inequities are reduced. And Angus Deaton says that as far as health is concerned the market by itself is not a substitute for collective action. So the imperative of globalization is collective action, not just abandoning everything to the forces of the market. Therefore, we need to recognize that market interventions are required for protecting health. Even in the national context, we have recognized that asymmetry of information and decision-making power doesn’t make health a perfect market. In fact, it’s a very imperfect market. And the same thing applies even at the global level when trade and other market compulsions often negate the need for policies which are conducive to good health at the global level. Therefore, recognizing that the market is here with us and is something that we have to reckon with, we need to mold the market by adopting a number of other forces which are favorable to public health.

Firstly, we must raise consumer consciousness so that the demand for healthier products steers the industry towards them. We must also offer the industry incentives for producing healthier products by pointing out the health dividend that comes from a health society which is much more productive, which stable labor and consumer markets for a variety of goods. We need to see that public-private partnerships are much more responsible and are responsive to health concerns and produce healthier products for the global market.

At the same time, we ought to adopt national policy frameworks with political, economic, and social motivators that reduce some of the distortions brought about by globalization, whether it is nutrition which has to have incentives for healthy foods in form of subsidies, or disincentives for unhealthy foods in terms of increased import tariffs. We also need global agreements for example by way of the framework convention on tobacco control or agreements to ban advertising of junk foods and soft drinks to children. So there are a large number of global agreements also which can bring about some degree of balance in the market forces that dictate global health. As Nancy Birdsall, the director of the Center for Global Development remarked, globalization as we know today is fundamentally asymmetric. In its benefits and its risks, it works less well for the currently poor countries and for poor households within developing countries. In a very famous phrase, Thomas Friedman described the world as being flat; basically pointing out globalization has brought in a number of opportunities across the world reducing the asymmetries that existed prior to that. But even what appears to be superficially a very flat surface sometimes can be very tilted. And that is the asymmetry of power, even in a globalized world. With multilateral institutions like the World Bank, the IMF, the World Trade Organization, the distribution of power is unequal. The G-8 nations account for nearly half of the global economy and trade. They hold four of the five U.N. Permanent Security Council seats and have a major shareholder control over the International Monetary Fund and the World Bank. So even in the era of globalization, which offers considerable opportunity for other countries in the world to benefit from an integrated global economy, it is this asymmetry of both economic and political power that brings in distortions. So we need to insure that those are corrected if we are really pursuing the goals of global health and health equity. So for globalization and health what needs to be done is to make more resources available for health systems by expanding and improving the overseas development assistance, improving debt relief. That’s very critical because countries which are actually in the poverty trap because of huge, unaffordable debt need to be provided support so that they can escape the poverty trap and invest much more in their own health systems. We need to reform the international trade regime, bringing in health front and center as a consideration. And ensure that the WTO regulations do not undermine what the WHO is trying to do or what countries are trying to do. We need to consider health as a human right because unless we do that, we’ll not be able to set right some other distortions that have occurred because of globalization. We need to protect national governments policy space for addressing the social determinants of health in light of the unpredictable nature of financial capital. We can’t leave everything to globalization which brings in investment because we know how fickle financial capital is. At the earliest sign of risk, capital flees, leaving the countries high and dry. And that can have a detrimental effect on their own investments in the health sector as well as in the social determinants of health. So we ought to be able to insulate some of the fundamental things like water, sanitation, nutrition, environment and basic health services against some of the imbalances that occur because of the imperfections in the financial markets. But having looked at some of the flip side of globalization, we must also recognize that globalization has several advantages to offer. Firstly, there is globalization of knowledge. Globalization of knowledge in terms of science, in terms of technologies, all of these can be highly beneficial to humanity if they’re shared. And we recognize whether it is the causation of disease or interventions to prevent disease or reduce the impact of disease, this knowledge has been transformational over the 20th Century, can be even more so in the 21st Century. So we need to build bridges by which knowledge can rapidly diffuse across the world and act in favor of good health.

At the same time, in terms of reverse innovation, there is a lot happening in the low and middle income countries where because of some of the challenges faced by the health systems they’re coming up with absolutely brilliant innovations which are problem-solving and low cost. And some of these innovations can now become portable even to the high income countries and they can benefit from some of this new knowledge that’s being created. In terms of global financing of health, we now recognize that there can be increased funds flowing into the health sector to a variety of poor resources. Countries need not be all the time essentially living on uncertain charity. Pre-committed funds as the part of global programs for health are going to be very important for supporting some of the health system innovations in low and middle income countries and helping them to overcome their own health inequities. In terms of globalization of health norms we now recognize that communications have now transported role models across the world through the media which is now globally shared. Whereas people were looking at unhealthy foods as one of the norms, now they’re looking at healthier foods, physically active living habits as the desirable social norms. Nothing illustrates this more than tobacco-free public spaces. Now in many parts of the world to smoke in public is not only legally taboo, but socially frowned upon. And these are changes in health norms that have actually come from some of the developed countries and are now rapidly moving for adoption in the low and middle income countries.

So globalization of health norms can be very effective too. And again, this can be  didirectional because some of the traditional cultural norms and traditional health norms of the low and middle income countries can also be adopted by the high income countries. Globally shared goals are important. We’ve seen the tremendous impact of the millennium development goals and that has been an important area of global cooperation, where a shared vision enabled different countries to work together to reduce maternal mortality, child mortality, under-nutrition and poverty. But for all of this to happen, we need globalization  of solidarity. You cannot have narrow, self-serving sectoral interests driving the forces of globalization.

You need a common commitment to global good as the unifying force of globalization where we are looking at economic inequities being reduced, we are looking at health inequities being reduced and we recognize human welfare as something that we’re all concerned about as a common human family. So if we can actually make that as the unifying platform of globalization, then we will be able to eliminate or substantially minimize the distortions of globalization on global health and really build upon that solidarity for advancing global health to levels that we have never seen before and reducing health inequities to the lowest possible. Go back to start of transcript.

