Arquivo de etiquetas: Saúde Global

Infectious Diseases I

The Changing Patterns of Infectious Diseases in Time and Place

In this lecture on infectious diseases, I’ll be covering a number of topics in the various chapters. This first one will be on the changing patterns of infectious diseases in time and place, that is looking at infectious diseases in a somewhat historical context.

I’ll also be covering the control or eradication and elimination of infectious diseases, 31infecaonos individuoszoonoses, emerging and reemerging infections, and lastly diarrhea and respiratory diseases in children as they are a major killer in this group of individuals.

Before we get into this historical look I want to give you some common definitions. What is an infectious disease? It’s a disease caused by the entrance into and growth and multiplication in the body of…of an individual of bacteria, Rickettsia, viruses, parasites, protozoans, fungi and prions. All of these are considered infectious agents. Another term which we should become familiar with is incidence. This is the number of new cases that occur per unit time. That time could be a day, a week, a month, a year. But time is very much a factor here. Prevalence on the other hand is the number of cases that occur at any one moment in time, today for example.

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I’m going to give you an extremely abbreviated history of epidemics, that is a large number of cases occurring, although that number could be just one. And pandemics which are epidemics that cover the global world. Diseases associated with many of these epidemics include plague, smallpox, influenza, cholera, yello fever and measles. Now some of these are more historical because they don’t occur today, especially smallpox and plague and yellow fever, but they are important. An example of a devastating pandemic was the black death from plague that peaked in the 1346 to 1350 time period and it was estimated to have killed 30% to 70% of European population. Smallpox and tuberculosis, killed up to 90% of the indigenous population of the New World when they were introduced by the Europeans. Cholera pandemics began in 1816 and now take up, we’re in the seventh pandemic worldwide.

doencascriancas1The largest single pandemic was that of the 1918 influenza pandemic which led to between 75 million plus deaths worldwide. These infectious diseases can be noted in history where they left their mark. For example in this mummy Ramesses V dated about 1157 BC we can see evidence of smallpox lesions. The pandemic epidemic that I want to focus on in the next pictures are those of plague. Plague was so common and was such a killer in Europe that there were dances of death that were developed to deal with the large numbers who were dying in various communities. This is a picture of a bubonic plague from one of the Bibles and we would probably not find these lesions to be consistent with plague today but this is the way people saw them. Doctors would oftentimes have very little to offer and would go around in these long black coats wearing these masks shaped like that of a bird’s head which limited the air that they would breathe in since they believed,in some cases correctly, that the miasma- the surrounding air, is what caused these diseases to occur in populations. People were so afraid and felt that the devil had entered their body and that’s why they would get these diseases that people would go around the countryside flagellating themselves to try to get rid of these evil forces and to show that they were deeply religious. Unfortunately, one of the things that often occurs in any epidemic or pandemic is we tend to blame the most impoverished, the poorest people who are there as we see them as the ones that have caused this to happen. And of course this is oftentimes very untrue. Jews who were burned alive because they were thought to be the cause of the Black Plague.

Oftentimes people were labeled as witches, as other non-desirables in populations and so that if we got rid of them, the plague would go away. Of course we even do this today and we’ve done it today with HIV/AIDS and other similar types of pandemics.

This is the organism that causes plague. This is called Yersinia pestis, it’s shaped a bit like a safety pin and these are transmitted through these fleas. Obviously not this large

but these fleas live on the body of rats, Rattus rattus and so oftentimes when there would be a rat die off these fleas would escape and then bite humans causing the plague. Sometimes there were large numbers of rats because the cats had been killed in some communities because they were seen as the animals of the devil. In addition to the tremendous number of deaths that occur, we also have to look at the historical changes brought about by any large pandemic. For example in the Black Death there were huge demographic changes. With 30% to 70% mortality in many areas of Europe, which took at least 150 to 250 years to recover. There were labor shortages, serfdom disappeared, wages became higher, labor saving technologies developed because there was a shortage of labor, land became plentiful, see these were all actually positive outcomes, despite the high numbers of death. However religious intolerance and the tradition of blaming others also increased and this was a time, oftentimes of religious intolerance that went through the countryside. Let’s go back to the terminology that we started talking about. If one is exposed to an agent, an infectious agent, a number of possibilities could occur. That is nothing, there could be clinical infection, the second line, or sub clinical infection or the person could carry the organism but not be sick. For clinical infection, one could see that death might occur, immunity that is what that an individual recovering from the disease might be immune or they might carry it or they might be non-immune and for the sub clinical infection of course there wouldn’t be death but immunity, carriage, and not-immunity might also occur. Also there are a number of factors that influence disease transmission and we should be aware of these. One is the agent itself which is the bacteria, viruses and so on. How infectious is it? What kind of illness does it cause?

What leads to its survival or death? Then there’s the host which is humans or animals, our age, our sex, our behavior, our nutritional status and so on, our health status, and then there’s the environment in which we live. What is the weather like? The housing? How crowded are people? What is the geography and what occupations do we have at the time that make it more susceptible. What’s the quality of the air, the food, our socioeconomic status and even the political nature of the situation. Now again, when something infects an individual there are a number of outcomes. An individual becomes infected and then there’s an incubation period which then leads to clinical disease or no disease. When somebody is incubating that infection, that is they’re not sick but that it’s growing in their body, there is a latent period. A period when they’re not infectious at all. They can become infectious, even before they get clinically ill, and it is during that infectious period that they can infect another. So you see in the first patient there’s the incubation and clinical disease, a latent period, in infectious period, and during that infectious period they infect the second patient.

This gives you an example of how infectious diseases have changed historically. In 1909 the percentages of infections in Chile causing mortality and morbidity was about 50%. Fast forward to 1999, those figures are now down to about 22%…23% so in 99 years, or in 90 years, we have seen a dramatic reduction in the importance of…of infections as causes of mortality and morbidity. We’re going to look at what we can do to reduce the importance of infectious diseases. There are a number of basis of infectious disease control. One, what is the quality of water and sanitation? What kind of water are we putting into our body? And how do we dispose of human waste and other waste? What about improved hygiene, hand washing for example. Housing- By decreasing crowding we can decrease diseases like tuberculosis. Improved nutrition also has a bearing because the host is stronger and able to combat certain infections. In the last 70 years or so we have developed incredible array of vaccines and antibiotics or antimicrobials. And lastly there have been certain behavioral changes. Here’s a young girl in a program that is teaching kids the importance of hand washing and how you can use soap and water to reduce risk, particularly after…after going to the bathroom for example. Unfortunately in crowded cities in many low income countries waste disposal through these latrines which are over-hanging a body of water in which kids sometimes swim and which are right across from a better off section of a city also leads to environmental contamination and increases the risk of the transmission of infectious agents. Far better that if we could put even this simplified form of a SanPlat latrine which people could use to get rid of waste rather than putting it directly into the water as shown earlier. Going back to vaccine development, the first one was in 1796 where Jenner used cowpox to in fact protect people against smallpox. We’ll see more of this later. In the 1800s we then had the development of rabies, cholera, typhoid and plague vaccine, but the huge increase occurred in the 1900s with diphtheria, pertussis, BCG which is for tuberculosis. In the 1950s we developed poliomyelitis vaccine and then in the 18…1980s, ’90s and to the present day there’s been a huge development in vaccines such as hepatitis A and B, pneumococcal rotavirus, meningitis, et cetera. The first antibiotics interestingly enough, this was not the first but one of the first, go back really to the late 1930s with sulfonamides but here is streptomycin, 1943 it was developed by Selman Waksman and first given to patients in 1944 for tuberculosis and you can see from this list of tuberculosis drugs that at least seven, and there are many more actually that have been developed since that first…since the first discovery of streptomycin. We now have other anti tuberculosis drugs which are used particularly against the drug resistant tuberculosis strains. Now lastly, I want to go back to our examination of the basis of infectious disease control and indicate a few other measures that we can use. One of these is surveillance and reporting, that is who is getting the disease, where are they getting it, and so on. So that we can then institute certain disease control programs, be it against malaria, other vectors, parasites. And we can institute preventive measures such as the promotion of hand washing, screening, education in schools, behavior modification, social marketing and so on and lastly the development of early and effective and affordable therapy to deal with the infections that are…have occurred in the past and will continue to occur into the future. So in this first brief lecture, I’ve tried to give you a few definitions of infectious diseases and how they might be transmitted. I’ve tried to look at the history of one of these, that is bubonic plague and pneumonic plague, and lastly to give you a brief outline of some of the basis for infectious disease  control.

Introduction to Public Health IV

Measurin Health Status

When we talk of health we also need to measure it, because as is often being said in management circles, what gets measured gets done. So when we plan health programs, then we need to find out what the impact of those programs is in terms of improving health indicators.

This is important for national systems to look at how they’re functioning and faring in terms of various health priorities. It’s also important to compare across different countries, over time within countries and across geographies in different countries and sometimes over time in terms of the global trends.

Policymakers will also find it very important not only to use it as a measure of progress, but also for priority setting. Clearly when there are a number of priorities which need to be addressed in terms of different health challenges, and they have to allocate resources, they will have to decide which are the ones which are really the most important in terms of tackling early on and those which can be tackled later on or how to allocate resources across different programs.

The WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.Therefore it s a positive definition, not a negative definition, therefore it goes beyond the absence of disease or infirmity in stating positive attributes of health.

However, it s a holistic definition which is very pleasing but difficult to measure and pin down. So how do we actually measure health? One of the important measures is longevity because as societies advance one expects life expectancy to improve and life to grow longer and longer. So that depends upon when and why people die. And that captures the life expectancy on an average within a country. But as we know, there are wide disparities in life expectancy across different countries. Japan for example has a life expectancy of 83 years, whereas Mozambique has a life expectancy of 53 years and in between we have Sweden at 82, Bangladesh at 70 and Tanzania at 59.

But the important thing to remember is that while we must try and reduce this huge gap in life expectancy as a measure of health across the world, it is quite clear that all the years of life are not lived in good health. So there are some years which are compromised by ill health. And therefore we are also looking at a modified measure of life expectancy which is healthy life expectancy. That means if you remove the amount of years lost due to ill health, by adjusting in some way for the level of ill health and the years lived with ill health and then subtract that from the total life expectancy, then you come to healthy life expectancy. And Japan in this case has 75, which is very good. That means the gap between life expectancy and health life expectancy is not very large.

On the other hand, Mozambique which started off with a low life expectancy has a very low healthy life expectancy of only 37. And the gap therefore is quite substantial of 16 years. That means, even in the shortened life expectancy of Mozambique, several years

are consumed by ill health. So when we re looking at cause of death for example, one of the very important measures in international comparisons, there is an international classification of diseases which was first proposed by William Farr. And now we are in the tenth revision. So different diseases are provided different criteria of diagnosis and then we attribute the cause of death to the most important cause that contributed to death. And then we compare again, across countries as to which are the dominant contributors to death and within in countries too we compare across social groups and we compare across time periods to see whether there are transitions occurring or whether health policies and health programs have had the desired impact.

And some of these are also linked to individual causes of death or age groups or particular types of programs that we are really trying to assess. Like for example, infant mortality rate, child mortality rate, maternal mortality ratio, or disease specific mortality. What is the mortality contributed by cardiovascular diseases as a whole and what is the mortality contributed by coronary heart disease and stroke separately? So we look at all of these in a manner that is disease specific.

And this we gain from different sources of information. Usually countries should have vital registration systems which are quite robust. They should also have very good cause of death certification procedures based on the international classification of diseases. You can t go around classifying death in a very arbitrary manner and then expect good comparison. So you need a standardized method of certifying death and physicians and others who certify death must be trained properly to really adhere to that. Others include hospital records, national and international surveys like demographic health surveillance systems,sample registration systems and so on. Cause of death information is best generated from systems of civil registration and vital statistics. When these systems are either incomplete or dysfunctional and not really reliable in terms of the validity of the information generated or the completeness of information generated, we can still attempt to gain some useful information on births and deaths from other sources. These include demographic surveillance sites, sample registration systems, population censuses and household sample surveys.

None of them give the full information that we can get from civil registration systems. However by supplementing the limited information that they offer with structured verbal autopsy techniques, we ll be able to get additional information which can inform policy and programs even as civil registration systems are being established or strengthened.

In some countries where the vital registration systems and cause of death certification is not very widespread, well established, or reliable, people also undertake techniques known as verbal autopsy. In order to try and send trained people into the community to try and identify deaths which have taken placeand then through a very well structured interview, try and ascertain what the potential causes of death might have been in those cases. And these are usually verified against available medical records or a physician opinion. So there are different ways of ascertaining mortality data.

But we also need to measure morbidity because death is not the only thing that matters in life. Good health matters and therefore living a life in good health without disability is a very important objective in any society. And therefore we have to measure disability or handicap. And therefore we have to first start defining disability. So every disease carries a certain degree of disability. In some cases, very short-lived, in some cases chronic or in some cases, permanent. So we have to try and measure what the durational disability is and what the degree disability is. So in terms of health expectancy measures, we do look at disability measures and there are multiple disability measures that are there for different categories of diseases. But again, we are faced with a challenge of compressing all of this into one or two indicators which capture all of the information. And there we ideally should look for measures that combine mortality and morbidity, particularly for comparisons across countries and comparisons over time within countries.

So disability adjusted life expectancy has been something that was proposed in the World Health report of year 2000. And now it s called Healthy Life Expectancy. If you assess the nature of disability, attach some weights to it, estimate the number of years lived with that particular disability which could vary actually in terms of its severity across those years, but ultimately calculate the cumulative loss of healthy life years because of the disability and subtract that from the overall life expectancy, then you get healthy life expectancy. So this measures the equivalent number of years expected to be lived in full health.

Now there is another measure that has come in to play, particularly through the global burden of disease project. This was first introduced into global health in the year 1994. This was again to capture the combined burden imposed by premature mortality and prolonged disability as a summative measure. It combines the years of life lost due to premature death and the years lived with disability weighted for the degree of disability. And therefore it subtracts the amount of life lost because of that weighted disability. And this again has become an important measure though it has become a little controversial sometimes by saying that it s a bit of an ageist measure and then it sets too much premium on years of life lost and substantially overweighs certain categories of death and disease over others. But nevertheless it s a useful measure for global comparison.

At the same time, there are other estimates that have come in in terms of measuring health gaps. Years of life lost. This is estimated on a population basis, compared to potential maximum life expectancy, which in this case is Japan. Then we also look at years lived with disability. These are all subcomponent measures of the DALYs. These all go into the calculation of disability adjusted life year lost. So the years lived with disability, they estimated on a population basis the number of cases with that particular condition must be multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale from zero, which is perfect health to one which is death.

The global burden of disease studies as I said, first started in 1990. They were published in the first version in 1994 and subsequently they have been revised extensively in 2010 and are going to be also periodically revised. And currently the Institute for Health Metrics and Evaluation in the University of Washington-Seattle is now leading this effort. And they do comparisons of global burden of disease across different countries and groups of countries using the disability adjusted life years. This has had an unprecedented scale and effort going into this, of looking at multiple data sources and compressing that all into a measure that provides for global comparison. It does give a global picture of progress and the status of health which is not available presently through any other source because most of the other measures fall short either in terms of measurement of disability or being very disease specific or particular age specific.

But it also is an important measure for highlighting emerging focus areas and improvements in health. For example, in 1994, when the first global burden of disease study came in, people were surprised to note that many of the low and middle income countries already had very advanced epidemics of non-communicable diseases where there was a lot of premature mortality and a lot of disability. And until the calculations of disability adjusted life year loss was done, mental health did not emerge as a very major factor in global health. So the DALYs calculated for all of these were a great contribution in helping us to re-prioritize some of our public health interventions.

But there are some justifiable criticisms. There are always issues raised on the quality of data available from different countries and ultimately whatever is the summative measure is dependent upon the quality of the data and the extrapolations made. And again, there is a little criticism that this is an ageist measure and this weighting system also is sometimes controversial. The amount of weights attached by patients, by physicians and by people who are healthy tend to vary. And therefore we re not sure which the actual weight to be utilized is. The DALYs and the global burden of disease are supposed to be guides to resource allocation, but they do not always account for differentials in resource availability.