Trends in Public Health I

Demographic and Epidemiological Transitions

As Bob Dylan sang, “The times they are a-changing.” As the cliché goes, change is the only thing that is unchangeable in this world. It is true that even in terms of public health and global health, we see change almost constantly. But there are certain driving forces which are responsible for the direction as well as the dimensions of the change. And it’s important that we understand them so that we can not only predict what is likely to happen, but also position our public health interventions so that we anticipate and avert some of the major public health problems as well as advance health equity in the desired direction.

The transitions that shape public health have been described by Rayner and Lang as demographic, epidemiologic, urban, and nutritional. These are traditionally seen by most public health experts as the important drivers of health transition. However Rayner and Lang also emphasize that there are others that we do not conventionally take into account but nevertheless are very important for understanding changes in public health. The economic transition, energy transition, the biological and ecological transition, cultural transition and democratic transition. Of these, the demographic transition is the most widely studied and most often discussed. This is where there is a transition within a country from high birth and death rates to low birth and death rates, along with the development from a pre-industrial to an industrialized economy. Warren Thompson developed this concept in 1929. And then he basically based it on the historical demographic observations in developed countries and later on this has been adapted to the study of developing countries as they are in developmental transition with accompanying epidemiologic and health transition.

In terms of demographic transition we are looking at five stages where in the earliest stage, which is high stationary, we find a fairly high death rate as well as a high birth rate on the population. And when we look at the population itself, because the deaths and births are canceling themselves out, the population growth is actually high stationary. Then we see a stage where the death rates start falling first and the birth rates continue to be high and therefore the population starts expanding. This is early expanding.

In the later stage we see the birth rate also beginning to fall but the death rate continues to fall fairly sharply and therefore we see a late expanding stage of the population. Then by the time the death rates and the birth rates both fall to low levels, where they reach approximately each other, the population growth becomes stationary and the population level remains stable. But then the birth rate continues to decline as in some advanced countries like Germany and Italy and there, because the death rates have now fallen to a lower level, but the birth rates are fallen even to a further lower level, the population starts declining. And that is where we find the fifth stage in some countries.

So there are several countries which are going through these phases and demographic transition therefore is an important concept in understanding how the age profile of the population, the size of the population, as well as the disease patterns of the population are determined. When we look at China for example, we see a huge shift in the demographic profile from a pyramidal shape in 1990 to a virtually, a cylindrical shape in 2050, where we see that the bulge is mostly in the middle and the top of the age profile, rather than at the bottom of the age profile where the young predominate. And we see also this happening in terms of life expectancy. As we understood previously from the millennium Preston curve, as per capital income rises, we find life expectancy rising up to a certain level and then gradually plateauing it off. And we found this in the case of China, where up to 1970, life expectancy rose very sharply as the economic development went in and also the social determinants like water, sanitation, nutrition were addressed in a very equitable manner across that society.

But then the population growth started stabilizing a bit and life expectancy also started plateauing off a bit. On the other hand, in India we are seeing a steady rise in life expectancy as we move from 1960 to 2010. And as a result of this, what we see is thatthe total fertility rate in China has fallen over a period of time. This of course in China has been accelerated by the one child policy. On the other hand, in India, we do see a falling fertility rate, but far less sharply than in China. As a result we see also a relatively delayed demographic transition in India in comparison with China. In China, the working age population actually peaked close to 2010 and is now on a decline in terms of the ratio of the working to the non-working age population. So China has already had its demographic window of opportunity when there is a large expansion of the working age population, which can give a thrust to economic development through increased productivity. India is still to have that demographic window of opportunity in terms of a rising working age population. This is beginning to happen now and we can anticipate an accelerated economic growth from this demographic dividend.

However, in order to harness this demographic dividend, India will have to invest both in education and skills for the young people, but also in protecting the health of the population. That is where public health becomes a very important element for economic development. Otherwise the demographic dividend can turn into a demographic disaster with a large number of working age people suffering from early death or prolonged disability.

The concept of epidemiological transition based on demographic change was originally propounded by Omran who described three stages. In the first stage where societies still experience a lot of pestilence and famine, the average life expectancy is about 35 years. And infectious diseases and nutritional deficiencies dominated that society. And later on, as people moved from a life expectancy of about 35 years to 50 years, the pandemic started receding and we started seeing the slow advent of non-communicable diseases like hypertension. But even those were substantially related to hypertension with hemorrhagic bleeding stroke. And we found that later on, in the mid-20th Century we saw the age of degenerative disease becoming the dominant epidemiological profile of a demographic transition. And in this, life expectancy rose to about 60 or above, but we found that by now the clotting stroke and ischemic heart disease or coronary heart disease became the dominant killers, infections receded, particularly major infections which killed people all across the world, became, less of a public health challenge. And even nutritional deficiencies were substantially corrected in several parts of the world. But this was a profile seen mostly in high income countries. Low income countries continued to experience some of the earlier phases of transition. And then we also had other transitions that were added on later in which we had a stage of delayed degenerative disease which is proposed by Olshansky and Ault, who said that by the time United States and Europe crossed the 1980s, we started seeing life expectancy cross 70 years, people still died dominantly of non-communicable diseases like ischemic heart disease, stroke and cancers, but many of them died above the age of 70 years. What we saw in Russia was a reversal after the fall of the Soviet Union where a stage of social upheaval suddenly came in in a period of transition life expectancy among Russian males fell to 58 years the lowest in the century because of the variety of reasons cardiovascular death rates went up, alcoholism became a major problem killing a larger number of people, and that actually can have a reversal of the epidemiological transition. But we can also anticipate that there could be an era of environmental degradation if we do not protect the environment on the planet.

And we do not know exactly what’s going to happen in terms of resurgence a of a large number of infectious diseases added on to the already existing problem of non-communicable diseases and how that is going to play out. We should try and avert that by protecting the environment. So these are the kind of transitions that we really ought to be looking at in terms of various developing countries and seeing the stages in which they’re transiting. But one of the important lessons is we don’t necessarily have to go through each phase for exactly the same length of time that the high income countries experienced. By utilizing the knowledge that we already have, we should try and telescope the transition by abbreviating the stage 3, where there are large number of mid-life deaths and move quickly onto stage 4, where even if people die of non-communicable diseases, they’ll die mostly after the age of 70 years.

This particular health transition model has been very helpful in providing an model for predicting what’s going to happen and understanding some of the dynamics. However, it’s been somewhat limited because it is focusing mainly on proportional mortality. While giving us an evolutionary perspective rather than a limited cross-sectional view, it is underestimating the burden of non-communicable diseases in countries of Africa for example where we see in Tanzania already the age standardized mortality rates of stroke in the age group of 15 to 59 far exceed those in England and Wales. But you don’t capture that by only looking at proportional mortality, because HIVAIDS, malaria, and others are actually killing a large number, therefore the proportional mortality due to non-communicable diseases appears to be lower. So the model that was proposed by Omran which is mainly based on proportional mortality, looking at the ratio of deaths from a particular cost to total mortality serves a useful purpose, but has some limitations. The other limitation is, health transition is not simply a linear model, because all of these are likely to be determined by complex interactions among various determinants. And these complex systems are nonlinear. So while we do depend upon the health transition model, the epidemiological transition model, we will have to look at other elements which determine global health. Some of these transitions can occur very rapidly. For example in Mexico we have seen between 1950 and even by year 2000, a massive increase in the deaths attributable to non-communicable diseases and a substantial decrease in the deaths attributable to infectious diseases.

So transitions are happening very rapidly because unlike the leisurely pace of transition that took place in Europe and America in the 19th and 20th Century, we are seeing the forces of rapid urbanization and globalization propelling countries in the low and middle income group into a rapid health transition with a very speedy rise of non-communicable diseases. And sometimes the coexisting burdens of infectious diseases and non-communicable diseases overwhelming the health system simultaneously as in the case of India.

Now in terms of nutritional transition. The traditional diets are now being replaced by western diet patterns. And there is an accelerating rate of change in diet, particularly through transnational trade, aggressive marketing of unhealthy food products. Simultaneously, there is a shift in physical activity patterns with a large number of labor saving devices at home and for transport. We now find that people are far less physically active. In fact this is the paradox of modernity that previously people used to be paid for doing physical work, now people have to pay for doing physical work. They have to actually become members of a gym. So we have seen a fair amount of changes in the nutrition profile across the world. But this pace is not uniform across the world.

For example in Asia, the number of undernourished people are declining as demographic and economic transitions take place. But in sub-Saharan Africa, there still continues to be a huge unresolved public health challenge. In terms of obesity however, we are seeing a rapid rise almost in every region of the world. And we are seeing that overweight and obesity are going to be one of the major public health challenges of the 21st Century, not only because they’re a problem by themselves, but they set the stage for a huge rise in non-communicable diseases like cardiovascular diseases and diabetes and cancers.

There are other transitions also that we must understand. The biological and ecological transitions. When we start deforesting and herding animals close together for increasing our meat consumption, we are also creating a conveyor-belt for vectors and viruses to migrate from wildlife and forestry into veterinary population and human habitat. As we alter the environment and create climate change that is also going to affect our health in very many ways. So understanding ecological determinants of health is becoming even more important in the 21st Century than ever before. Even in terms of energy security, this becomes very important. Because the pursuit of cheap energy is also shaped by the desire to replace human and animal labor. But as we move towards increased energy utilization we also have to see what it is doing to the environment, ambient air pollution, indoor air pollution, and also to see whether that is also transforming our life in terms of reduced physical activity.

All of these matter. And even energy security across the world has economic implications which in turn determines how health systems are funded. So all of these are going to be very important, because there are countries which provide huge energy subsidies. Can some of that be withdrawn by reducing the amount of energy dependency we have and the savings be transferred to health for universal health coverage? These are the kind of questions we ought to be discussing in global health in the 21st Century.

Similarly, democratic transitions are also very important. Because how much of  decisions are made in a country by the people at various levels? Are communities empowered? Are the provinces and regions empowered? Or is everything so centralized and dictated by a central authority with very little participation of people is going to be important. In the 21st Century democracy is moving from a representational model to a participatory model. Social media are becoming very important. And therefore a lot of public health knowledge is going to be disseminated and a lot of public health action is going to be driven by this kind of participatory democracy. So these are all trends that are going to be determining global health in the 21st Century. So when we look at all the determinants, we look at demographic shifts such as aging, urbanization and industrialization which alter living habits, globalization, which actually through marketing can accelerate a lot of changes in the way we live and education and culture which shape our beliefs, not in one community but across the global community and poverty which limits access to health both in terms of being a barrier for health information as well as health services.

And we are looking at urbanizing environments where the built environment can either be a barrier to physical activity or it can be an enabler or it can create pollution or provide clean air. And underlying all of these, there are also vectors like tobacco, unhealthy food and alcohol which are rapidly driving the health transition across the world and towards obesity and non-communicable diseases. Understanding these determinants is absolutely pivotal to global health in terms of its actions in the 21st Century.

So we understand health transition, but we need to respond to it. There are populations because of demographic and social determinants which are being propelled from low risk to high risk. Like rural populations, populations in low and middle income countries which are moving to westernized patterns of living in terms of food consumption, or tobacco consumption.

There are also.people in each country who are actually at low risk. Children, children are not born with a high risk. But the way we actually nurture them in our society can create high risk for them. So we need to provide these low risk populations from moving to high risk through public health interventions which create a healthy society.

At the same time in every population, there are individuals who’ve already acquired high risk. We need to return them to low risk by clinical and behavioral interventions. So while high risk may be determined by a combination of biology, beliefs and behaviours, there are a number of interventions that we have which can actually reduce the risk. And our public health interventions in the 21st Century must combine all of this knowledge into effective interventions both at the population level and at the individual level through competent health systems which take the lessons of health transition into account while framing global health policies and shaping global health practice.