Remember, sometimes you have to take equity also into consideration. You have to take affordability issues into consideration. And there are multiple other factors that go into policymaking. Nevertheless, for prioritizing public health action and to some extent resource allocation, the GBD is useful indeed. We understand that measuring disease burdens is a complex activity but a very important activity. It s an evolving process. We are still gathering knowledge about what are the best methods of assessing disease and the disease burdens and measuring health free from disease but global health requires these metrics for decision-making, for comparison and for advancing our progress to adequately prioritized public health programs.

But we also recognize that health now must be positioned fairly effectively in the broader developmental context. It can t be seen in isolation from other developmental activities, including the whole area of sustainable development which is now coming to the fore in the United Nations. So there are some of the indices that are coming up in which health forms a part of a broader development index. Dissatisfied with the gross domestic product as an indicator of economic progress, Stiglitz, Sen and Fitoussi who are very major international economists developed what is known as a well-being index which captures multiple areas including environment, education, poverty reduction, health, among several others. And therefore this is a composite index. There is a multidimensional poverty index developed at Oxford which looks at health, education and living standards and measures poverty in multiple dimensions, including the lack of health. There is a social progress index that s currently under development which looks at basic human needs, foundations of well-being, opportunity and brings in some of the environmental concerns as well.

So as we move towards the sustainable development goals we need to definitely improve our measures of health, but we also need to see how we can coalesce those measures with other developmental indicators to get an idea of what a healthy society should be in all dimensions.

Introduction to Public Health III

Evolution of Global Public Health

We have seen that concepts of public health are centuries old. However the idea of global public health has been evolving over the last few decades. And this has been brought about by substantial changes in the way people have looked at international health and then, and global health. Peter Piot, who is the director of the London School of Hygiene and Tropical Medicine and previously the director general of the UNAIDS has classified global public health in four stages. The first stage was one of tropical medicine. This was during the colonial period when many of the countries which colonized countries in Africa, Asia or Latin America were concerned about their soldiers and their traders as well as their administrators suffering from the tropical diseases like malaria. And they invested in programs for prevention and control primarily to protect their own people and their commercial interests and of course the local population benefited incidentally.

But then we moved on to an era of international health in the post-colonial period in which people were interested in finding out what the health trends in different countries were and what the comparative profile of public health challenges and predominant diseases was in the world. Indeed, this is not a curiosity that is very recent. Even in the 19th Century, epidemiology was principally described as geographical epidemiology. And therefore the whole idea of geographical medicine in which they compared people across different countries. But we now see that apart from international health, we have moved on to a third stage where people from rich countries who are leading research programs in poor countries started organizing substantial research programs funded often by the governments or donor agencies from rich countries in order to investigate the causes and course of diseases in the poor countries, more as a matter of international cooperation. But now global public health have entered a fourth stage. Where global health activities, including research are being led by people from poor countries. Indeed, there’s a much greater amount of collaboration including leadership of major programs by researchers as well as public health leaders from the low and middle income countries. I would actually put it in a slightly different way. I would say international health was when people went from the high income countries to low income countries and said, what can we do for you? And now global health is where people everywhere in the world are sitting across the table together and saying, what can we do together to identify and solve the leading health problems of the world by working together? I think the recognition that many of the determinants of health today are transnational, whether it is movement of viruses or migration of people or sale of tobacco and essential medicines, all of these have become transnational activities. So global cooperation is absolutely critical now if people have to solve the problems of global health. And it is this working together that really brings life to global health in the 21st Century. The whole idea is that we are really looking at not merely variations in health across the  world, but we are looking at common concerns and commitments in global health.

The 20th Century saw global health advancing primarily from a sense of shared vulnerability. There was this threat of bioterrorism. There was the big scare about SARS, H1N1. And many avian influenzas and so on. And people felt that they needed to protect themselves against various diseases that were moving across boundaries. The International Health Regulations came in. And of course we started looking at cooperation merely from the point of view of protecting ourselves against problems that can come in from elsewhere in the world. But in the 21st Century, we are moving beyond shared vulnerability to shared values to provide momentum to global health, because we are looking at issues like universal health coverage. We are looking at trying to reduce inequities across the world. We are looking at sharing knowledge and resources for improving health of people everywhere across the world, whether it is battling under-nutrition or whether it is battling Ebola.

And therefore we ought to be really looking at the fundamental values that guide global health in the 21st Century and that is universality. But universality doesn’t mean that everything is decided at the global level. We do have decisions to be made at the local level and a lot of action is led at the country level or even at the sub regional level within countries. As the Portuguese writer, Miguel Torga said, universal is local without walls. What we have done is to break down the walls in terms of shared knowledge and built bridges of cooperation across the world to tackle the problems, even as we are acting both at local and the global levels. Now what are we studying in global health nowadays? We are looking at trends in demographic transitions across the world where we’re trying to find out how aging populations are now facing different disease burdens. We are looking at the changing nature of disease burdens both in response to demographic as well as economic transitions. And we are looking at how risk factor levels are rising or falling across populations to predict what the disease patterns are going to be. We are also studying the broader social determinants of health, because they are fundamental to determining the health of populations. We are also looking at how the national health systems are responding to the various public health challenges. What are the allocation of financial resources for health within countries? For example, if you’re really looking at universal health coverage, can it be funded at a low level of resources or do the resources need to be augmented? We are looking at health workforce issues. Do we have a multilayered, multi-skilled health workforce, which is capable of delivering a wide range of services which are promised in universal health coverage? We are looking at the access to drugs, vaccines and technologies and trying to find out whether countries need to be supported in promoting greater access and affordability for their populations. We are looking at how health systems are organized. Are there vertical disease programs or is there horizontal integration or what we are now calling a diagonal approach in which there is a certain degree of focus and verticality within a health program but the results are a great amount of sharing and capacity-building for the health system which can be accommodated even within a vertical program which can also support some other objectives of some of the allied programs.

So we are looking at rapidly evolving models of health systems. We are also looking atpublic health emergencies whether it is Ebola or natural disasters and seeing how health systems in general are capable of responding to it, how they’re collaborating with othernational disaster response systems and how international cooperation can help in that. So if somebody is really suffering as a result of Ebola in Africa or somebody is suffering as a result of a post-tsunami effect in Indonesia, it does not mean that they’re going to be isolated. There’s a whole global health community which is going to be responding to that challenge. And that is the essence of global health.

So we are also looking at global health constructs. We are looking at flows of knowledge, technology and services across the world. We are looking at reverse innovation. We have had Lord Nigel Crisp from the United Kingdom who headed the British National Health Service. He was sent by Prime Minister Tony Blair to look at countries in Africa, Asia and Latin America to see what the National Health Service could provide those health systems in terms of support and guidance, in terms of sharing best practices. He came back after a good study and wrote a book called Turning The World Upside Down. He said, there are so many innovations going on in these countries of Africa, Asia, and Latin America, which the British National Health Service could benefit from. So he said, the whole world is now a very different place.

You’re seeing a lot of innovation happening in the so-called low and middle income countries which the high income countries should learn about. So there is a greater opportunity for bidirectional, or multidirectional sharing of knowledge. And of course, we require much greater cooperation as well in terms of not only scientific research, but also in the application of research and sharing of resources. We also are looking at governance. Not only of governance in national health systems, but how international health agencies are now trying to look at global health governance with multiple players coming in now, not only the World Health Organization, but also various foundations and a number of governments coming in, how do we coordinate the functioning of all of these agencies at the global level in order to optimize the benefits of their working together and really achieve the maximum impact on global health? So the whole idea of global health governance or governance for global health is becoming a very important area.

So also the whole area of financing of health, particularly in terms of achieving the objectives of the millennium development goals and the sustainable development goals. We are looking at transnational determinants like trade. Trade- whether it’s in tobacco, whether it is in fruit and vegetables, or in essential drugs, all of these affect health. We are looking at traffic and migration of people across continents. We are looking at conflicts which are also having refugees moving across different countries, across borders and carrying health problems with them. Or suffering their health consequences of forced migration. So we are looking at communication, how that�s bridging a lot of the knowledge gaps across the world but sometimes also creating problems by breeding unhealthy living habits as aspirational goals in changing cultures. And as we move towards the sustainable development goals from the millennium development goals We still have a problem of tuberculosis, especially multi-drug resistant tuberculosis. We still have HIVAIDS in many parts of the world. And we have now emerging infectious diseases, including zoonotic diseases like Ebola.

We are also looking at the major new challenge of non-communicable diseases. The idea of controlling cardiovascular diseases, diabetes, cancers and chronic respiratory diseases across the world becomes a major priority for global health. And we say we now move to adding NCD agenda to SDG agenda. At the same time, mental health is a major cause of disability and therefore we are looking at an expanded NCD agenda by incorporating mental health and also adding injuries in what is now being called chronic conditions and injuries agenda.

So we are looking at the prime causes of death and disability across the world and trying to accommodate all of them in the SDG agenda and global health is going to be the principle platform where this action is going to take place.

We are also looking at health equity and particularly universal health coverage. Provision of multiple services to all the people who require them, but with adequate financial protection. That has become a rallying cry for global health equity over the last 15 years. And we are going to see that resonate in the SDG goals. At the same time we are now bringing back primary healthcare very front and central into the health agenda. Alma-Ata is not dead.

We are now bringing back Alma-Ata’s spirit into SDGs by saying that universal health coverage, if it has to be delivered, has to revitalize primary healthcare. So that again is a major global health agenda. But at the same time, we have seen a fundamental shift in the way the world has looked at the health system. Previously health system was being dismissed as a black box. They were looking at vertical programs. Let’s go and attack TB. Let’s go and attack HIVAIDS. Let’s go and attack tobacco separately, and the cancer separately, and so on. Now people have realized that vertical programs, however well designed and well-intended cannot be force-fitted into a weak health system. A weak health system will not be able to deliver them. And also there is an opportunity cost of other programs suffering. So the idea of creating a strong health system which acts as a switchboard to integrate all of these programs and effectively synergize them for better delivery, including health equity that has become a primary goal of universal  health coverage and that is the driving spirit again behind global health initiatives.

So when we’re really looking at public health research which has to inform public health action, the objectives for public health research are to provide evidence based, context specific, resource sensitive, culturally compatible and equity promoting recommendations for policy and practice. And these are going to be fundamental for global health.

So when we are really looking at these as the primary objectives for driving policy and practice, we must recognize that policy whether made at national or global level has to be informed by interdisciplinary effort to create the required knowledge base. So public policy sometimes can be an unedifying spectacle when it is based on unenlightened approach. But on the other hand, even an enlightened policy needs scientific credibility. Is there evidence and rationale? For that you require biomedical and epidemiological research.

Financial feasibility. For that you need health economics research to find out whether something is cost effective or affordable for a national health budget. You require operational stability. Is the proposed intervention sustainable and scalable apart from being successful in a pilot? For that you need health systems research. But you also need political viability. Is there a ready and receptive community for accepting whatever is the proposed intervention? This could be the community of policymakers, this could be the wider community at large. And for this you need social sciences research. So unless you combine all of these fields of knowledge, you not be able to create the impetus for public health action within a country or of the global level. That’s why we emphasize bringing together multiple disciplines in order to inform and to actually guide public health action. In terms of public health practice we are really looking at integrating evidence with practices into primary healthcare for preventing and reducing the risk of diseases in a period of health transition. And ultimately when we’re acting at the level of the communities or at the level of populations, we will impact upon people and their health on…and the health of individuals.

But how do we implement all of these interventions? Now global health is beginning to talk about operational research or implementation science as a very critical piece. Previously we were trying to create knowledge about what is wrong and what could be done to set it right. But we still have not understood fully the science of delivery, especially a lot that goes into it in terms of human behavior, in terms of organizational behavior, in terms of management practices, in terms of cost effectiveness of interventions. So for all of these we require operational research or implementation science. And one of the prime elements of global health in the 21st Century is going to be implementation science.

So when we’re really talking about global health in the 21st Century, the spectrum of research must stretch from molecules to markets. The span of policy must range from persons to people to populations. And the arena of advocacy and action must extend from risk factors to rights, rights of people, human rights.

Introduction to Public Health II

Multiple Determinants of Health

In this chapter we’ll be looking at the determinants of health, especially the social, ecological and political determinants. Of course biology is absolutely critical too, but that is most often dealt by clinical medicine. But we will also look at the interplay of these other determinants with human biology and ultimately how they shape health at the level of populations.

Let me start with the story of Rudolf Virchow, who was an eminent pathologist in 19th Century Germany. He was also the founder of the Anthropological Society of Germany. And he had a place in the Kaiser’s court. A highly respected academic. When he was sent off by Kaiser, or the emperor of Germany to investigate an outbreak of typhus in Silesia in Prussia. He came back with a report not looking at the biology of the disease, but on the social circumstances which caused the outbreak. He said the principle cause of that outbreak of typhus in Upper Silesia was poverty and inequity. And he recommended that there should be measures taken to reduce poverty including abolition of feudal privileges and greater levels of democracy. That did not make him popular in the court, but as a philosopher of social medicine Rudolf Virchow has a very prominent place. He said, do we not always find that diseases of the populace traceable to defects in society? If disease is an expression of individual life under unfavorable circumstances, then epidemics must be indicative of mass disturbances.

He went on to say that these mass disturbances are disturbances of culture and therefore great social changes sometimes also bring epidemics in their wake. What was true of typhus in the 19th Century is true of tobacco in the 20th Century and now we are seeing other social movements which are also resulting in the epidemic of overweight and obesity because of unhealthy foods. Even in Victorian London, poor living conditions were recognized to be responsible for ill health. The Black Death of 1655 was again, strongly related to poverty and poor living conditions. And when we had epidemics in London or the United Kingdom, then the rich left the town for their estates while the poor who were to remain, suffered. And we have seen the descriptions of this kind poverty and deprivation affecting health in the books of Charles Dickens. When we look at how sometimes social circumstances can actually change for the better and thereby bring about improvements in public health, we also see the decline of tuberculosis antedated the discovery of drugs against the tubercular bacterium, or the bacillus tuberculosis. And that is where McKeown brought about his famous thesis that it is the social conditions which actually are responsible for decline in infectious diseases in countries which are improving economically.

While it is true that science and technology are also very important allies in bringing about public health improvements, we definitely have to acknowledge the important role of socioeconomic development. But this development also has to be equitable. Now we recognize that if you actually look at populations and compare them. We also find out that some of the diseases which appear to be very common in some countries are far less common in other countries, even at the same level of economic development. For example, in Finland, in the 1960s and ’70s, coronary heart disease was extremely common. Whereas at the same time in Japan, coronary heart disease was very rare. And we find that the way the populations live in terms of their living habits, of diet, physical activity, all of them are responsible considerably for these inter-population differences.

Geoffrey Rose from the United Kingdom, a famous epidemiologist, while studying cardiovascular diseases across different countries said, sick individuals come from sick populations.

If your average cholesterol level in the population is high, the number of people who will get heart attacks because of high cholesterol is going to be high. Similarly if your average blood pressure in the population is high, the number of people with hypertension who are going to get a stroke is high. So we have to really alter the population dynamics of risk acquisition and risk reduction if you want to make an impact in public health across the population. Now we also know that migration into urban environments also accounts for a great deal of this change. When you look at Kenyan nomads who live in very rural conditions and London civil servants at the same time, this is one of the earlier studies of Geoffrey Rose, you find a marked change in the distribution of the systolic blood pressure across these two populations. In London, the entire distribution is far to the right. That means even the average blood pressure as well as the proportion of those with hypertension is far higher than those in the Kenyan nomads. And therefore the way in which we lead our lives makes a difference.