Infectious Diseases V

Childhood Diseases with a Focus on Diarrhea and Pneumonia

In this next chapter I’d like to look at some childhood diseases that are particularly common in low-income countries and focus particularly on diarrhea and pneumonia, as they provide some very interesting examples of both how to prevent as well as how to treat these conditions so that the mortality and morbidity continues to go downward. The pie chart indicates the prevalence of each of these conditions in today’s world. You can see both diarrhea and respiratory diseases make up a large segment. And in some parts of the world, malaria is a major contributor as well. This is mostly in sub-Saharan Africa. Now here’s a child with a severe dehydration caused by diarrhea. Dehydration is the loss of fluid from the body. It’d be like if you took a grape and made it into a raisin or a plum into a prune. And you can see the child’s eyes are sunk back.His breathing would be deep and rapid. His pulse would be rapid. He’d have very little urine output. All signs of the loss of fluid and electrolytes. And here is a, a much younger child. And here you see the top of the head is depressed. This is called a fontanel, soft spot to many of us, before it closes. And here the dehydration has led to this sort of depression of the fontanel. Sometimes mothers would actually put mud or other substances there to try to draw this out, not recognizing that it might be due to dehydration. For a long time, in the summer months particularly through out the world, America, Europe and in lower-income countries you would see this scene in hospitals. Bed after bed after crib with children with diarrhea. And you could see here the dehydration, the loss of food and electrolytes are being replaced by I.V- intravenous solution. That’s fine if you have that solution, but in some parts of the world, this was very hard to come by. The IV solution wasn’t available or if it was available, it was expensive. You needed the tubing and the needle to insert and someone to do it. So there was a search for many years to find something that could be given orally, as this would eliminate the need or greatly obviate the need for interven…intravenous fluids. Now I show you this picture of a cholera cot, which is a wonderful piece of appropriate technology designed to be used with someone who significant diarrhea. And it’s simply a, a jute cot with a plastic sleeve that fits over it with a hole right where the buttocks would be. And that plastic sleeve goes into a bucket. So the liquid stool goes through the hole, through the sleeve, into the bucket. And one can then measure how much fluid has been lost. And the simple way of treating diarrhea is the patient gets exactly in what they have lost. And a way of measuring the level of hydration of course is whether they’re putting out urine and the concentration of that urine. Here’s a little girl who’s severely dehydrated. You can see again, that face that she looks. Again her pulse would be rapid. Urine output very low, rapid deep breathing. Now the mother is giving her an oral solution with the proper amount of electrolytes and glucose, that’s the magic ingredient. And to hydrate her. She’s alert enough to take it by mouth. And just a few hours later, here’s that little girl again and you can see a tremendous difference in the way she looks. The basic principle is simply this, a plant without water and you restore that plant by giving water and in the, in the case of diarrhea, electrolytes. Now what is the oral rehydration solution? It’s simply sodium chloride- table salt; sodium bicarbonate or Trisodium citrate; potassium chloride, and potassium is found in bananas and various fruits, citrus fruits; and glucose. Glucose is the key. And you can see on the other side that the sodium chloride, potassium bicarbonate and glucose are the millimoles per liter. In today’s solution, the sodium would be down to about 75 millimoles and the bicarbonate would be somewhat lower. And…. But that would be the major changes. Lower sodium chloride, slightly lower glucose and so on. But the basic principle and the basic composition remains the same. The message of course is to hydrate, hydrate, hydrate, because without the hydration other things can occur that will be a detriment to the individual, including circulatory collapse. To remind you, the…another side effect of continuous episodes of diarrhea is under-nutrition. Oftentimes because the mother will not necessarily feed the child, sometimes doctors recommend against it, unfortunately, and also the child may lose their appetite. Here’s a child who’s got severe marasmus. You can see the thin extremities. The child seems to be sensitive to light. The hair is thinning. And this is obviously a very poor family. Also the giving of a bottle of milk through the bottle can also be problematic if the water is not clean and if it sits out in the sun and bacteria are allowed to grow. Here’s a child who’s had multiple episodes of diarrhea and formula feeding. And you can see he has severe marasmus. So breastfeeding should always continue. And mothers should continue to feed their children if they have any appetite whatsoever, with whatever food is presently given to the child. So if the child wants to eat and the child is hungry, the child should be encouraged to eat. The teaching of this is best done of course in the community itself with three or four women who are taught now to prepare, shown how to prepare it and actually prepare it, which is what is being conducted here. You also notice lots of children around and these kids are picking up the message, just like their mothers are. And since children learn quicker than adults do, they’re going to carry the message into the community as well. One of the early tests of the oral rehydration therapy was in a refugee camp in 1971, refugee camps, where people from, refugees from what was then East Pakistan fled into West Bengal. And here they took up residence essentially in the pipes that were going to be placed in the ground to take away sewage. And when one lives in these kind of circumstances, you can guarantee that diarrhea is going to be a major problem unless there is strict attention paid to water and sanitation. And if that occurs then the treatment of this both in adults and children is essential. Another example of that is this is from a flood that occurred in Bangladesh. These occur periodically. This was 2007. And you can see individuals in an urban setting are trying to get clean water, even through a, a tube well pump which is almost totally submerged. This led to a major outbreak of diarrhea where up to 44,000 patients were seen at a treatment center within a nine-week period. What is interesting about this picture is that the family members are very much engaged in the treating of their loved ones. This is very critical because in these huge outbreaks it’s very difficult if not impossible for the medical staff to treat everyone. So one can engage family members who can be taught rather quickly how to deliver oral therapy and how to feed the patients and so on. And in that 44,000 cases, there was no one death from diarrhea and dehydration. This is a, an example of a packet that was found. This is for 500 cc’s which is now the standard in many countries. One liter is the standard in many other countries. So this, these salts can be given through a distribution scheme of these packets, as long as the packets are designed for whatever standard container people have. The next area I’d like to address is pneumonia, especially bacterial pneumonia, because this is what kills children. A number of years ago WHO developed what’s called an algorithm, a way of looking at pneumonia and deciding how to treat it given the severity. So in this particular algorithm you’ll notice on top that very severe pneumonia is defined as when the patient is confuse…cyanosis has set in. That is the child looks a bit blue, their lips look blue. They’re unable to drink. They’re unconsciousness, state of consciousness may be reduced. They’re clearly very, very sick. Severe pneumonia is when the lower chest in-drawing occurs and these children also need antibiotics. Where the respiratory rate is accelerated in the next box, going down, either above 50 is the child is two to eleven months or above 40 is one to four months, pneumonia is also the diagnosis. But if none of these occur, the child need not be treated for pneumonia. Now fortunately there are a number of vaccines that can prevent acute respiratory infection, many of which lead to pneumonia. Pertussis vaccine, diphtheria. Measles is a very important component, a very important vaccine. As is HiB conjugate vaccine, and the pneumococcal conjugate vaccine, two vaccines that have appeared on the scene in the last number of years that can make a significant impact on the incidence of disease. I put in meningitis because although it doesn’t cause pneumonia, it is a respiratory infection. Lastly I have this last picture in to remind us that malaria in some parts of the world can be a devastating disease to young children. This is simply an Aedes aegypti female, cause it’s only the female that takes a blood meal to help to grow her eggs. And you can tell the kind of mosquito by the white banding on the legs. So malaria can be a devastating disease to children, especially in low-income areas of sub-Saharan Africa. So what I’ve tried to do in the, in this chapter to point out that infectious diseases are certainly still with us and a major cause of morbidity and mortality, especially from diarrhea and pneumonia. But both of these conditions can be treated with oral solutions or I.V if necessary for diarrhea and antibiotics or other supportive measures for pneumonia. And both of them can be prevented through clean water and sanitation or vaccines, depending on the type of illness we’re talking about. The same by the way is true for malaria where the use of bed nets and early diagnosis can dramatically reduce the incidence of malaria, particularly in high incident countries.

Infectious Diseases IV

New and Re-emerging Infectious Diseases

Today’s chapter, is going to be on new and reemerging infectious diseases. Let’s again try to define these terms. Infectious diseases with an incidence in humans that have increased in the past thirty years or threaten to increase in the near future we tend to term new and reemerging infections. HIVAFRICANow new infectious diseases that have come about in that, roughly in that time period would include HIV/AIDS, SARS, Lyme disease, Nipah virus, influenza H5N1 or H1N1. Infectious diseases are however often times emerge in new places and they are sometimes called reemerging diseases. This would be diseases such as West Nile virus and monkey pox. Then there are diseases that reemerge in drug resistant forms. A particularly worrisome group which includes malaria, multiple drug resistant tuberculosis, and some bacterial pneumonias and sexually transmitted diseases. Now there are a number of factors that have contributed to the arising of new and reemerging infectious diseases. These might include increased population density, inadequate infrastructures for water and sanitation, movements of people through travel and social disruption, the centralized production of food and it’s distribution, environmental changes, misuse and overuse of antibiotics and other drugs, changes in human behavior and sometimes dysfunctional governments. Let’s look at some of these in greater detail. In terms of the increase in population it was estimated that the population in 2000 was about 6.1 billion people and by 2050 this will come close…become close to doubling to 9.4 or 11.2 billion people. We’re also seeing a tremendous increase in urbanization going from 47% in 2000 to 60% to 65% increasing urbanization of the global population. Now as the population of the world increases of course there are going to be greater contacts between humans and wildlife in habitats that normally we don’t venture into and because of this interaction with both humans and our animals, we may see the rise of new viruses. The coverage of water supply, particularly in least developed countries, is also very problematic.

HIVContagioParticularly in both urban and rural areas in least developed countries the percentage that have access to potable water is anywhere from 50% to 60% Most of the drawing of water in rural areas and in urban areas is work of women. That is, they are the ones who are doing all the work of getting it from wells, from rivers and so on and taking that water back to their home. This is assuming that there is not an indoor water tap. And in this, the bringing of water into urban areas through trucks and so on where people are then forced to come to this area, collect the water, take it back to their home, is another way of distributing but it’s also very problematic as that source could be contaminated as well as the buckets and vessels which carry the water back to the home could also be contaminated. It also limits the amount of water that’s oftentimes available. The disposal of human waste is an increasing problem. The privies are directly linked to a body of water which connects to other parts of the city and that…that fecal disposal is of course quite unsatisfactory. We are increasingly discovering that open defecation may well be linked to under nutrition in children where this is a broad problem. The increase in travel both internationally and locally also provides opportunities for diseases to move about. We can move Ebola from one country into another in a matter of a few hours by air and we have seen this…this happen. No place in the world is unconnected to any other. We are really truly a global village. The production of food on an industrial basis has allowed for increasing availability of food, both grains and meat, but has also intensified the use of antibiotics and the raising of animals and where a central food supply is contaminated that contaminated food then travels far and wide. It’s not the same as getting milk from your local farmer or buying vegetables at the local farmers market. When we buy vegetables and fruits in many of our large cities of the world we have no idea where this comes from. Here’s the production of chickens in an industrialized production where thousands upon thousands of chickens are grown together in oftentimes extremely inhumane circumstances where they have no movement and so on and one can see that where a disease would enter this population it would destroy many, many chickens in a short period of time. This is of course quite different than what takes place oftentimes in local areas where there may be one purveyor of chickens from a few individuals in the community. Where ecology is involved is of course in climate changes, where temperatures have increased in certain areas which have allowed for the introduction of mosquitoes for example that had not been there in the past.