This doesn’t mean that everybody has to live in relatively primitive conditions and shun modernity, but we are to make sure that as we advance towards modernity we retain some of our healthy living habits. And that is the basis of public health. So when we look at the principles of risk and prevention we understand that since much of this is determined by the population profile of a risk factor, small reductions in risk factor levels when achieved across the whole population. That means when the whole population distribution shifts to the left, shifts to a better level, then that results in a large reduction of adverse events like strokes and heart attacks across the population. Even though the individual shifts are small, cumulatively the population benefits are large. At the same time you have to also look at people who are at the high risk end of the distribution and who at the individual level have a very high risk and we have to focus public health interventions to get them the appropriate mode of risk reduction therapies. So we need to combine both of these strategies.

These are not mutually exclusive but are synergistically complimentary. But when we look at what makes people healthy, or unhealthy, we realize that there are elements in the health system which are very important. The health workforce, are there enough doctors, nurses, allied health professionals? The infrastructure, are there well equipped health facilities? Do they have enough drugs, vaccines and technologies available and affordable across the population? How is health being financed? And what are the health information systems like? Do we get ready information on what the risk factor levels in the population are? Or what is the spread of disease across the population? How is the whole system being governed? Is it efficient? Is it suffering from corruption? Is it accountable to people? All of these matter in the health system. But over and beyond that, we also have to look at the social determinants of health and nutrition. For example, these are factors operating at the societal level. Like the availability of clean water, sanitation, food systems and agricultural systems which provide healthy nutrition across the life course to every individual. A clean environment, having as little air pollution as possible. Social stability, free from conflict and violence and having adequate degree of community participation.

Then all of these matter very much in terms of the societal forces. The level of development and distribution of incomes within society matters. At the personal level, income, education, occupation, social status, gender, participation in social networks, all of these are important social determinants of health. So when we really look at all of these, public health operates at each of these levels. But underlying all of these are political and economic systems which ultimately make choices with respect to many of these determinants. We recognize for example that as per capita income grows across countries, up to a certain level the life expectancy also increases.

Once you reach a certain level of about close to ,or beyond $3000 or $4000 per capita, then the effect starts plateauing off. And this is known as the Millennium Preston Curve. But the fact is, per capita income which means the overall income as assessed as the income per population, per unit, actually matters a lot in terms of life expectancy.

However, how this is distributed within the population also matters a lot. Like for example, in the United Kingdom, there’s a huge difference in life expectancy between one county of the United Kingdom and the other county of the United Kingdom. Almost, whereas one county has a life expectancy of 54 years, the other county has a life expectancy of 82 years. Again, even within the U.S. you have differences in life expectancy which is considerable between different counties. Where in Washington you have a predominantly black population, you have 63 years as their life expectancy. On the other hand, in Montgomery County, which has a predominantly white population, you have a life expectancy of 80 years.

Now we also know that because of income differences, but also because of educational differences and employment differences you can have substantial differences in mortality rates. For example, if you look at the mortality rates across different classes of occupation, the people who are in higher grades of employment in the Whitehall which is the secretariat in the United Kingdom, they have had much lower levels of mortality as compared to some of those in the lower professional grades who, where the stress levels are much higher. And in terms of health inequalities we also recognize that educational levels play a great role.

Even at the same levels of income, differences in education make a lot of difference. Those who have had university education have a much lower mortality as compared to those with only elementary education. So there is a growing recognition that whether, between countries or within countries, we ought to be addressing inequality much more effectively. Michael Marmot who headed the WHO Commission on Social Determinants of Health remarked that the fact that there is a spread of life expectancy of 48 years among countries and a spread of 20 years or more within countries is not inevitable. This is not something that is a given, irreversible. We can, by addressing through appropriate public health strategies and equitable socioeconomic development and distribution bring about a shrinkage of these huge gaps that lie within life expectancy across and within populations. And we see this can happen in different countries where the differences between the wealth quintiles can be substantial even in terms of the number of births that are attended by skilled birth attendants. And within countries we find that the poorest, again, have unattended births with a likelihood of higher maternal mortality. But as universal health coverage takes place across countries, even in countries with lower incomes, we find that these differences across wealth quintiles are substantially reduced or even obliterated. So we ought to be really looking at universal health coverage to reduce health inequalities brought about by income inequalities. We also recognize that by making determined efforts to bring about greater equality in society you can overcome many of the existing inequalities. Brazil is a remarkable success story in this direction. After the revolution in Brazil where the military dictatorship was overthrown, and a constitution enshrining the right to health was adopted, Brazil had a number of social initiatives which were directed against reducing income inequality and reducing poverty. And that has had its effect on health. If you look at the stunting rates across income quintiles, then we find that earlier on we had a huge gap pre-revolution in the stunting rates between the high income groups and the low income groups. But subsequently we find that in the last decade these differences have greatly narrowed and we find the stunting rates in the lower and the high income groups are virtually very similar. So by bringing about a greater degree of equality in distribution and greater access to nutrition, also other social determinants of health as well as health services we can actually reduce some of the gaping health inequalities that are a major problem in terms of inequitable development. And that is a very important mandate for global health. How best can we reduce inequalities in health across populations and within populations? We do have the knowledge, we just have to apply it political will and determination supplemented by professional skill brought about by good public health systems.

Introduction to Public Health I

Introduction & History of Public Health

Welcome to this course on global public health. Quite often we are asked what is public health? How is it different from clinical medicine? Is it something to do with water and sanitation or is it something more? And for even people who have studied a bit of public health, they say, how is it different from epidemiology, which understands the causes of disease and identifies the means to prevent it. Others wonder what is global public health? How is it different from international health or public health in general? So let us start examining some of these questions. Firstly, public health looks at the determinants of health which act at the level of populations, or people has a whole in a community or a country, and then tries to influence those determinants so that ultimately the impact is on improving the health of individuals who constitute that community or that population.

So it doesn’t deal with the individual disease in terms of trying to identify what a person’s clinical complaint is or by providing treatment that one individual as clinical medicine does. On the other hand it tries to set right some of these determinants at the societal level so that people don’t get ill. It also tries to create robust health systems which will deliver health services in a manner that is effective as well as equitable so that people can get protected against diseases through preventive services as well as get a wider range of diagnostic, curative, palliative and rehabilitative services as needed through a well-functioning health system. And all of these also have to be done cost effectively in a manner that the health system doesn’t become bankrupt and individuals have to be protected against health related impoverishment. One of the main driving values of public health is not only to improve the health of people within communities and populations, but also to insure that there is greater degree of equity. Because even in countries where the health standards are considered to be generally very good, we see several population subgroups who do not enjoy the same good health. And we find wide disparities in life expectancy, in maternal mortality or infant mortality or even cardiovascular mortality, between these groups. So public health also aims to reduce those gaps and bridge the inequities. And when we apply the standard of equity across the world, public health then becomes global health and it also starts to examine the determinants which actually act across the global level, across countries in a transnational manner and also tries to provide a concerted multinational or a concerted worldwide response so that these determinants can be further modified to improve global health.

Now if you look at clinical medicine and take the example of somebody who died of a heart attack, well the clinician, the cardiologist would say that the person died because of blockages in the blood vessels to the heart. Absolutely true. But then the epidemiologist would say, the person developed those blockages because he had consumed tobacco as a cigarette smoker from the age of 16 and therefore he had a premature heart attack at the age of 42 and died suddenly. And therefore the cause of death according to the epidemiologist is smoking tobacco. But then the social scientist would say that in virtually every country of the world, now tobacco consumption is much more among the poor. And this poor person had consumed tobacco because he fell, trapped into the habit, did not have adequate information about it. And after having developed some other cardiac problem, did not have the ability to seek affordable healthcare and therefore died of it.

Therefore the social scientists would write down the cause of death as poverty. Now every one of them is correct. And therefore public health has to look at not only the immediate cause but the combination of causes and the causes of causes. And that is where public health becomes a very broad, integrative discipline which makes the understanding of health and disease much more holistic than any single branch of medicine.

Now in terms of public health, we also have to look at systems as I said, are doctors and nurses available in adequate numbers? Are for example affordable medicines available, accessible? Let us take for example a person who meets a nurse or a doctor in a clinic.

That is clinical medicine, if the blood pressure is being checked up and some drugs are being prescribed. But what happened to the person before he came to the clinical facility? Could the problem have been prevented by appropriate advice on how to protect health to the community? Could it have been detected early, before it went into the stage of established disease or complications? Could the referral system have functioned better by providing a timely referral? All of these issues are part of public health.

When the person leaves the clinic or the healthcare facility, are the drugs that have been prescribed by the doctor, are they available in the market? Are they affordable? Can they be taken on a long-term basis? Are the kind of dietary prescriptions given in terms of fruit and vegetables? Are they affordable again in the market? Or if it’s an infectious disease, are there systems for isolation? Are there rehabilitation support systems available for a person with mental illness, or with any other form of physical disability? All of these come under public health. Even what happens in the healthcare facility is also public health because we have to find out firstly, was there a doctor, was there a nurse? Were they adequately trained? Were they following standard management guidelines?

So the whole system organization is also part of public health. So if you want even clinical medicine to function well, you need a very strong public health system. And when you take it on the global scale and look at the determinants of disease and health on the global scale, and look at systems functioning on the global scale, including the production, export, import, regulation of drugs for example, all of that is part of global public health. So public health really covers health systems, services, policies and other sectors too.

For example, when we look at what happens in terms of agriculture, food systems and the effect on nutrition, that again has to be aligned to the health of the people. Now you may say, why do we actually think that public health links to every single system, whether it’s urban design, urban transport, agriculture? Now is there no limiting factor for this? Then we have to really understand that is the primary intent of any measure is to protect health, then that is public health. Like for example, if we say, a seatbelt law, or a motorcycle helmet law, that is public health because the primary objective is toprotect health. If the primary measure is for some other objective, but still we need to align those policies and programs and those sectors to the objectives of health, then that is not strictly in the domain of public health, but public health needs to link up with it. The primary objective of agriculture may be to provide food security, may be to provide cash for the farmers, but even there we have to insure that agriculture and food systems are producing the kind of products that are better suited to human health. So that becomes an extension of public health into another sector. So public health is truly multidisciplinary in very many ways. Now when you look at how public health has evolved this is not a new concept. Even in the Roman times there was a diversion of human waste and the Roman civilization knew that if human waste accumulated, that would be a cause of disease. That was a good public health measure.

In the 19th Century Europe we saw the so-called miasma theory coming in where they felt that miasma was bad air caused by rotting organic matter and they attributed all kinds of diseases to miasma. We know that’s not entirely true, but we also know that it is important to have clean water and good sanitation and the beginnings of the sanitary movement in Europe actually brought about marked advancement in the health of the population and that was good public health. We also know that public health can use several technologies. For example, vaccination.

Vaccination again is applied at the population level so that individuals do not get the disease. Like for example, Jenner’s vaccine in 1796, Edward Jenner brought in the vaccine against small pox. Though it is said that the Chinese used this form of variola inoculation as early as a 1000 b.c., but anyway modern documented history attributes it to Jenner. In 1747, James Lind, an English sailing captain experimented and then proved that serving lime to sailors prevented scurvy, otherwise which was a major problem on long sea voyages. And that is why the English came to be known as limeys in slang.

The history of modern public health in London began with an act of vandalism. Yes. Somebody actually broke the handle of a water pump and carried it away. And this was John Snow.

In the Broad Street in London, where there was an outbreak of cholera, where cholera was spreading across in concentric circles and affecting a large number of people, John Snow mapped out how the outbreak was spreading. And then found that the center of the circle was a pump which was actually resulting in bad water coming out because of contamination with sewage. So John Snow broke the handle of the pump and the outbreak ceased. So it’s an important measure of public health to link sanitation and good water quality to people’s health. We have had several public health movements across the world, but at the level of global health, the World Health Organization which was established in 1948 became the principle catalyst and custodian of global health movements across the world, legitimized by the will of all nations.

And one of the success stories led by the World Health Organization in terms of public health has been the eradication of small pox. We know that this very deadly infectious disease have claimed a large number of lives and even in the beginning when people started getting inoculated, there were many people who did not believe in its effectiveness, but it was very clearly shown that those who were inoculated had very little mortality whereas those who were un-inoculated had a very high fatality. And the global eradication of small pox is one of the grandest success stories of public health.

But we have also seen public health evolving in terms of the understanding of the links between health and development. In the World Health Assembly of 1977, there was a resolution of health for all which resulted ultimately in the Alma-Ata declaration which also emphasized the importance of primary health services. Then it was decided that in the whole area of environmental sustainability health also needed to be accommodated and that came about in the Brundtland Commission of 1987. But the question was whether health would automatically benefit from economic development or investments in health also were needed for accelerated economic development. And that conversation began in terms of this bidirectional relationship in the World Development Report of 1993, investing in health. It was advanced then by the Commission of Microeconomics and Health which was formed by the World Health Organization. And recognizing that health and development are integrally related, at least three direct health related goals were accommodated in the Millennium Development Goals of 2000 which were adopted by the United Nations.

And now as we move towards 2015, when the United Nations is looking at adoption of sustainable development goals, the whole relationship of public health and global public health in to sustainable development is so abundantly clear that we see global health as one of the important points around which the SDG’s will revolve. We will find they’re in one way or the other linked to global public health objectives.

 

Universal Health Coverage V

The Challenges of Health Coverage in High-Income Countries

We’ve been looking at the challenge of health in the very poorest parts of the world. I’m going to move all the way to the other end of the income spectrum, and look at the challenge of health in the upper income countries in the richest parts of the world. You’d say what is the challenge life expectancy is high and the healthcare system is technically very sophisticated.

And while in the poor countries we scramble and wrack our brains to figure out how to reach a level of $60 per person per year. In the high income countries, the spending is typically around $3,000 to $4,000 per person per year in the public budget and if one looks in the United States at public and private spending for help, it’s $8000 per person per year. What’s the problem? Well, the problem especially in the United States is $8,000 per person per year. The health system has become incredibly expensive. So expensive that it is a major burden on the economy.

A major burden on the budget. A major burden on poor people who are priced out of the health care market even in the rich countries. And especially among those rich countries in the United States, where we have high inequality of income and prices of health care completely out of sight. And, as we’ve seen earlier, a rather limited or tattered social safety net. So many people not covered by government programs. The puzzle I want to explore is a specific one to the United States. In one sense, why is the U.S. healthcare system so expensive? But it is a more general lesson about the role of the public and the private sector in healthcare provision. One of the reasons why the U.S. system is so expensive is that it is a privately oriented health delivery system. Well, something isn’t right about that from the point of view of the common insistence that the private sector is very efficient and the public sector is bureaucratized and very costly. In the United States, where health care is provided mostly by private sector providers, the costs are completely out of sight. And this is a purpose that I’d like to look into now to understand why that is because it teaches something more general. For health systems around the world, it helps us to understand what are the boundaries between public and private. And in general it helps us to overcome a presumption, among at least some people, that the free market is always the solution to one’s problems. Well, we don’t believe that at sustainable development because we see that the solutions to the challenges of sustainable development require the interaction and often the cooperation of government, business, civil, society and academia. But sometimes it’s argued naively. Let the markets do it and the problems will be solved. In the United States, while healthcare is by no means a free market commodity. It’s more market oriented than in just about any other high income country. And the results are peculiar, to say the least. Well, we should know right from the start that health isn’t exactly a normal market kind of commodity. For one reason, it’s a merit good. We want health to reach everybody. Once it’s a merit good, it’s quite different from a bot, a can of soda or a piece of furniture or a, a new kind of car. Those may be desirable goods to some people but they’re not merit goods in the sense that we would expect on a moral or ethical basis. Universal coverage of those commodities, they’re not a basic human right. So, we know that health starts out in a very specific situation, just as does education. We also know, therefore, that public provision of those services is important. If for no other reason than to help ensure that the poor, alongside the rich, are able to gain access to those merit goods. But the problem goes even deeper than that. Kenneth Arrow, the great Nobel Laureate economist, observed all the way back now fifty years ago indeed, that health could not really operate like a competitive market sector. Because there’s a fundamental problem. Patients do not know what’s best for them in general. There’s a huge asymmetry of information. And Kenneth Arrow noted that when there is such an asymmetry of information, it violates one of the basic assumptions of the free market economy. Or I should say the basic assumptions of why the free market economy works well, and that is full information of consumers as well as information of suppliers. What happens when only the suppliers have the information? You go in to your doctor, and your doctor says, you need such and such test. Generally, if you’re like me, say, you’ve got it, let’s go for it. Maybe you go online and you see a whole debate about this. But then you don’t know what to do. You ask for a second opinion or a third opinion. Somewhere you’re going to, most likely, listen to what the doctor says. In the United States, oddly enough, doctors own a lot of the imaging equipment for CAT scans or for x rays or for other equipment. They order a lot of tests. And there is inherently a problem. When there is a symmet, a symmetric information, a symmetry of information, and the supplier is the one that has the knowledge, and the consumer is the one that generally follows along. One can see that if the incentives are not done just right, one could get over use, over charging, over billing of consumers who are in the hands of their doctors. Moreover with health if you’re like me, you don’t want to play around and especially if somebody is very sick. You don’t start negotiating in the emergency room or in the in the coronary care unit. when, the doctor or the hospital says that something’s needed almost all of the time you say yes, please proceed. And this is at its core one of the fundamental barriers to simply organizing the health sector as a, a normal market activity. There are others health requires insurance because bad luck, a bad bout of disease it a person stricken with a a, a very costly ailment would not be able to pay out of pocket. So, people buy insurance in the United States or receive a public insurance in other countries. And with insurance markets there are many, many problems as well. One problem with insurance markets is if individuals know  their health conditions but the insurance company doesn’t necessarily. Perhaps only the sick will register for insurance and if they’re asymptomatic they will sign on as needed. Healthy people won’t. The insurance companies will find that their burdens of disease are unexpectedly large. They’ll raise the fees. That will keep healthy people outside of the system. Only the sick or those who have the likelihood of becoming sick will be covered. And what can ensue is sometimes called an insurance stat spiral. Where a smaller and smaller, but sicker and sicker proportion of the population is faced with insurance. Prices soar for the insurance premia and the rest of the population opts out or simply rationed out of the market by the very high costs. Another aspect of the health system that I think is quite notable, is that it is a system. With a sick patient facing a complicated set of conditions, you want the generalists to be dealing with several specialists. You don’t want each specialist taking all the same tests again. Ih, you would like the doctors analyzing a case to be working in a systematic, cooperative way in which information is freely flowing throughout the system. Sometimes health care works like that. But very often it does not. If it’s not organized that way. If individual doctors have their individual practices. Then a private market economy can drive up the costs considerably. If the government reimburses private providers in particular ways that do not encourage the building of those systems it makes matters even worse. Well, now you’re looking at a graph where, that dotted black line at the top is the cost of spending in the United States per person. It’s soaring. Back in 1980 the average spending on health per person in the United States was about $1,000 per person. By the year 2009, $8,000 per person. And you can see, by far, the most expensive in the world. Norway, another rich country, comes next. But at a level much lower, say $5,500 per capita, roughly $2,500 per person less than in the United States. And in general, the rest of the countries are clustered around this lower level. Typical spending perhaps around $4,000 per person per year, outside of the U.S. half of the U.S. level. If you look at the next graph you see the spending now divided by national income because we’re looking at the share of health outlays as a percentage of income. And you can see that back in 1980 the United States was spending about 9% of its national income on health. By 2009, that had doubled to 18% of national income. Notice that back in 1980, all of the countries, including the U.S., were rather tightly clustered between 6 and 9% of national income. Since then, the U.S. has separated from the pack, becoming by far the most expensive health care system in the world. In general, health costs have been rising and health outlays as a share of national income have been increasing, but in other places not by anything close to the increase experienced in the United States. You can see that as of 2009, for most countries, the spending is on the order of about 10% of gross national product, not the 18% in the United States. Well, this is shown for the year 2011 in the next bar chart, again you see that the United States, all the way on the right, has the highest level of spending as a share of Gross Domestic Product. The next chart also, this set of columns by country, also for the year 2011, shows the United States as another kind of outlier. What this graph is showing is the proportion of the total spending. Say the U.S. $8,000 that comes from private spending, maybe the households buying health insurance, maybe the employer in the private sector paying for healthcare, maybe people paying out of pocket. As supposed to what government programs are funding. What you can see is that the private health outlays in the United States are a bit over half of the total spending. So a bit more than $4000 per person comes from private spending by the households, the employers and so forth. But in all of the rest of the high income countries this share of private spending is much less, or to put it the other way, the proportion of total health spending by government is much higher. In essence the U.S. runs a system that is partly public, partly private with an accent I would say on the private sector. Whereas most of the rest of the high income world runs essentially a public finance system, with a small private sector alongside. The U.S. is the only one that goes for a very big private sector and private spending, that accounts for more than half of the total. What’s the problem? The problem evidently is that the private sector in the U.S. in very high priced. And what essentially is at play is the observation that Kenneth Arrow made 50 years ago. This is not a very competitive sector. Price competition does not work very well. In fact, individual patients often have no idea of how the price they’re paying compares with the price paid by other patients. So much so, that hospitals themselves engage in what’s called price discrimination. Charging very different prices to different patients within the same hospital unit. Shocking actually, because there is no standard public price that applies for all. There is instead a very hard to understand negotiating process where the unwary U.S. health consumer spends a often far more than the hospital charges to other patients facing the very same kinds of treatments and with the very same kinds of conditions. The result is that hospitals get away with a lot. They are not competitive they price discriminate. The prices that they charge are indeed very very high and one can see this in a systematic comparison of U.S. costs with the cost in other high income countries. In the United States for example the if, if the U.S. cost of 30 commonly prescribed medicines is set at an index of one, then the cost in New Zealand is 0.34, one third of the U.S. cost. The cost in Australia 0.49, in other words one half of the U.S. costs of those medicines. In the Netherlands 0.45, in other words 45% or 45 cents on the dollar of what’s spent in the United States. If you look at the cost of a visit to a physician you can see that, while the cost of a physician paid for by a public sector program, $60 is comparable to what is paid for in other countries. The cost that’s paid for by a private payer out of pocket or a private insurance company is out of sight. It’s twice the amount paid for by the public payer. And it’s much more in general than paid for in most other countries. Well, condition after condition, intervention after intervention, the U.S. system is simply out of sight. If on average a hip replacement is for a private payer is $2,000 in the United States, it’s $4,000. And this high price is found in every aspect of the U.S. system. One can look at the spending for each patient discharged from a hospital, how much was spent on that patient? In the United States in 2009, it was $18,000 per hospital discharge. In France and Germany, less than a third of that all the way at the other end of this graph. In the average of the OECD that is the high income country group, one third of the discharge cost on average in the United States. U.S. doctors make far more than doctors do in other countries. Orthopedic physicians in the United States make $440,000 in 2008. In Germany, less than half of that $202,000. So we can see that, essentially, the U.S. system is remarkably expensive. Not because it’s delivering a, a huge range of things that other countries are not doing. Not because the outcomes are better, but because the unit cost of the interventions is simply out of sight. What are some of the causes of this? Well, you could say this is very specific to the U.S., though that’s an important economy, but I think that the lessons are more general. In the United States, some of the things keeping the high costs high are the limited supply of doctors, controlled by the American Medical Association itself, which works with the medical schools to determine the flow of new doctors. Market power, that is the lack of competition. A true price discrimination in the hospitals. A true highly concentrated ownership of major hositals in a region. By the conflict of interest of doctors who own their own diagnosticlaboratories and then prescribe heavily imaging for instance MRIs or CAT scans on equipment that they themselves own. We see drug pricing at levels far above what is priced in other countries often because of close tie ups between the doctors and the pharmaceutical companies. Enormously high administrative costs because in the U.S., in the private economy, each hospital perhaps, or each group of hospitals has its own insurance connectors. The systems of different kinds of payers, public and private don’t communicate very well with each other. Whereas in other countries, in many cases there’s one single payer the government, and the government may be at the provincial or the national level, pays all the health bills. And so the administrative costs of managing America’s more privately oriented system is very high. And now I’ll add one final huge dimension, political economy. The health sector in the United States is powerful. It is one of our four most powerful lobbies in the United States, just along side Wall Street, thefinancial markets number one, big oil number two health sector number three and the military industrial complex number four. Four giant, powerful lobbies in the United States that also helped to prevent remedial action on these issues. Now, one of the leading organizations in understanding the U.S. health system the Institute of Medicine of the U.S. National Academy of Sciences did a recent study. They found something extraordinary. That the waste, fraud and abuse in the system, the over billing the waste of resources the repeated tasks, the outright fraud, the high management costs amounted to 5% of U.S. national income. That’s astounding. 5% of of, of U.S. national income is with a $15 trillion annual economy nothing short of $750 billion dollars a year in waste. And when you put that into context, the U.S. is spending 18% of gross national product in health. And what the Institute of Medicine is suggesting is that maybe out of that 18%, it’s getting 13% of national income in real value. Well why does this system persist? Partly because of its history of having organized itself as having a private sector economy that is not effective and doesn’t obey the principles of free markets. But partly because of the power of the lobby. And if you look at total lobbying outlays according to various sectors, you find something quite astounding. Adding up all of the registered lobbying outlays between 1998 and 2012. While miscellaneous businesses abroad grab bag category comes number one in the list. Number two in the list is the health sector. More than $5 billion of lobbying by private health companies to Congress, telling congressmen and the President and others influenced by this, don’t regulate us, don’t force us to expose our price discrimination. Don’t regulate us as other countries do so that there’s one price that applies to all patients within a certain category. Don’t regulate the prices that pharmaceutical companies charge on their patent protected medicines and so forth. Don’t try to reduce administrative costs, those are our profits those are our earnings those are our employment, say the big health insurers. And they do this through mega-lobbying. They also do it through campaign financing, shown on the next page. It’s the fifth of the sectors from the top, in the amount of financing spent by the industry during the most recent campaign cycle, complete campaign cycle, of 2011 to 2012. The health sector contributed, and this is means people from health companies registered as they make campaign con, contributions, giving about 260 million dollars of campaign contributions. You can understand that this leads to some attentiveness of the politicians to the interest of this concentrated group, not necessarily to the interest of the taxpayers, or the citizens more generally. What are some of the reform options? Let me conclude with that. First, would be to move to a single payer system like Canada has. It’s not simply in the imagination it’s in the real world. And Canada’s health system is far lower cost than the United States, with very high quality. A second possibility is what’s called an All Payer system. Sure, money would come from private employers, from out of pocket, from private insurance but there would be one price paid, per condition or diagnostic category or per individual covered per year. Rather than price discrimination where the hospital or the health, private health provider tries to get as much as possible. And if the unwary consumer doesn’t realize it it fleeces the unwary consumer by imposing costs far higher and prices far higher than other patients are paying. A third possibility is even more transparency, a certain fee paid by government or by employers per patient per year, so it’s not on the basis of services rendered, not on the number of tests, not on the number of hospital visits. That, the provider would have to provide efficiently, and at low cost if they want to make a profit. And so, another possibility is what’s called capitation. That the insurance company or the government would provide one amount of money per year, rather than fee for service. Another aspect would be increased supply. To remove the ability of the American Medical Association to constrict narrowly the number of doctors and specialists that come online. And finally I would mention how technology can be the friend of lower costs. With information technology, smarter systems, patients monitoring their vital signs at home or telemetry where a patients information is automatically being read at a distance at low cost and the patient comes in for visits only when the indication is there. Or community health workers, as in the low income countries working in the high income countries to reach people in their communities, rather than waiting for mega disease costs in the hospitals themselves. Plenty of reform, plenty of way forward, partly changing the incentives, partly employing new technologies. Of course that kind of reform also depends on politics. If the lobbies get their way, you get inflated costs. If this is a system that is run for the public benefit, there is tremendous good that can be done to reach more people, improve health outcomes, and accomplish that, especially in the United States at considerably lower cost.

Universal Health Coverage IV

Ten Recommended Steps to Health for All in the Poorest Countries

The period of the millennium develop goals since the year 2000 has been an exciting one for public health. Because public health is really proved its worth showing how a science based approach starting with epidemiology. Building health systems supported by international help in the form of Official Development Assistance.

Malaria is a not only a lethal disease but it’s a disease that spreads very widely. And in many parts of Africa is what’s called holoendemic. Endemic meaning that people are infected. Holoendemic meaning that the whole community, everybody is infected and basically the whole year round. So to control malaria is really it’s a great feat. And malaria is being controlled right now in Sub-Saharan Africa. Thanks to the focused efforts of the Global Fund to Fight AIDS to be malaria or the U.S. initiative of PMI and others alongside it. And because of the great advances in public health and in technologies that make it possible. Long lasting insecticide treated bednets.