processosdecontagioThe tires are often traded internationally but when one trades in tires, there’s oftentimes water that is in the bottom of the tire and those…that water will you don’t need much to set up a breeding ground for mosquitoes. Those mosquitoes can then carry the viruses from where they came from to where they are going. And then the misuse of and overuse of antibiotics has led to the development of antibiotic resistance. We have only had antibiotics really for about 70 years. A blink in the eye in terms of evolution and yet we have managed to create a number of organisms that are extremely difficult to treat and far more expensive to treat. For example, multiple drug resistant tuberculosis is much more expensive to treat than is regular tuberculosis. Artemisinin which is the last, the latest drug we have to treat malaria, the last in the line, resistance is developing to that even though we treat these…malaria now with three drugs to try to avoid resistance to artemisinin. Tetracycline for cholera, multiple drug resistant gonorrhea which is a problem and in our hospitals, multiple drug resistant staphylococci which can infect wounds and cause devastating diseases. I would now like to focus on one particular new disease that has taken the world by storm over the last 30 plus years and that’s HIV which leads to AIDS. One might ask, where did HIV come from? Now is it a….. It’s defined as a new disease. It most likely came from somewhere in sub-Saharan Africa. There is a, an infection in some of the great apes, simian immune deficiency virus. It might well have been that someone in the forest or in a market was skinning a, a chimpanzee or a related species and cut themselves with a knife that carried the blood of this animal and therefore infected themselves. And unfortunately this virus adapted itself to humans. It then spread from that person through sex most likely, but it could have been through other means to another person and so on, until there was a critical mass of individuals who were infected and then the epidemic gradually increased. And then of course spread globally over time. We don’t know the initial events but it would seem to be that this was a zoonosis where the organism adapted itself very effectively to human beings. The distribution of HIV even though it came upon the world within probably five or six years it had been introduced everywhere, you can see that the distribution is of quite variable with most cases occurring in sub-Saharan Africa and if one looks at the population to case ratio, it’s even higher in that part of the world. Which raises an interesting question: why though HIV appeared in the world in many parts of the world around the same time, why has the spread been heterogeneous, not only globally, but even with the epidemic in sub-Saharan Africa? And I’d like to explore those ideas for just a moment to look at why this might happen and what does it tell us about prevention of these conditions? Now the spread of HIV in sub-Saharan Africa between 1984 and 1999 was quite interesting because it in 1984 it was fairly evenly distributed. By 1999 this had become a disease much more in the very southern parts of Africa and eastern Africa and West Africa in some parts have remained somewhat unchanged, Senegal, Mauritania, Niger, and so on. The dark red represents the highest prevalence of HIV. Now there are certain risk factors, I’ll call these proximal determinants that are associated with HIV/AIDS, the getting of…the obtaining of this infection. Clearly transfusion with contaminated bloods or contaminated needles and syringes which is like a mini-transfusion. Unprotected sex with a single or particularly multiple partners can increase your risk substantially. Mother to child transmission through delivery and breast feeding and interestingly the non-circumcision of men in certain parts of the world. Let me look at that last issue. Male circumcision interestingly enough is probably one of the oldest forms of surgery going back to at least 2200, 2300 years before the common era, as seen in this hieroglyphic from ancient Egypt. The circumcision rates in different countries in sub-Saharan Africa you can see are quite different with the highest level of…of AIDS in those countries which have the lowest level of male circumcision. Now why…why should male circumcision protect one? Well, it turns out that the inner lining of the foreskin contains cells which have a particular avidity for the HIV virus as well as the human papillomavirus which is associated with cervical cancer. Also when one removes the foreskin, the skin underneath hardens a bit and is more impenetrable probably to the virus itself. So there are biological reasons for why this particular simple operation reduces risks. We should remember that the initiation or the institution of…of male circumcision which by the way has nothing to do with female circumcision, was related to tribal or religious identity. It was not initiated initially to as any type of health measure. Certainly we didn’t know about these issues hundreds of years ago when these practices were introduced. Now distal determinants, that is those factors that affect the proximal determinants would be socioeconomic conditions, domestic violence, the status of women, the degree and type of migrant labor, sexual practices and values as defined by culture, and we have to be very careful that we don’t associate practices and values with any kind of ethical or moral character of the individuals involved. They have their antecedents in other…in other issues. And then concurrent partnerships. This is having many partners over a week as they have…having those many partners serially over the course of a year. Now what strategies then can we use based on these risk factors to reduce the possible risk for HIV? Well, if we delay the age of sexual debut that is when adolescents begin to have sex, we clearly reduce the time when they’re going to be exposed as we would be reducing the number and the exposure to high risk partners. If we reduce the degree of concurrency that would also reduce risk. If we limit alcohol and drug use prior to sex we make sure that the inhibitions to using condoms for example are not taken away. We can increase the level of male circumcision where the rates of HIV are very high and this would be again very much in southern Africa but not in…and East Africa but not in many other parts of the world. We could presumptively treat some sexually transmitted diseases to reduce transmission and certainly test the blood supply and needle exchange and syringes for I.V. drug users. One could also treat individuals who are HIV positive and thereby limit the transmission of this to their partners. This is problematic however and is not as easy to implement. If one looks at this schema of the HIV infection, one will notice that the first few weeks, months is when we have the highest level of viral particles in our blood, viremia. It is during that period of time when one is most likely to transmit the infection. So if one has a number of partners during that time, has sex shortly after one is infected, you are more likely to transmit the infection than when you enter the asymptomatic period which can go on for a number of years. Now we can measure the viral load in the blood and we can also look at other associated factors such as the CD4 count but it’s those first few weeks, months maybe, that we are most likely to transmit the infection because we don’t know we’re infected. There is no way of telling other than to do frequent HIV tests which is somewhat impractical. We can also reduce the risk of infection post exposure. That is, if someone is exposed, we can give nevirapine for the transmission, to reduce the transmission of mother to child. We can treat with ARVs as I noted post exposure or even give it prophylactically especially to high risk groups, people who have multiple partners for example. The use of vaginal microbicides has also been recommended but these are the factors that you can do post exposure. Clearly it’s far more practical if we can prevent the infection to begin with. Well, what I’ve tried to do in the…in this brief chapter is to look at new and reemerging infectious diseases. Why they occur, what are the risk factors in the modern day world. I then focused on HIV/AIDS as an example of a new and reemerging disease.

Infectious Diseases III

Zoonoses

In this next chapter I want to take up the subject of zoonoses. Zoonoses is an infection or an infectious disease that is transmittable under normal and natural conditions from vertebrate animals to humans. It may be enzootic or endemic or epizootic or epidemic. There’s also another term, zooanthroponosis which is a disease transmitted from humans to animals. Now there are different types of transmissions with zoonoses. There is direct transmission, that is intimate contact with an infected animal, a person such as with a bite, a scratch, a spray by infectious urine, contact with fecal material, inhalation of a discharge, respiratory droplets due to coughing or sneezing, airborne spread, this is direct HIVAFRICAtransmission. Then there is indirect transmission where there is an arthropod vector such as a flea, a mite, a mosquito, a tick and fomites such as cockroaches that are contaminated with the particular product going from an animal to a human. Another term we should be familiar with is species jumping. This is the transmission from animals to humans followed by human to human spread and this is the group that we are most interested in. That is, we shall see with HIV/AIDS, with SARS, with flu, that the particular agent went from an animal to a human and then began to spread from human to human. So the first one I’d like to take up is SARS or severe acute respiratory syndrome. If you’ll recall, this completely paralyzed the world a number of years ago because the mortality was quite high from this. Well, it turns out that SARS as we found out much later on was due to a particular virus called the coronavirus which was found in a particular animal called the civet cat which was slaughtered in some of the markets of…of China. But these civet cats had in fact been infected by bats, so it was bats that had the coronavirus, it infected the civet cat, the civet cat when they were killed, the spray of blood, sometimes people inhaled, they got it and they were then able to transmit it to other humans and it led to a type of pneumonia and if you’ll recall there were often pictures such as this from China, which is where the disease particularly had a major impact although it then spread to Honk Kong and Singapore and Canada and to Vietnam and so on. It never became the global pandemic that some of these conditions can become.

ebolaThis is the latest of pandemics, this is the Ebola virus. Many of you have heard about this. It’s been particularly devastating in West Africa in this recent outbreak but it has occurred in central Africa as well, and let’s take a look at this particular virus which has been considered very contagious thought not very infectious. That is it can spread from one person to another through contaminated feces and blood and so on but doesn’t spread from person to person in a crowded room for example. It doesn’t spread through the aerosol route but rather through the blood and feces and so on of individuals who are infected and sick. They have to be sick with this disease. Here are some of these workers carrying…wearing these gowns to prevent them from having contact with this particular virus. This virus has probably, though we’re not sure, been spread by fruit bats, that is the bats again carry this particular virus. The bats may have contaminated food that was then eaten by an individual and that individual developed this disease, Ebola, and then spread it to other people through their bodily secretions. But it was the bat that originally harbored this virus, and then spread it, gave it to people and it was through the person to person spread that it has taken off. Let’s take a look at another one of these zoonoses. This is one called Nipah virus. Quite interestingly, again, this giant fruit bat and why they harbor these viruses we’re not sure and it’s very uncommon actually, would eat some of the fruit of these trees in Malaysia that were planted in areas where pigs were…pigs were grown. The pigs ate the fruit that fell to the ground and because this fruit was contaminated by the virus, the pig in eating the fruit developed an infection. When these pigs then were taken for slaughter and killed by, in the Abattoirs, the slaughterhouses, the men who were involved in this in the pig killing got the infection from the pig. So it went from a bat to the fruit to the pig to the people who were killing the pigs and up to 250 people about developed or died from this condition, a mortality of around 40% or 50% and this occurred in 1998 and 1999. And to get rid of this particular condition, first of all when the pigs became sick the first thing people did is they took them to market, so oftentimes these sick pigs, and they had developed a pneumonia, were taken to market and people would buy it unsuspecting that this might be this particular condition. And the way that Malaysia eventually got rid of this Nipah virus is they took pigs and they killed them and there is no longer a pig industry in Malaysia where at one time it was quite flourishing. This now takes us up to Bangladesh and in Bangladesh there was also an outbreak of Nipah virus and they couldn’t figure out how did this virus get into the human population. Because there were no pigs in that part of Bangladesh. It was a predominantly Muslim society and pork was not eaten, but they pieced together a story that showed that when these bats went to this date palm juice…now here’s a pot on a palm tree that is collecting date palm juice which is a sort of sweet juice that can also be made into something called gur which is a type of sugar. And when they would lick this because they’re fruit bats and it was very sweet and sometimes they would defecate into the pots. The men who sold this and this date palm juice was considered quite a delicacy would take it from house to house and sometimes this date palm juice was contaminated and individuals who took it would get Nipah infection and the mortality again was around 40% or 50%, sometimes 60%. This was a meningoencephalitis, that is it affected primarily the brain. Here are some bats flying just at dusk and they’re quite large, they have a large wingspan but they only drink fruit and sweet things. So the way to get rid of this was to put a skirt of bamboo over where the…the sap came from the tree into the pot and by doing this you can actually reduce the contamination of the date palm juice because the bat can not have access to that…to that sap that’s coming from the tree. So again a bat to the fruit, contaminating that, humans ingest it and it can spread from one person to another on…only on very, very intimate contact. And this is only through respiratory droplets, so it’s not like someone can walk into a room and cough and others would get it. You have to be extremely close to the individual to get this particular infection. So how do we control the transmission or the introduction of zoonoses? Well, this diagram here shows the linkage between wild EID is emerging infectious diseases, domestic animals and humans. And you can see that they interact. Now I’m not going to go through this entire graph but let’s just take a look at a few of the linkages. The linkage, say between wildlife and domestic animals. Here if domestic animals are closely associated with certain wildlife as we saw with the Nipah virus in Malaysia, there’s a spillover effect and these domestic animals can pick up the infection. If we look then down to the bottom of domestic animals and look at the food processing technology industry, we see that this virus got into humans through the infection in pigs which was then picked up in the slaughterhouses and then in humans it spread from person to person. So we have to break…break a number of these links between wildlife and domestic animals, between domestic animals and humans and even between humans and wildlife and so a lot of the strategies that have been developed to control zoonoses have focused on this type of diagram that we see here. All or most of the new and reemerging diseases, not all, will in fact be related to zoonoses so zoonoses are clearly very, very important and extremely costly. Bovine spongiform encephalitis or mad cow disease costs the U.K.  over $9 billion in lost revenue. The Nipah virus which I just talked of cost Malaysia $540 million because of all the slaughter of pigs that had to take place. SARS which we started with cost China upwards of $50 billion because of the lost revenue from trade and tourism and so on and avian flu, H5N1 which we have not covered is going to cost billions and billions of dollars. In fact, another type of flu, H1N1 or what was called unfortunately swine flu, this is just a picture of the economic impact it had in Mexico where this beach would be filled with tourists at a particular time of year and of course it’s empty now because people are afraid and go elsewhere. What I’ve tried to do in this brief time is to talk about the importance of zoonoses. That is the diseases which linked animals to man and how they can spread, how they develop, SARS, Nipah virus are but two examples and there are many, many others. And then how they might be controlled and the economic impact that they can cause. We must be prepared to put much more attention into zoonoses and there is a global program called One Health which is trying to do just that.

Infectious Diseases II

Control, Elimination, Eradication, Extinction.