Community health workers who go into the communities, rather than waiting for sick people to carry their young. Often dying children many, many kilometers in their arms, hoping to arrive at a distant clinic in time. With the community health workers out in the communities, cases can be picked up much faster. Lives can be saved. A prick of the finger allows a community health worker to know within a few minutes whether that child is infected with malaria. And new medicines that replaced those fading, failing medicines like Chloroquine now based on Artemisinin. Very interesting story because Artemisinin is a molecule, extraordinarily effective in fighting malaria that was identified by Chinese scientists. How did they come to that? Because there was an ancient Chinese herbal treatment for malaria and for other fevers that came from a, a plant that the Chinese called (XXX) And that we know as Wormwood, or in its Latin, as Artemisia annua. And that was an ancient herbal remedy. But when the Chinese scientists went after it, the found out what is the active molecule and that we now call Artemisinin. When Artemisinin is put into medicinal form now, it’s enormously effective to control Malaria. And that’s one of the breakthroughs of recent years as well. If deaths of children under five have declined from 12 million back in 1990 to under 8 million in 2010, that’s a huge progress. But obviously, far from where we should be because most of those 8 million deaths are also preventable. We’ve gotten half way to building the primary health systems and we should take inspiration from that. And understand what it would mean finally to fulfill the commitments that was made already back at the founding of the United Nations and the World Health Organization. The commitment that was enunciated once again in Alma-Ata 1978. The commitments that was the motive spirit of the Millennium Development Goals of ensuring health for all and universal health coverage. Let me give ten basic recommendations of how we can move from the improved situation today. To the full breakthrough of universal health coverage and health for all within a short period of time, even within a decade. The first is a financial point. If we look at what the poor counties simply can’t afford on their own and need to be filled by official donor assistance. We can calculate how much aid should be directed at the health sector. Now mind you, I’m not talking about aid, year in, year out forever. I’m talking about an amount of aid that will shrink, as the poor countries develop, and reach a threshold, of income, where on their own, they can fund their own health systems. That threshold is reached probably somewhere around $1,200 per person per year, measured in current prices and market exchange rates. If you calculate the gap that the poor countries simply can’t manage out of their own budget, it’s around $40 billion a year Roughly $40 per person for a billion people that need that extra help. 40 billion how should we think about that is that a big number or a small number for the rich world. Well one way to think about it is that as we know there about a billion people in the rich world so it’s on the order of about $40 from each of us in the rich world, to save millions and millions of people in the poor countries. But $40 per person in the rich world is the bargain of the planet in terms of the lives that could be saved. Let me put in terms of the proportion of the rich world income. We know, that the average income of the rich countries is on the order of $40,000 per person per year. For the billion people in the rich world, it comes to about $40 trillion of income of the countries that give Official Development  assistance. 40 billion out of 40 trillion is one out of a thousand, it’s one tenth of 1% of our income. Or to put it another way it would be like saying for every $100 in the rich world take a dime put it aside, next $100, take a dime put it aside. One tenth of 1% of the income, would accumulate into a total fund of $40 billion per year.  So the starting point, number one, in the recommendation is a, annual flow of funds from the rich countries to the poorest. 40 billion a year right now. A number that would shrink over time. One tenth of 1% of high income world output each year. That would close the financing gap and enable millions of lives to be saved. Second recommendation. Put that money into highly effective organizations. My own recommendation would be to build the Global Fund to Fight AIDS, TB, and Malaria. Which has done such an outstanding job, into a Global Health Fund more generally and channel through it about $20 billion per year. So that the Global Health Fund could effectively support the basic health systems in the poorest countries. Letting those countries know that as they develop and lower disease will help them to develop. They will get less and less over time, because they will eventually graduate from the aide itself. Now third is that the low income country’s have to do their bit. They can’t fund their health systems just on their own. But they can make the valiant effort needed, they should contribute as much as feasible. And as I’ve mentioned, most fiscal experts that have looked at this regard 15% of the total budget as a stretch. But realistic and reasonable target for funding help. So the third recommendation is that the poor countries would be called upon to meet what became known as the Abuja Targets. Because of a meeting that took place in Abuja, Nigeria. The Abuja Target calls for the poor countries to devote 15% of their budget revenues to the health sector. The fourth recommendation is to finish up this job of comprehensive malaria control. Malaria is getting under control. You’d think I’m a little bit obsessed with it. And the fact in the matter is you’re right. Malaria is such a pernicious disease. Such a killer. Such a burden on development.  ut so much within reach of control that we do need to put the focus on it. And we’re close to getting the job done, but still underfunded roughly by half. So my third recommendation, fourth recommendation is that the world should adopt a plan for comprehensive malaria control. That would cost roughly, $3 billion a year. Which enable the poor countries to finish up the supply chains, the funding of community health workers, the rapid diagnostic tests, the medicines and so forth to really get the job done. Fifth recommendation. The leading donor countries should fulfill their longstanding commitment to providing universal access to antiretroviral medicines for individuals infected with HIV. And having the clinical indications for antiretroviral treatment. These medicines work. The treatment to poor people saves their lives. It’s been shown to be highly effective. More treatment would mean lower transmission of the disease because when an individual is treated with antiretroviral medicines. The viral load, that is the concentration of the virus in the body diminishes sharply. Making it much less likely for the virus to be transmitted from one individual to another. Sixth recommendation. That the leading donor countries should also fulfill their commitment to partnership with the poor countries. In funding following the global plan to stop TB, to stop tuberculosis. This too has a financing gap on the order of $3 billion a year, roughly $3 per person per year in the high income world. Roughly, cup of coffee at your favorite coffee shop in a high income country would be what is needed incrementally in order to build the requisite fund. Recommendation seven. That the world, especially the donor countries and their financing and the poor countries and their implementation, should guarantee access to sexual and reproductive health services. This would include emergency obstetrical care for safe childbirth, antenatal care for safe pregnancy, and contraception. Because many, many women around the world want to have fewer children. They want to use modern contraceptives. But they lack access or they lack the funds to, be able to afford it on a market basis. And so we need full funding of family planning services, contraception and emergency obstetrical care. Pregnancy safe management. And, again, at a very low budget. These services could be made universal. Eighth, the Global Health Fund would take up what have sometimes been called neglected tropical diseases. The neglected tropical diseases are diseases less in the headlines than malaria. Less in the headline than AIDS. The experts in those disease communities feel a little bit neglected because they are saying wait a minute, we also have powerful tools to fight deeply debilitating diseases. And yet, we are sometimes overlooked because our diseases that we’re studying and trying to control are not in the  headlines. And when I tell you the names you’ll say, you’re right, not in the headlines, never heard of them at least for some of them. But among these neglected tropical diseases are hookworm, that I presume most have heard. Ascaris which is a kind of worm infection. Trichuris another worm infection. Onchocerciasis, yet, another infection in the tropical areas that is absolutely a killer, but can be prevented and can be treated. Schistosomiasis, a disease in which a snail plays an important role in the life cycle of this disease. Filariasis, lymphatic filariasis, another vector borne tropical disease with, terrible consequences. Also controllable through bed nets. and, with, ample effort and organization, a disease whose burden could be reduced very, very sharply. And various forms and causes of blindness including trachoma, that is an infection of the eye that can cause blindness. And that can be prevented,ah, that is wide spread, a major cause of blindness. Also, we know, one could add though it’s not in the usual list of the neglected tropical diseases, is cataracts. Where advances in surgery allow for remarkably low cost replacements of the lens when individuals are blinded by  cataracts. And this is another case where communities especially elder, older people can be brought back to sight. With the tremendous benefits of course for themselves in the community at very, very low cost. So category eight, expand the Global Fund’s reach to these neglected diseases. Category nine, the Global Fund should establish special financing to complete the health systems. Not only the targeted diseases, but the training and deployment for example, of community health workers. This would be a crucial part of the, transformation from a disease targeted fund to a general global fund that’s providing a broad base of services. We have called at the United Nations for the deployment of a 1 million community health workers in Africa by the year 2015 as a major boost for achieving the Millennium Development Goals. Malaria control, it’s essential to get the community health workers out into the communities with their rapid diagnostic test with their Artemisinin in their backpacks. With their mobile phones for, getting advice from the clinics or being able to call an ambulance. When the community health workers are out there, the malaria burden, plummets. And finally, recommendation ten, is that there are now, a number of noncommunicable diseases. Typically that have been overlooked in many of these urgent MDG related efforts that also can be part of the primary health system. Dental care for example, treating cavities, something very basic, but often not present in poor countries. Eye care, mental health counseling and mental health interventions for the massive burden of depression for example which is pervasive around the world. Many cardiovascular diseases where people have undiagnosed high blood pressure, hypertension that can cause loss of life for adults. But if treated, brought under control can absolutely have the consequences meliorated or the adverse consequences controlled all together. A number of cancers can be addressed at very low costs. And of course, campaigns against tobacco use are part of any good public health system because tobacco remains a massive killer. That’s a behavioral challenge but it’s a behavioral challenge that we need to meet because it’s one of the most effective ways to save lives. Moral of the story, we’re close. It’s not so hard, the Millennium Development Goals have given a big spur to effort, we can now see a pathway to help for all. In the next phase of the Global Development Objectives, the Sustainable Development Goals. I would expect that universal health coverage will feature prominently in the next phase of goals. And we will have the opportunity indeed to complete what we have started. To finally achieve to realize health as a basic human right.

Universal Health Coverage III

Designing and Financing a Primary Health System in Low-Income Settings

We have a challenge, a heavy disease burden in poor settings. We know that poverty itself is a major contributor to this disease burden. We know that most of the causes of disease are preventable or treatable. The question is how to design a delivery system in health and in the related sectors at low enough costs that it’s possible to make great headway even in the midst of poverty.

931Solving that problem has a huge, huge benefit. And not only would it tremendously improve health and we already see such improvements on the way, but it can break the poverty disease spiral and turn into a health development upward spiral. That’s our goal. The starting point for designing an appropriate health system is the science of public health. But what is public health? We know what medicine is. We think of doctors and nurses. They’re treating individual patients. Public health could be called population health. It is treating the health of a large population and partly of course through the work of doctors and nurses. But also through other tools that they don’t necessarily depend on doctors and nurses, through attention to safe drinking water, through attention to, The access of the community to anti-malaria bed nets through attention to widespread coverage of effective vaccines against the vaccine preventable diseases. So, public health looks at health from a population perspective. And scientifically addresses what should be done. The answer differs, differs by location, differs by income level because the answer in public health depends on the disease burden that needs to be addressed. I regard public health as being not not only highly effective, but quite systematic. And I would describe the public health approach this way. First, understand the Epidemiology of disease, that means understand the, nature of the diseased burden in a particular population. What is the DALY count? The disability adjusted life years. What is the prevalence of the disease that is it’s frequency in the population. What is the incidence of the disease? The number of new cases. In a given time period. Epidemiology measures the disease burden in a systematic way, and also focuses on the transmission mechanisms. Is the disease transmitted person to person, is the disease transmitted by in, intermediate vectors, so called, such as the anopheles mosquito Which bites one person infected with malaria and then later on bites another person, transferring the infection to that second person. In which case, the mosquito is serving as the vector of that disease so, the epidemiologists need to understand a lot about what kinds of diseases, who’s affected, how the diseases are transmitted. The second stage of good public health thinking is to examine the feasible and desirable interventions. What should be done? A lot of public health comes packaged, essentially, as apps. There’s an app for vaccines. There’s an app for distributing antimalaria bed nets. There’s an app for antenatal care. There’s an app for safe childbirth. Of course, that’s not the the, the way that the public health specialists might phrase it. They use the term interventions, but the, what they mean is systematic packages that address particular conditions. How to de-worm, how to control malaria, how to ensure safe childbirth, how to ensure neonatal survival how to get a new good nutritional outcome, how to face a diarrhoeal disease. How to break a cholera epidermic. These are the interventions. Based on the epidemiology, proceed to understand what are the interventions, both within the health sectors specifically and in the closely related sectors of nutrition, farming, safe water infrastructure and the like. Third is systems design. You have a list of interventions. Every child should get an immunization, every household should have bed nets, every mother should have anti-natal visits, every newborn should be visited by a health worker. Great. That’s a list. That’s a bunch of bullet points. How to deliver? That list effectively. Real implementation. That in essence is about systems design. Who should do that work? Who should give immunizations? Is that doctors? Is that nurses? Is that clinical officers? Is that community health workers? How should bed nets get distributed? Who guarantees the supply chain of medicines? Who reads the diagnostic tests? Who manages the work force? Who supervises the workers for their honesty, or for, their level of training and their competency This of course is the kind of challenge that a business faces in running an organization. Running a public health system is quite a complicated challenge. Building that system, often nearly from scratch in a very poor setting is extremely important because, comes to the question of training, recruitment, job designations and so forth. Now, part of that system, then, has to be translated into actual management and implementation. There are many things to do, especially when you’re starting in a very poor community and you’re building up a whole system, you have to invest, build an operating theater for emergency obstetrical care. And build an examination room, build a new clinic, build a new bore well for safe drinking water. You have to train a labor force, typically in a poor setting, a place where healthcare has been under invested for years, decades, or forever, there’s a tremendous amount of training to be done. Of course, there is community empowerment. The health system by it’s very core, involves the individuals in the community. They have to seek health care. They have to be. Connected with the health facilities. If they’re health workers, they have to trust the health workers into their homes, for example, or have the confidence to call the health workers. So community involvement and community empowerment is essential. Oversight, like in any business or any organization, How do you make sure the work is actually getting done, that the funds are being used properly and not being embezzled, that the disease burden is as it was thought, not some completely different and unexpected mode of disease transmission. And a good system has not only monitoring, but evaluation. Assessments, how are we doing? Why did mothers die last month in childbirth in this district? What went wrong? Were those deaths preventable? Is the doctor competent? Is the ambulance broken down? Is the power not actually available in the emergency room and so forth. So, this is the systems design that is absolutely crucial for practical success. Then comes financing. It’s not surprising that money looms large in this issue, we’re talking about poverty. We’re talking about places where the absence of money plays a pervasive role in the presence of disease burden. And the question is, even if a health system is designed that With high efficiency, very smart epidemiology, very cost effective interventions. Can a poor community afford this? If not, where can the incremental funds come can make this happen. Let me discuss just a few of these aspects, and, hope that some of you. Will go on to great careers in public health. I emphasize it again because I think it’s a such a wondrous profession that actually saves lives, delivers results, has the systematic and scientific approach that is so useful. Some of the interventions that are feasible based on the local epidemiology, include malaria, a disease that is a killer. It is a pathogen, a single-celled organism called plasmodium, which is transmitted from individual to individual. By a mosquito, that as I mentioned bites an infected individual, in a subsequent bite about  two weeks later, infects a second individual unless there’s protection. What kind of protection? Well, it could be medicines that kill the pathogen in an infected individual and it could be a prevention of what’s called vector control because the mosquito is the disease vector. Vector control could be something like putting larvicide to kill the larvae of the mosquitoes before they hatch and can transmit the disease. Or it can be bed nets that block the mosquito from biting. Or, if the mosquito sits on one of these bed nets and takes up the insecticide, kills the mosquito before it can become ineffective and transmit the disease to somebody else. Vaccine preventable diseases, like measles, which otherwise claim huge numbers of lives. But we have many, many vaccines that are highly effective but often don’t reach the children in need. De-worming, as I’ve already mentioned, infections like hook worm. Which are very debilitating for children, rob children of nutrients create a loss of physical growth and many many other terrible health problems but are easily solved by very low cost de-worming medicines the problem is, the children aren’t getting them. Neonatal survival, a child is born, but doesn’t take a first breath. But it’s known there are simple interventions, that the pediatricians call helping babies breathe. Simple resuscitation techniques. That at almost no cost Could save huge numbers of new born’s lives. Famously oral re-hydration, when a child has a severe case of diarrhea and is losing water, and can, can die from the diarrhea itself, that child needs to be re-hydrated To have fluids reestablished, and the right kind of solutions can rehydrate the child and save lives. And this has been now known for many decades that even community health workers without medical degrees or nursing degrees can effectively Provide oral re-hydration and save children who would otherwise die. Antibiotics to fight respiratory infections. Many other kinds of preventions. A notable one that is a major global effort now is to prevent the transmission of an HIV virus from an infected mother to a newborn. Because it is the case that if a mother with HIV infection that may or may not yet be AIDS has a child, that child has a reasonable chance, maybe a, a third or half if no precaution is taken to contract HIV in childbirth or subsequently in breast milk during breastfeeding. And so there are now protocols to put the mother onto anti-retroviral medicines. Dramatically reducing the viral load of the HIV in the mother. And dramatically reducing the chance that the virus, thereby, is transmitted from the mother to the child in childbirth or breastfeeding. These are all examples of how a good epidemiology can be connected with a good set of interventions and the results can be very striking and hugely positive. Look at a picture, rather unpleasant but I think important for us to get a reality check. Of this very cute little girl with the kind of distended belly you would see in many villages in many parts of the world. Have a look at what came out of that belly. You see a, a horrifying plateful of worms that came out after the little girl was administered with the, the basic, very low-cost anti-worm infections. And as a result of her deworming, she and little children like her have a growth spurt afterwards, because those worms have been taking away her nutrients, her absolutely valuable nutrients necessary for her Brain development and her body development. They’d been taking them for, the worm’s growth, which is obviously the opposite of what we want. De-worming, therefore, allows a growth spurt, just like disease controls allows an economic spurt in countries that are otherwise burdened by massive disease burden. This set of interventions and others like them, properly identify through good epidemiology, can be administered at low cost in a highly effective very cost health system. In today’s dollars of say the year 2013. The cost of such a basic primary health system addressing the diseases, conditions that I just described, might reach no more than $60 per person in the community per year. A remarkably low cost to address all of those disease conditions. And you would say, 60 bucks per person per year to save all those lives and to reduce the disease. Why hasn’t it happened? And the irony is, and this is the really basic point, I sometimes call it the iron law of poverty. Even $60 is too much for a government in a very poor country. And this, I think, is the part that’s hard for us to appreciate because we assume and again, it makes sense intuitively, it’s just not correct, that if this kind of disease continues in poor  communities, maybe the government’s not trying very hard. That’s not correct. Consider the following, a country, say, is at $400 per capital, not in purchasing power, but at current market exchanges rates. That’s the kind of pricing that I’m using for this $60  example. Now, a country at $400 per capital, a country like Malawi, might collect 20% of its national income in taxes. Probably wouldn’t be able to manage more than that because a lot of the income isn’t even monetary income, it’s just the production around the farm household itself. So, as a thought experiment, consider a country at $400 per capital. Whose tax collection is 20% of the national economy. 20% of $400 is 80 dollars per year. What that means is that the governments revenue out of its domestic revenue collection would be $80 per person per year in the country. What is that $80 per person have to go towards? Well, it has to run the government, the parliament, the courts, the president, the national defense, the police, the roads, the power, the infrastructure, water, sanitation. I, the it has to go for the schools, it has to go for construction for environmental conservation, and yes, part of it has to go for the public health system. But think of it, you have $80 in total You have to allocate it to all of those purposes, and experts that have looked at this repeatedly say that a country really focusing on health, but also on education, infrastructure, courts, decency, rule of law, might be able to stretch and devote 15% of the total budget. to the health sector what’s 15% of $80 per capital? Yikes. That’s just $12 per capital per year devoted to health. How much healthcare can you get for just $12 per capital? And keep in mind that in Europe and the United States, the public health budget is $3,000 per person per year. Or $4,000 per person, per year. The point is the following: for a poor country, even trying hard out of its own revenues, it can’t reach the $60 per person per year. On its own. This is why development assistance, ODA as we talked about it, Official Development Assistance, is so important for health. And now you can see the complexity of this challenge. On the one hand, we need good epidemiology to describe what should be done. Next, we need to identify effective interventions. Third, we need to identify the kind of system that can bring about those interventions. Fourth, we need to manage and implement such a system. And now, I’m saying, we have to pay for it, not a fortune, but an amount that is beyond the means of the poor country itself. The answer, in my view, is official development assistance Carefully, scientifically, professionally targeted towards improving the health of poor people. Helping them to build primary health systems. This is what I advocated when I chaired the commission on macroeconomics and health for the World Health Organization. And what I have championed for a dozen years as special adviser to UN Secretary General, Coffee Annan first, and now to UN Secretary General Ban Ki Moon, on how we can achieve the millenium development goals. We’ve taken the targets of reducing child mortality, maternal mortality, and the burdens of infectious diseases. To do the work, we now see scientifically how it can be done. We see, even, that the budget is very, very small, but too big for the poor countries. That’s why I am a strong believer in organizations like the global fund to fight AIDS, tuberculosis, and malaria, which I’ve participated in the design and launch, now a dozen years ago. We need extra funding to fight those three diseases. That’s why I’m a great fan of the global alliance for vaccines and immunization. GAVI, which provides extra financing for immunization coverage. That’s why I’ve been a great fan of the United States Pepfire program, the emergency program for Aids, and the USPMI Program the Presidents Malaria Initiative that has given extra income to Poor, malaria stricken countries to fight malaria. These kinds of targeted focus, official development aid programs have been hugely effective, very successful. Because you know how the money should be used. You can monitor it, you can watch it, you can assess it, you can evaluate it. And the results are very strong. And what’s heartening is the figure that you are looking at of the take off of official development assistance, especially bilateral assistance. That is from governments to other to low income country governments. Especially after the year 2000, because it is with the millennium development goals that these great breakthroughs are being achieved. Malaria is coming down, the AIDS  urden is coming down, a treatment for tuberculosis is expanding. Under five mortality rates have come down considerably, maternal mortality rates have come down considerably. We’re seeing that public health works, but we’re not yet at the full system to deliver it in part because the budget gap remains significant even if it has declined. This has made a big difference, but there still is an important gap that needs to be closed so that we can truly achieve our long-standing and crucial objective of health for all.

Universal Health Coverage II

Poverty and Disease

The problems of health that are problems for all societies. In the rich world where health conditions are far better than in the poor countries. The problems of very high and rising costs of health care are front and center on the political and the economic agenda. In the poorest countries the challenges of course are also about finances but much more importantly about the tragic loses of life and the very high burdens of disease. Often from conditions that have been eliminated completely in the high income world.

921Poverty and ill health go together and we need to understand that linkage of poverty and ill health because understanding it enables us not only to. Address the challenges of heavy diseased burdens of pour countries but also gives us an added and important tool for breaking the poverty trap itself. We should expect two-way causation, that poverty Contributes to disease in many, many ways, but disease of course also contributes to poverty. An individual suffering from disease loses income. A community or country with a heavy disease burden similarly loses income from. Sickness in the population, lack of productivity, other burdens that arise in the economy when there is a large amount of unattended disease. How does disease contribute to poverty? Think about the, the following pathways. First through the adverse life cycle development of a, of an individual. If a young child survives illness but is buffeted by repeated illnesses when you. We now understand better that not only is that likely to set the child back in terns of readiness for school perhaps in terms of school enrollment or primary school completion. But that early bout of illness can have a lifetime effect on cognitive and physical development and on vulnerability even.

At adult ages to various kinds of diseases unexpected diseases. Cardiovascular disease can be affected by nutrition that is poor in early age. So human development across the life cycle. Is strongly affected by health and disease. Disease can have long term individual consequences. Disease burdens of adults in the labor force of course can have large and adverse results for an economy. Think about a village that has to harvest the crop. The crop may be the absolute lifeline for the village to enable it to eat throughout the coming year. But in many places, just at harvest time, there’s also the risk of a malaria epidemic. Malaria is a disease that is transmitted by the bite of a mosquito. The mosquitoes are breeding during the rainy season, the same time that the crops are growing. By the time it’s right to harvest the crops, it may be that the larvae have developed into mosquitoes now transmitting malaria infection. It’s not uncommon, therefore, that just when harvest time comes, the whole community is knocked out by malaria and can’t harvest the crops. Think of the consequences of that for poverty for devastation, for hunger, even for famine in the coming year. Of course, another economic consequence of ill health is the direct cost of health care itself, if a community can afford the health care. That eats up a budget, and it can be very, very expensive treating the diseases for very poor people. Even what would seem to be, modest outlays of a few dollars or a few tens of dollars, for a disease. Amounts that would hardly be noticed in the rich world can be the margin of survival for poor families that hardly have enough to eat to start with and may lose their last remaining monetary income to the effects of a disease.

922A disease burden contributes indirectly and over the long term to demographic problems. Remember how high total fertility rates can impede economic development, when the population’s growing rapidly, and when the community is supporting a lot of young children, and looking after them. And having to put them through school, and build new schools for a growing youth population. Who are not themselves earning income at the time, the burden of rapid population growth and a very young age distribution, I, is a huge hindrance for economic development. We’ve noted already on several occasions that a rapid voluntary reduction of fertility can be a big boost as it was in China to economic growth. But consider what happens when there’s a heavy disease burden. When out of every 1000 children born, 100 or 200 or 300 don’t survive to adulthood. Parents knowing of the high risks of children’s deaths. Therefore respond by having large numbers of children and if the household wants to be absolutely sure that there is a surviving son. For instance, for cultural reasons to perform the funeral rights or for very pragmatic economic reasons to support the mother and the father in their old age. Families may choose to have two or three or four sons to make sure that at least one survives but having two or three or four sons might mean having four or six or eight children as a whole. And so this is another indirect way often overlooked at how high disease burden is conducive to a perpetuation of poverty. Finally, one should note, investors are not so keen on investing into a high malaria zone or into a high AIDS region. Think of it that you are aware that your labor force could be very sick, could be dying young. A need to replace many, many workers as a hotel manager you’re aware that you’re trying to get guests to your hotel but after every rainy season there’s a malaria epidemic. It doesn’t seem very attractive for investment. You’re a mine manager. But you’re surrounded by infectious diseases like malaria. Well, foreign investors don’t like to head to those locations. This is yet another way how disease leads to poverty. But the arrow goes the other way as well. And I think that’s the direction that people perhaps most naturally consider how poverty contributes to disease.The answer that  trips off the tongue and comes to mind is can’t afford a doctor. And of course poverty does mean a much lower access or no access at all to medicine to modern doctors to basic health services, but there are many, many other ways that poverty contributes to a heavy disease burden.

923One that I’ve mentioned already is the immuno-suppression that comes from chronic under-nutrition. Children who are not fed well, who lack basic micronutrients, have immune systems that are tuned down, that are not as effective, not as able to resist disease. Poverty also tends to mean a more dangerous physical environment. Poor families in rural areas typically don’t have reliable sources of safe drinking water or reliable clean sanitation. There’s open defecation it means that many diseases cycle through the body and are spread by open deification and the pathogen getting back into the ground water. And back into the wells and back into the water supply a diseases like cholera are spread in this manner. And so poor communities have poor infrastructure lack of access to the basic environmental conditions for good health. Poor people live in adobe huts with thatch roofs, often with a gap between the thatch and the walls a gap in which various insects can easily enter, mosquitoes bearing malaria or flies bearing other diseases or other insects that are coming and spreading disease. So even the physical structure of the housing can make a very, very big difference. Poverty is related to the ecological conditions of disease. Worm infections like hookworm or Trichuris or Ascaris are in warm, wet, tropical climates. Poor people living in the warm, wet tropics are subject to a much heavier helminth or worm infection. That’s part of the reason for their poverty, but it’s also the cause of poverty coming from the disease burden. Malaria is a disease of the hot tropics and, as a result the poor people living in that region have this extra burden of disease. One can say that it’s a condition of poverty, it’s really a condition of the geography associated with poverty. Poverty is also associated often with illiteracy, innumeracy the lack of ability of individuals to seek health in the right way or to understand what to do or how to fill a prescription or how to adhere to a drug regimen if that’s what’s needed. And so, health seeking behavior is extremely important for all of us. Poor people have a harder time with less education and less ability to fair out the right kinds of help. That’s why workers like community health workers can be so important to help poor people make the connections with the health system itself. And people living in poverty are very, very vulnerable to doing dirty and dangerous work. Young women who because of their extraordinary vulnerability, end up in sex trades, for example. And vulnerable to AIDS and other sexually transmitted diseases or to violence, and to other life threatening conditions of life, is another aspect of poverty itself. And so once can see this two way direction. Poor health leading to poverty Poverty leading to poor health. Whenever you have the arrows working in both directions, you have the possibility of a vicious spiral. Poverty, poor health. Poor health, even more poverty. More poverty, worse health. Worse health, even worse economic outcome. But whenever you have a vicious spiral you generally have the possibility of a virtuous spiral as well. Disease control raising income, higher income improved health, further improvement of health. Even yet further improvements of income in a virtuous spiral, exactly the opposite of the vicious downward spiral. It’s part of the effort of health the policy to break the vicious circle that traps people in a poverty disease trap and to make it a positive spiral of a health development upward spiral. So how can this be done? How can one intervene to control disease and thereby start the virtuous spiral? First of course is implementing what the health ministers called for back in 1978 in Alma Ata. They called for a primary health system for all, and implementing that basic primary health system is a crucial first step. Second is helping poor communities to have better nutrition. Part of that may not be directly in the health sector but in the agriculture sector. More productive farmers growing more food will support healthier diets. The community may generate a surplus that can be used for school feeding progr, programs for example. And therefore, agricultural interventions can play a role not only in agriculture and income, but also in reducing the disease burden. Local infrastructure, is another kind of investment not in the health sector per se but in safe drinking water and sanitation in. Power supplied which is vital for everything. Electricity to run the refrigerator in the clinic to keep the vaccine supply chain adequate to ensure that doctors have the facilities. Water to pump the irrigation water to improve agriculture. And a thousand other uses of electricity absolutely vital to improving overall health. Mobile phone connectivity, internet connectivity. We don’t think of those as health interventions per se. But communities that have access to phones have access to better health. They can call the doctor, they can call the health worker, they can call the ambulance and so investments in infrastructure extremely important. Education at all levels absolutely essential just so individuals understand how to seek help. But also, education raises incomes, we know that higher incomes for all the reasons we’ve discussed improve health outcomes as well. And local business development by raising the incomes of the community also cut that downward spiral of poverty and disease. How far do we have to go we have a ways but we’ve made also a lot of progress have a look at the data on the mortality rates of children under the age of five. Back in 1990, 12 million children under the age of five died. By 2010, the number was under 8 million. This is a huge, huge victory for public health. It is still 7.6 million too many. It’s still multiple and preventable tragedies, but there’s progress. There’s very substantial progress in reducing the mortality rates. If you look at the next graph, those same mortality rates are put in terms of numbers per thousand live births rather than the aggregate number of millions. And this is quite important as well. In 1990, on average in the world, 88 of each 1,000 children did not live to their first, to the fifth birthday.

By the year 2010, that rate had declined to 57. Per thousand. Still, a high number, still a number of deaths that can be cut sharply. But the under five mortality rate is falling sharply. Now remember, we also have an important clue where we need to put the extra special effort. If you look at the total number of deaths in the year 2010, the 7,600, more than 6,000 of those deaths were in just two regions, Sub Sahara in Africa and Southern   Asia. These are the epicenters not only of overall poverty but the epicenters of the disease burden and of the preventable and treatable diseases that could reduce this amount of suffering. And where are poor people succumbing to what kinds of conditions? That is shown by the estimates of the causes of deaths of children under five. And when you look at this chart, the 100% of that’s allocated in proportions to different diseases. What you see as the overwhelming message of this chart is this still very high burden of communicable, that is infectious diseases that can be spread from individual to individual. Diarrhoeal disease, pneumonia, measles, malaria, other infectious diseases, are a very large part of these deaths. What you also see are the number of deaths of children just in childbirth. As newborns, or neonates. And in the first four weeks of life. In the very vulnerable conditions just after birth. And so we see birth asphyxia. And the trauma, prematurity. A severe neonatal infections. A whole cluster of a causes of death related to childbirth and very often to the lack of sanitary conditions that face mothers giving birth. Threatening their own lives and threatening the survival of their children. Well, this is a, a good start for us in terms of understanding what to do. We have a poverty disease trap, each feeding on the other. Poverty feeding disease, disease feeding poverty. We know that this is heavily concentrated in Sub-Saharan Africa and in South Asia, we know that it’s heavily concentrated in diseases that are infectious and communicable. Or in conditions related to childbirth, or as a consequence in addition of chronic under-nutrition. So this gives us ideas where should the focus be how should we proceed? Building a primary health system that is responsive to those specific challenges is in essence the source and, and the starting point for addressing this wholly solvable but continuing crisis. We’ll now look at how that primary health system in a low income setting can best be designed

Universal Health Coverage I

The Human Right to Health

Good health stands at the very center of sustainable development. It is one of the most important goals of humankind, in and of itself. And good health is also vital for everything else we hold dear. It’s vital for economic development through a productive workforce through the ability of children to not only survive disease, but also to flourish, to learn to make their way through school.

911For the ability of a community to be able to undertake economic activities or to attract investment. So health has always been  regarded as central to basic human rights, basic human needs, and to the aspirations of ending extreme poverty. It’s notable that in the millennium development goals, for example, of the eight goals about ending extreme poverty in all its forms, three of the goals, absolutely centrally, are about health. MDG-4 is about reducing child mortality. MDG-5 is about reducing maternal mortality. And MDG6 is about controlling the mass, killer epidemic diseases like AIDS and malaria. And one can absolutely say that, all of the other goals as well, ending poverty and hunger, having children in school, gender equality, a safe natural environment. Are also goals in which health plays an important role.

Both as a determinant of outcomes and also, as one of the main objectives. It’s also an area where there’s progress. And the science of public health breakthroughs in modern medicine and breakthroughs in other areas, such as in food production or in clean water from safe infrastructure in urban areas, have contributed to important gains. But we know that the challenges of achieving health for all as it’s often called, or universal health coverage, when we see a picture of this young child, sick with malaria and remember that hundreds of thousands of children like this one, will die, of malaria unless the control measures that are effective and accessible are actually implemented. We’re reminded of the kind of challenge that we still face. Millions and millions of children, especially in the very poor countries, die each year of utterly preventable, or treatable causes that could be ended.