In this chapter I’d like to look at the control, elimination, eradication and extinction of infectious diseases. Again, let’s look at some definitions here. By control we mean the reduction of the prevalence, that is the number of cases at any one time, incidents, the number of new cases over a period of time, to locally acceptable levels which is usually interpreted to indicate no longer a public health priority. Intervention however is still required. Elimination is the reduction of disease to zero and or infection to zero. The intervention, however, may still be required. An eradication is the permanent reduction of global, we’re now talking about the whole world, incidence of disease to zero with the organism not present in nature. No intervention at this point is required. And now let’s take a look at some of these terms as they play themselves out. The criteria for eradication which is the area I’m going to focus on in a moment is that humans are the only reservoir and there are no non-human vectors. Now we’re talking about eradication in people.The absence of a carrier state. That means that people don’t carry the organism even though they’re not sick. The feasibility of the intervention, is it effective? Is it acceptable? Is it affordable? Do we have ways to monitor whether this infection is present in the community, surveillance? Are people concerned and fearful enough that they will buy into these programs and does government have a strong enough commitment to try to eradicate a condition? Now infectious diseases that have been eradicated, there is only one and that is smallpox. And this was done primarily through a vaccine. Other infections that have been pretty much eliminated from many countries are guinea worm, which is only now found in some parts of sub-Saharan Africa, neonatal tetanus or the tetanus of the newborn. Again, vaccines here. There are still some cases but not very many even though the tetanus bacilli exists in the ground around us. Polio, we’re very close to eradicating this through vaccine but there are still cases in some parts of Africa and South Asia. Diphtheria, these have come way down, as has leprosy. The…but again, smallpox is the only human disease that we have been able to eradicate. There is a disease in cattle called rinderpest that has been eradicated, but this is the only one for humans. This is what smallpox looked like. It was a terrible disease. This child has lesions all over the body, it sometimes would in addition to causing a lot of deaths, it also caused blindness, and many other complications. This was a typical picture of a smallpox case. I’m now going to talk about the vaccine that was developed to deal with this. It was noted by Edward Jenner, a practitioner in rural England, that cow…that women who milked cows, cowgirls I guess you’d call them, did not get smallpox and he noted that on their hand was a lesion that was gotten from the cows that they worked with which was cowpox. He reckoned that if it protected these  women and he took this from one woman who milked cows, Sarah Nelmes, that maybe this would protect people against smallpox. And in fact, he tried out the first vaccination was in 1796. Now prior to this, people had taken the serum, the lymph from the smallpox lesion of very mild cases and gave it to people hoping they would also develop mild disease. Sometimes it worked, sometimes it didn’t. Now despite the fact that this was shown to be extremely effective, there was a lot of resistance against this. This is a picture from a British publication, a humor publication called Punch and here is Jenner in the middle and people have cows growing out of their arms, their back sides, their face and so on. People figuring if they got the cowpox they might even turn into cows. Now, smallpox actually had eradication potential. What was that? Well, going back to those earlier criteria, there was universal fear, there was no animal reservoir, people were the only ones who had this disease. Nobody was a carrier, there was lifelong immunity after a single episode and a characteristic rash. There was no transmission from subclinical cases, as there were none. And we had a very, very effective heat stable ‘ (We didn’t need a refrigerator) vaccine and we had the development of a needle called the bifurcated needle which allowed us to easily transmit the vaccine to an individual. We also developed a very effective way of searching and containing this because smallpox moved relatively slowly through populations, once we found a case we could immunize around it so the case would be the orange circle there, we could then immunize around it, that would be the purple, and then we could also immunize the contacts of the contacts by taking these circles and moving out in this ring vaccination area we could reduce and eliminate smallpox from areas without having to immunize absolutely everybody in the population. We also minimize adverse events and we found that this vaccine was highly efficacious in preventing disease. The last case of…major case of variola minor occurred in Bangladesh in a young girl, Rahima Banu in 1976 and in 1977 the last case of variola minor appeared in Somalia in Ali Maow Maalin who just died recently. He devoted much of his life to also dealing with other disease elimination and eradication programs. The next disease I’d like to address is polio. Here are some children, we don’t see this very much anymore, because polio has almost been eradicated and has been eliminated from almost every country of the world. These children would develop paralysis, primarily in their legs, and in some places they would have to be beggars unless there was some way of looking after these children. In certain cases the disease affected the bulbar region of the brain and people would have to be on respirators, sometimes for lifetime because they could no longer breathe on their own. But with the polio eradication campaign globally we are down to now hundreds of cases rather than hundreds of thousands of cases. Getting those last few cases of course are extremely difficult so we can not say that this disease has been eradicated but it has been eliminated from probably 98% of the world. This is a very inexpensive, very efficacious vaccine. This is the oral vaccine. There’s also IPV which is an injectable vaccine but it is more expensive. If you look at the polio incidence by month, just in a four year period between 1994-98 in India, you can see that it was very high in 1994, peaked to over 110,000 cases, then came down in 1995 and at the end of ’95 and the beginning of ’96 they had national immunization days where they gave the vaccine to every child under a certain year. I think under five years of age. This was repeated again at the end of ’96 and ’97 and again at the end of ’97 and ’98 so that the number of cases came down dramatically. In fact, India has now been declared polio free and it has been eliminated officially from this country, which is a huge undertaking given the population of 1.2 billion There are other infectious diseases that have decreased dramatically in incidence, that is the number of new cases, with a significant reduction in mortality and morbidity. Measles is one of these which is a major killer, was a major killer of children. Rheumatic fever which affected the heart, hepatitis B which sometimes leads to liver cancer, and also peptic ulcer and helicobacter where treatment of these conditions with blockers of stomach acid and antibiotics has greatly reduced the incidence of these conditions. Here’s a child with neonatal tetanus, a condition which we rarely see today and that’s because now mothers are immunized against tetanus and they pass this immunity on to their child until that child can be immunized themselves. And lastly here’s a picture of measles which has been up until recently a major killer of children in low and middle income countries. So what I’ve tried to do in this last chapter is to review for you control, the terms control, elimination and eradication. I haven’t dealt with extinction because extinction means that there is no presence of this organism anywhere in the world and most of these organisms exist still in some laboratories. I’ve shown you eradication as it occurred with smallpox and the efforts that are going forward with polio. And lastly we’ve looked at a couple of diseases that have come down dramatically in their incidence and prevalence in the world.