912These lives could be saved. Children who are dying today, or are left with lifetime disabilities could, with proper organization of our response, have happy lives and safe lives, that would give them the opportunities that of course, they want and we yearn for on their behalf. Since the beginning of the United Nations itself, the priority of health has been clear. And in the Universal Declaration of Human Rights back in 1948 it was already made clear that health is a human right, a part of our basic needs. As we know about the basic declaration, those were rights, are not the kind of rights that can be achieved all at once. They are to be progressively realized. But time is going, and we could move faster. When the World Health Organization was created as well, right in its central constitution, in 1948, it was declared that health the highest attainable standard of health, is a fundamental human right. Quote without distinction of race, religion, political belief, economic or social condition. Health for all, universal health coverage. One of the really notable global efforts to achieve health for all started in 1978 in Alma Ata now called Almaty Kazakhstan. When world health officials, the health ministers from around the world gathered and made a very important Alma Ata declaration. That called for health for all by the year 2000, a notable specific objective dated for 22 years after that event. Unfortunately, when the year 2000 came, it wasn’t health for all. Unfortunately, it was pandemics for many, many parts of the world almost contrary to the aspirations two decades earlier. The AIDS pandemic was running rampant millions and millions of people infected with the HIV virus. More then 20 million, millions dying every year. Malaria which is a tropical killer disease had risen tremendously in in number of infections and in number of deaths. Because the first line medicine used in Africa to treat malaria had lost its efficacy the parasite had become drug resistant to chloroquine and so 2000 was very bleak for malaria with a surging death toll.

The year 2000 was also bleak for tuberculosis another horrific scourge of humanity that claims millions of lives each year. With tuberculosis there was a surge partly riding on the HIV/AIDS pandemic, because immuno compromised individuals suffering from AIDS died in very large numbers from tuberculosis infection. There was also as with malaria, the crisis of drug resistance and new lethal very difficult to treat strains were spreading of what we called then, multidrug-resistant TB, tuberculosis bacteria that were resistant to way wide spectrum of traditional medicine. And this also became extreme multi drug resistant TB when even the rescue medicines lost their effectiveness as the bacteria continued to evolve resistance. In other words the year 2000 did not meet the hopes and aspirations of the health ministers who had assembled in 1978, nor did it fulfill the promise of the Universal Declaration of Human Rights, nor the Constitution of the World Health Organization. So, it was notable that in the year 2000, the Millennium Development Goals put three of the eight goals so centrally on health and took up the challenge of fighting these scourges that were spreading malaria, TB, AIDS, and other killer diseases. We’ve made a lot of progress since then. The distance from 2000 till now is a period of tremendous progress. It rekindles for us the hopes of 1978. Indeed we see within reach the possibility of truly honoring the commitment to help as a basic human right. Now health like education is a merit good. Remember that a merit good is a good that should be accessible very broadly or universally in the population. Health is considered to be such a good not only because it’s so vital for individuals that we feel from a moral and ethical point of view that everybody as human beings deserves access to health. But very practically, health is a merit good, because untreated disease is a threat for society and a threat that spills over to the rest of a population when an epidemic is left to fester and to spread. Think of the devastation that comes when a highly communicable disease races through a countryside, races through a continent, as AIDS has done. The death tolls that can result in the cost to the whole community are huge. We’ll see other reasons as well why government has a necessary leadership role, not only to ensure widespread coverage, but to ensure the efficiency and, the results orientation of the health care system. Now when we look at the actual experience, in health, this is like economic development itself, one of the real achievements of the modern era. Back in the industrial revolution, worldwide life expectancy was perhaps 35 years.

913Of course, we don;t have the, records to establish with precision, a world wide number. But something around the order of 30 to 35 years of life expectancy is a reasonable estimate. This does not mean that people were dying at the age of 30 or 35. It means that a newborn on average would reach, an age of 30 or 35 taking in to account that a very large number of deaths would occur within the first month after birth or the first year or the first five years. Once individuals reached an age of 20 or 25 or 30 there would be a chance, a good chance that they might reach 55, 60, 65. So life expectancy at birth is a measure that is made at the start date of life, just at the time of birth. And from there, to estimate statistically how long on average an individual can expect to live within the society. Now from 35 years in, 19, 1800 or so. By the time we got to 1950, just after World War II, there had been some gains in the average in the world. But remember, how much of the world was still mired in poverty and also in the aftermath of war. It’s estimated that during the five year period 1950 to 1955, worldwide life expectancy was perhaps around 46 years. That’s the average as estimated by the United Nations, but if you look at this graph that divides the world according to high income developed regions developing regions and the least developed countries. You can see that, for the developed regions of the world, life expectancy, in the period 1950 to 1955, was somewhere around 65 years already. Of course much lower still around 35 years in the least developed countries. Probably quite close to the health conditions that had existed at the start of the Industrial Revolution. We see from this curve though that the world has made progress and every category of country has made significant progress. By today, world life expectancy is perhaps 70 years, twice the life expectancy, roughly, at the start of the Industrial Revolution.

914This is one of the great achievements of modern humanity, one of the great achievements of modern science and of economic development. But one also sees the continuing large discrepancies between the high income and the low income world. In the high income, life expectancy is, almost 80 years. Whereas in the least developed countries, you can see from the graph,that life expectancy is, is still 60 years or even less. In other words roughly a 20 year, two decade gap in in life expectancy between the richest and the poorest countries. This gives us a, a measure of how much we have to do. Most of the causes of death in the poor countries are in some sense caused by poverty itself, suggesting that from a medical and public health point of view, these deaths are preventable. These diseases that are causing these deaths are treatable in many cases. In this interesting graph that you’re looking at we put on the horizontal axis the per capita income of countries. And on the vertical axis, the life expectancy at birth. And you see, in this graph, a rising curve. Richer countries, naturally, have a longer life expectancy. You also see in comparing the fitted curve for 1975 and for the year 2005, the two shown here with the dotted line for the earlier year, that the whole curve linking income and life expectancy has shifted up. This means that during that 30 year interval, at any given level of income, one expects a longer life in the more recent years.

Now why would that be? The answer is technological improvement, better ways to prevent disease. Better ways to treat diseases, that, that, occur, nonetheless. And the result is that even at the same income level year after year there is an improvement of health that comes from a rise of the productivity of our public health and medical systems, as well as of other parts of our economic life. 915For instance, the literacy and awareness of people themselves, so that they can pursue health seeking behaviors more ably, or they can use their mobile phones to call for emergency help, and this is one of the reasons why life expectancy rises. Now, what I find extremely pertinent about this graph is the very steep part of the curve at very low income. This means that when countries are very poor, small increments of income going from $1,000 per year to $2,000 per year leads to very steep gains of life expectancy. Those gains later on level off so that increases of income say from $25,000 per person per year to $26,000, the same absolute increase, would have a quite small effect on the average life expectancy. Whereas that gain at the very low levels of income have a massive increase. This is to be expect. There are, diminishing benefits of added income to many things including to happiness, but also to human health. But what’s important about this curve, in my view, is, it says that even small increases of income, or I would also argue, small increases in the amounts that we are able to invest in health, can have huge benefits for the level of health. One of the themes that I want to emphasize is that very low cost investments in poor settings can have huge effects on saving lives on extending life expectancy on extending the quality of life and the health of, of people during their lifespans.

916Not surprisingly, when you look at a world map such as this one, showing the mortality rates of under 5s. Meaning, for every thousand births the number of those children out of a thousand who will die before their fifth birthday. We see that the under five mortality rate is by far the highest in tropical Africa. And next is in south Asia. Those are our two locations we constantly see as being the epicenters of the challenge of extreme poverty. And much, much lower under five mortality rates in the other parts of the world. So our challenges in health are heavily focused in the poorest countries. And, that means geographically they’re heavily concentrated in two regions of the world, Sub Saharan Africa and South Asia. The next graph shows you another asp, very crucial aspect of health and this is maternal mortality. This is measured as the number of deaths related to pregnancy of, of women for every 100,000 live births. And so the numerator of this fraction, number of deaths in pregnancy, typically at childbirth, but it could also be pregnancy related has a huge variation between rich countries where very, very few women, thank goodness, die of pregnancy related causes. Compared with countries in the poorest regions, and poorest of all in tropical Sub-Saharan Africa, where maybe 1,000 woman die for every 100,000 births, an astounding risk of death due to pregnancy. Those numbers are coming down. We see that, that the maternal mortality rate in the developing regions is falling sharply. It was around 440 deaths per 100,000 live births back in 1990. And now below 250 deaths per 100,000 live births as of 2010. We see that in the high income regions, the developed regions, the numbers are very, very small, a few deaths per 100,000 live births. The reasons for death in rich and poor countries differ. But for one basic reason, the poor die of the same reasons that the rich die. They die of cancer, they die of cardiovascular diseases, they die of metabolic disorders, say, related to diabetes. But they also die of conditions that rich people no longer die of, mainly communicable diseases such as children dying of measles, or children dying of malaria, or children dying of other kinds of infections which would not kill their counterparts in the rich world. But do kill the children in the poor countries because the children are hungry, they’re undernourished. And one basic principle of health, is that under-nutrition leads to immuno-suppression. What does that mean? Under-nutrition leads to a camping down of the immune system, the ability to resist infectious diseases and so poor kids die of diarrhea or respiratory infections that would not kill a child in a rich country better nourished. But do carry away millions of children, into death in the poorest countries. The disparities between rich and poor and across ethnic groups, another kind of inequality that we’ve examined can apply within countries as well. The United States, we know being the most unequal of all the high income countries for reasons that we’ve discussed, also has very high disparities in life expectancy. This is a map showing the measure life expectancy across counties of the United States and we see that the Northeast seaboard of the United States. Say Boston or New York City have quite high life expectancies, but in the deep south of the United States, in Alabama, in, in Mississippi, in Georgia, in Louisiana life expectancy is several years less. And we also know that minority groups in the United States, especially the African American community, has many years less of life expectancy compared to the white, non Hispanic Americans. And so these gaps cross class lines. They cross racial lines and they have geographic counterparts as well related to ethnicity, race, and perhaps at least some direct effects of geography as well. To measure the variation over time and across countries in health we use a number of statistics. The life expectancy at birth is an example. Under five mortality, another example. Maternal mortality rate, a third example. Infant mortality rate, which is out of a thousand newborns the numbers who will die before the first birthday. There’s also a very important concept that I want you to know because it’s widely used and very useful called DALYs. DALYs is the acronym for Disability Adjusted Life Years. The idea is that a normal lifespan is 80 years, according to the calculations of DALYs[1]. If an adult dies at age 60, this is 20 lost life years. If that adult is sick between age 55 and 60 and not enjoying healthy years even in those final five years of life, that’s an added penalty for disability. Paralysis, blindness, the loss of a limb, other kinds of disabilities can be translated into a partial loss of a life year by making an assessment how much healthy life is lost by the particular disability. What DALYs calculate in any population is on average the number of lost life years plus the number of lost years to disability add up those two components from death and disability and you get dis you get disability adjusted life years. The DALYs. And these DALYs are used to understand the varying disease burdens across the world. An example of this is this rather complicated chart, but a very, very important one. Every bar on this chart is for a distinct region of the world. At the top is the high income countries. Next Europe and Central Asia. At the very bottom bar, of the chart, is Sub-Saharan Africa. What is being shown here, are the disability adjusted life years lost to disease per population. So a large bar means that there’s a lot of lost life years, either to death or to disability. And we see that Africa has, by far, the highest disease burden, and the high income world, not surprisingly, the lowest disease burden. But this bar in each grouping is divided by colors in a quite interesting way. Those colors refer to different disease categories. So take the dark blue, which is most to the left of each of the bars. That is the amount of loss of life years due to HIV/AIDS. We can classify all of the diseases into a few categories and then measure the disability adjusted life years lost to that particular set of conditions, and group that in a category. What do you see when you do this? Very, very important to note this, Sub-Saharan Africa, for example, has by far The highest disease burden of AIDS. This is not surprising. The very epicenter of the AIDS pandemic is in Sub-Saharan Africa. Now compare the bar for Sub-Saharan Africa with the bar at the very top for the high-income countries You can’t even see that the sliver for HIV/AIDS. That doesn’t mean,uh, of course that there are, is no, death and disease from HIV/AIDS in the high income world, of course there is. But it means that the burden of the disease per person in the population is very, very low compared to the massive burden in Sub-Saharan Africa. And look at the part of that bar for  Communicable disease. You have to scrunch your eyes and see a tiny little sliver. Well why is that? It’s because in the high-income world the communicable and parasitic diseases like malaria, like measles, like diphtheria or typhoid are virtually gone, almost not heard of. Many of these diseases are completely and successfully prevented by immunizations. Others are treated by antibiotics. People, and mainly young children in the case of sub-Saharan Africa, suffer these diseases in the poorest countries, but not in the richest countries. And that’s good news in the sense that it means we have tools already to shrink the bar of DALYs, of the disability adjusted life years, in sub-Saharan Africa and in south Asia. So that the disease burden can get under control. So that life expectancy can rise. So that the quality of life lived is higher, and so that a healthy population can also play it’s part in in more dynamic e-, and more inclusive economic development. Let’s see how we can attack the those disease burdens by now going on to look in more detail at the nature of the diseases, and what can be done about them.

[1] http://vizhub.healthdata.org/gbd-cause-patterns/

Doenças infecciosas em Crianças : Saúde Global XII

Doenças infecciosas em Crianças com foco nas diarreias e pneumonias

Neste artigo abordamos as doenças infecciosas nas crianças. Constituem um grupo mais vulnerável às diarreias e pneumonias, duas doenças com maior taxa de mortalidade e morbilidade. De seguida abordaremos as suas formas de tratamento, na diarreia através de soluções orais e soluções de intromissão, no caso das pneumonias, através de corticóides ou outras formas de tratamento Abordaremos as formas de prevenção, através das condições da sanidade, da vacinação. Por fim alguns tópicos sobre a malária, uma doença contagiosa com elevada incidência em África.

Diarreias e pneumonias

Nos países de baixo rendimento as doenças em crianças são bastantes comuns. As deficientes condições sanitárias e de abastecimento de água dão origem a frequentes diarreias e pneumonias. No gráfico abaixo pode-se observar a prevalência destas duas doenças no mundo actual. Ocupam a maior para do espaço, ainda quem em alguns lugares de África a malária seja predominante.

A diarreia provoca uma forte desidratação e a perda de líquidos pode conduzir à morte. Um criança em desidratação é também mais vulnerável a outras infecções. Os sintomas são fáceis de visualizar. Um estado de prostação, olhos ausentes, uma respiração rápida. É uma criança que não urina. Por vezes suam e as mães põem lama para secar, não se dando conta que isso ainda seca mais a pele.

Crianças em desidratação foram durante muitos anos um problema nos países quentes. Assim como no verão, a ocorrência de diarreias. O que é comum hoje nos países de baixa renda, foi comum no passado quando havia menos condições de saneamento. Também as crianças resistem de modo diferente dos adultos à falta de água e aos micróbios. O não beber água durante algum tempo pode ser normal para uma criança. A desidratação é normalmente tratada com soro. Uma solução intra-venosa que rapidamente recoloca os líquidos perdidos, seja por sede, seja por rejeição da água em caso de diarreia. Nos paíse mais pobres, no entanto essa é uma solução que nem sempre é viável. Ou não está disponível ou é cara, ou não existe pessoal preparado. É necessário entubar, colocar uma agulha na veia, e alguém que o saiba fazer.

Tratamento

Por essa razão é necessário saber que existem soluções orais que podem ser usadas. Por exemplo, num caso de cólera, é quase sempre necessário proceder à hidratação do paciente, o que muitas vezes só é viável através de soluções orais. Uma solução de cloreto de sódio ou bicarbonato de sódio, ou cloreto de potássio são boas administrações, que existem em saquetas preparadas. Alguna alimentos tem alguns minerais necessários que ajudam a fixar elementos. Por exemplo a banana tem potássio, que ajuda a fixar os líquidos. Por vezes é importante dar água com açúcar para aumentar a glucose. O importante nestes casos é hidratar para evitar o colapso do indivíduo.

Para saber, por exemplo, a quantidade de líquidos perdidos numa diarreia, é útil ter uma marquesa com um balde por baixo. A quantidade de líquido perdida é normalmente a quantidade de líquidos a repor no organismos. Uma das causas das diarreias frequentes é a má nutrição A desidratação dá prostração e alguma perda de apetite e a criança não come. Nem sempre os adultos vigiam a alimentação das crianças e não reparam que entram em marasmo.

Prevenção

A melhor forma de prevenir a necessidade de comer adequadamente e manter uma ingestão de líquidos adequados é através da educação na comunidade. A educação para a saúde ajuda todos a compreender os problemas e a desenvolver uma maior consciência sobre os diferentes sinais que podem indiciar problemas com diarreias e pneumonias. Há casos onde os problemas se colocam com um risco mais elevado. No caso deo campos de refugiados, onde as condições de vida nem sempre são adequadas, há que ter uma particular vigilância no domínio da alimentação e hidratação das crianças.

A pneumonia é outra das doenças que mais afetam as crianças. Causam problemas respiratórios graves e normalmente necessita de ser tratada com antibióticos. Apesar de haver várias vacinas que previnem diversos problemas respiratórios, é necessário perceber que várias doenças também dão origens a problemas respiratórios. A vacina para a tosse convulsa, para a difteria ou para o sarampo são tem alguns efeitos preventivos para prevenção de dos problemas respiratórios. Algumas vacinas anti-gripais que actualmente são desencolvidas constituem um instrumento eficaz nas infecções respiratórias.

Malária

Finalmente o caso da malária que em alguns sítios é particularmente severa com as crianças. Apenas a fêmea é infecciosa, quando retira sangue para alimentar. Os mosquitos podem ser identificados pelas sua parta com listas brancas. Nestes casos podem se tomadas medidas de prevenção, como evitar as horas de maior contágio (amanhecer e entardecer), usar roupas de protecção e dormir protegido. Usar repelentes e evitar concentrações de águas paradas.

Novas e reemergentes doenças infecciosas: Saúde Global XI

Novas doenças infecciosas e reemergências

Neste artigo vamos abordar as questões sobre as mais recentes mudanças no campo das doenças infecciosas e como estão a acontecer essas mudanças. De seguida abordaremos o factores de risco no processo de globalização e finalmente aborda-se o caso do HIV/Sida, como exemplo das mutações que estão a acontecer no campo das doenças infecciosas.

Mudanças

As doenças infecciosas entre os seres humanos tem vindo a crescer nos últimos trinta anos, e a tendência é para aumentarem nos próximos anos, bem como surgiram mais tipos de doenças infeciosas e reemergiram velhas doenças com mais virulência. Há já novos tipos de doenças, como o HIV/SIDA o SARS (Síndroma Respiratório Agudo Grave) ou a Doença de  Lyme (Lyme deseas), o virus Nypah ou a gripe H5N1 ou H1N1. Estas novas doenças aparecem por vezes em novos lugares e outras vezes ao mesmo tempo em vários sítios. Quando são doenças já conhecidas em outros lugares toma o nome de reemergentes, como é o caso do  por vírus West Nile (Flavivírus) ou o Monkypox (o pox virus do macaco). Algumas  das doenças que já são conhecidas, por sua vez, tornam-se resistentes aos tratamentos, caso da malária, a tuberculose multi resistente, algumas pneumonias bacterianas ou mesmo algumas doenças sexualmente transmissíveis.

Há alguns fatores que motivam estas mudanças. Aumento da população, aumento da taxa de urbanização e da sua densidade, infraestruturas de água e saneamento débeis ou em colapso, migrações e diversos problemas sociais, a produção industrial de alimentos e a concentração da sua comercialização, mudanças climáticas, mau uso dos antibióticos e dos medicamentos, mudanças culturais e mesmo alterações nas políticas públicas. São fenómenos que tendem a aumentar.

Fatores de risco

A população mundial , estimada no ano de 2000 em cerca de 6, 1 biliões, em cinquenta anos irá situar-se entre 9,4 e 11, 2 biliões. A taxa de urbanização era em 2000 de cerca de 47 &, deverá ser em cinquenta anos de 60 a 65%. há medida que a população aumentar irão também aumentar o contacto e a circulação de seres humanos. É também facilmente previsível que as condições ambientais se alterem com estes fluxos.  Haverá certamente novos vírus a emergirem. São problemas que incidirão sobretudo nos países menos desenvolvidos aumentando os seus problemas. Por exemplo, nestes países, há ainda cerca de metade da população que vive em zonas rurais sem abastecimento de água e sem saneamento. A atividade de ir buscar água, nestas sociedade, é normalmente um papel desempenhado pelas mulheres. Isso aumentará o seu risco. Também o transporte de água das fontes para as cidades, muitas vezes feitas em sistemas pouco eficientes em termos de higiene é um risco que está a aumentar. Não será apenas a limitação dos recursos de água disponível, mas também os riscos da sua contaminação que poderão aumentar no futuros.

A disponibilidade de água é vital paras as comunidades humanas. Quer para o seu consumo, quer para as questões de saneamento. É cada vez mais claro que más condições de saneamento, nomeadamente a defecação em céu aberto está ligado à má nutrição de crianças que constitui um problemas adicional.

O aumento dos movimentos de pessoas é uma oportunidade para os vírus viajarem com mais facilidade. Por exemplo o Ébola pode passar dum país para outro em poucas horas, antes que qualquer sistema de alerta possa ser implementado.  Todos os lugares do mundo estão hoje ligados em pouco tempo.

A questão da produção alimentar, com base na industrialização tem contribuído para um notável aumento das disponibilidades alimentares no mundo. Há mais cereais e carne. Mas esta produção também resulta do aumento do uso de antibióticos, que vão contaminando os alimentos e as diversas cadeias alimentares. Hoje é diferente consumir leite ou produtos da horticultura produzidos localmente do que consumi-los em espaços comerciais que os recebem não se sabe bem de onde nem em que condições foram produzidos. Todos conhecemos as condições de produção da frangos ou porcos em ambiente industrial. Uma doença que surge, e surgem com cada vez maior frequência, implica o abate de toda a produção.  Se em alguns países esse abate é acompanhado pelos serviços públicos, em países com uma menor vigilância ou com um nível de corrupção mais elevado, as possibilidades de uma produção contaminada chegar ao mercado é maior.

As alterações climáticas também estão a afectar os habitats naturais. Por exemplo os mosquitos vivem em ambientes quentes e húmidos. O aquecimento global está a levar a uma ampliação dos habitats favoráveis para os mosquitos, que ampliam a incidência e ou a mutação das viroses

O uso indiscriminado de antibióticos, nos últimos 70 anos, está a produzir uma crescente resistência e a mutação do mundo biológico criando organismos resistentes.

O tratamento desta novas doenças é bastante mais caro. Por exemplo, a tuberculose multi-resistente tem um tratamento bastante mais dispendioso do que a tuberculoso comum. A artemisa, que era uma droga usada para tratar a malária, está a conhecer novas formas de resistência que dificultam o tratamento da doença. O mesmo da tetraciclina para tratar a cólera, a gonorreia multi resistente. E o resistente staphylococci que se transformou num problema nos hospitais de hoje e que está a infectar milhares de pessoas.

O Caso do HIV/SIDA

O caso do HIV/SIDA é um caso que ilustra bem o que está a suceder neste domínio das mutações das doenças infecciosas. O HIV é uma nova doença, que terá sido passada para humanos na África sub-sariana. Será uma doença endémica nas espécies dos grandes símios e terá passado por contágio para os seres humanos. É uma doenças que se transmite por contágios, do sangue ou da saliva. A pratica de atos sexuais potencia as possibilidades de transmissão. O que é surpreendente nestas doenças é que ela, tendo surgido nos anos oitenta, em cerca de uma década, rapidamente se expandiu, contagiando um elevado número de pessoas em todo o mundo. Sendo mais incidente nalgumas áreas (por exemplo na África oriental, onde se tornou epidémica), ela tornou-se uma infecção em todo o mundo.

É um caso de zoonose. Uma infecção que passa de um animal para o ser humano, tendo-se o microorganismos adaptado ao ser humano. A questão que interessa, para compreender este nosso problema das novas doenças infecciosas, é porque é que ele surge mais ou menos ao mesmo tempo em vários lugares do mundo, porque se espalhou tão rapidamente, não só globalmente, mas tão heterogeneamente, e que tipas de medidas de proteção podem ser tomadas.HIVmundo

Por exemplo, a sua expansão em África, tendo surgido por volta de 1984 e atingido o seu apogeu em 1999, a doença expandiu-se de forma muito intensa mas, olhando para a sua distribuição no mapa sub-sariano, mais numas regiões do que noutras.

É claro que o modo de infecção é feito pelo sangue, por transfusão ou por uso de seringas não esterilizadas. Por relações sexuais não protegidas. no caso das relações sexuais, a multivariedade de parceiros é um factor de crescimento da probabilidade de infecção. Pode passar pelo leite materno de mãe para filho.

Há na questão da prevenção uma interessante questão que se prende com a circuncisão masculina. A circuncisão masculina é uma prática antiga em África. todavia na África austral, onde a prática da circuncisão é menor, a incidência do HIV foi maior. Isso poderá esta relacionado com o modo de infecção, através da prática sexual. O indivíduo circuncisado, estará mais protegido pela células do prepúcio que produzem um pappilomavirus que evitam uma maior incidência do contágio.HIVAFRICA

Sendo um prática cultural, a circuncisão é antiga. Se contribui para evitar o contágio é importante conhece-la, mas não constitui uma prevenção eficaz. Muitas das doenças infecciosas tem uma maior incidência em situações em que os determinantes sociais são mais frágeis. As condições socioeconómicas, a violência doméstica, o estatuto da mulher, o tipo de trabalho, a condição de migrante, as práticas sexuais são todo um conjunto de condições culturais que influenciam o contágio e a disseminação das doenças infecciosas. em sáude pública é fundamental não envolver as questões dos valores e da ética das comunidades em que se trabalha ou com o caracter moral do paciente que padece duma determinada patologia.

A questão dos tratamentos dos doentes com HIV coloca este tipo de problemas. Sabemos que as relações sexuais e a troca de seringas aumentar a probabilidade de contágio. Para reduzir essa probabilidade era necessário que as relações passassem a ser protrgidas e a partilha de seringas evitada. Um processo que foi melhor implementado nuns locais do que noutros, através de programas caros, mas nem sempre é fácil de o fazer.

Por outro lado, no caso do HIV há também a questão do diagnóstico da doença. Dada a infecção, após as primeiras 3 semanas de elevada virulência de contágio e sem sintomas, o vírus hiberna por várias semanas ou anos para de seguida ir aumentando a sua capacidade de contágio. São factores que dificultam o rastreio da doença e a sua prevenção, pois durante o período de redução da virulência do vírus, a possibilidade de não ser diagnosticado em análise existe. Em teoria um indivíduo poderá estar durante um tempo bastante grande a ser portador e transmissor das doenças sem o saber e sem tomar medidas de protecção, dele e dos vários parceiros.

HIVContagio

Como prevenção de contágio pós-exposição tem sido eficaz administrar nevirapina. Por exemplo para prevenir o contágio entre mãe e filho em processo de aleitamento. Há outros processo profilácticos podem ser administrados retrovirais, principalmente a grupos de risco. Um ato médico a ser seguido por profissionais.

Padrões das Doenças Infecciosas: Saúde Global VIII

As mudanças de padrões das doenças Infeciosas: Tempos e Lugares

As doenças infecciosas estão a mudar de padrão. É uma variação de padrão e de história. As mudanças derivam de medidas de controlo, de irradicação ou de eliminação das doenças infecciosas, zoonoses, doenças emergentes ou reemergentes, diarreias, doenças respiratórias nas crianças que criam ou podem contribuir para aumentar a mortalidade infantil.

O conceito de doença infecciosa é doenças que resultam da intervenção de um agente externo: o agente infeccioso. A Intervenção do agente infecciosos é um processo de entrada, crescimento e multiplicação, no corpo dum individuo ou indivíduos, de bactérias, vírus, parasitas, protozoários, fungos, Rickettsia e Prions.

Alguns termos são úteis para estudar ajudar a entender as doenças infecciosas: A incidência duma doença, é o número de uma dada unidade de tempo em que se manifesta a doenças, medida em números de dias, semanas, meses ou anos. A prevalência é o número de casos em que ocorre uma doenças num determinado tempo.

As doenças infecciosas manifestam-se ao longo da história da humanidade de diferentes formas. É útil entender a maneira como as epidemias se manifestaram, para compreender o impacto que tiveram na sociedade. Uma epidemia é um elevado número de casos de uma determinada doença que ocorre num determinado lugar. Um pandemia é uma epidemia que cobre todo o mundo, um fenómeno que é cada vez mais fácil de acontecer nos tempos atuais, devido ao elevado ritmo de trocas entre os diversos espaços geográficos. As principais doenças infecciosas são a cólera, a febre amarela, a peste negra, a gripe, a varíola, o sarampo.

As várias doenças tiveram diferentes incidências ao longo dos tempos. As doenças infecciosas também resultam de alterações na natureza que levam a diferentes formas de ocorrência. Por exemplo a Peste Negra, que afectou a Europa no século XIV levou a uma taxa de mortalidade que variava entre 30 %a 70 % em diferentes regiões. A varíola e a cólera, levada pelos conquistadores europeus para as Américas dizimaram praticamente 90 5 da população americana. O surto de pneumónica que eclodiu na Europa em 1918, provocou uma mortalidade de vários milhões de pessoas, que abalou um continente, já bastante fragilizado por causa das guerras. O efeito duma epidemia é bastante alargado com a globalização. Por exemplo, nos anos oitenta, a gripe asiática, foi um dos primeiros fenómenos que permitiu entender os riscos que as actuais sociedades enfrentas face a um surto ou mutação de um agente infeccioso.

No passado, o desconhecimento das razões das infecções levava a graves problemas sociais. Por exemplo, na Europa durante o século XIV acreditava-se que andar com bicos de pássaro, ajudava a prevenir a peste, o que de certo modo era verdadeiro, pois criava um espaço pouco favorável à inalação do agente infeccioso. Mas por vezes, acreditava-se que a doença era motivada por intenções malignas de alguns membros da sociedade ou por aqueles que praticavam ações fora do que se consideravam “normal” ou correcto. As crenças conduziram a grandes violências e mortandades na fogueiras ou a ostracismo de todo o tipo de minorias, com acusação de feitiçaria ou de serem hereges. A ignorância é pois um elemento que agrava os efeitos das epidemias. Nos dias de hoje, algumas doenças infecciosas, como por exemplo o HIV/SIDA também produziram, sem razão, ostracismo de grupos sociais que podem ter resultados negativos no controlo da doença.

Se alguém é exposto a um agente infeccioso, com elevada probabilidade pode suceder uma das seguintes situações:

31processodeinfecao

Mesmo que não haja infecção, o agente pode transportar o agente infeccioso e transmitir a outro indivíduo. Por essa razão devem ser tomados procedimentos adequados a evitar a propagação da doença através da restrição e controlo de movimentos das população, o que nem sempre é eficaz.

Algumas das questões que afetam ou influenciam a transmissão do agente infeccioso passam por saber e registar as seguintes questões:

  • Qual é o agente. Saber se é uma bactéria, um vírus ou outro agente;
  • Como é que se apresenta (sintomas) da infecção;
  • Qual a causa da doença e de que tipo de trata,
  • Saber se o desenvolvimento da doença conduz à morte e qual a taxa de sobrevivência;
  • Saber se há um hospedeiro animal que transmite ao humano, ou se á uma transmissão entre humanos,
  • Saber, nos casos ocorridos, a idade, sexo, a profissão, o comportamento, o estado nutricional, e pode também ser útili recolher informação sobre o estatuto social;
  • Saber qual o ambiente é que o doente vive (condições da habitação e sanidade)
  • Qual é o clima predominante, em termos de temperatura e humidade relativa,
  • Quais são as crenças predominantes e que tipo de procedimentos as crenças apontam para situações de doença
  • A qualidade do ar, da alimentação das populações da área de incidência e qual a extensão dessa área.

Um dos principais problemas das infecções nos indivíduos, com implicações nos processos de controlo, relaciona-se com o processo em que a doença está em incubação, ainda sem sinais exteriores, mas que já pode ter tornado o indivíduo num agente infeccioso. É importante ir fazendo o rastreio das doenças para saber a sua possibilidade de extensão no grupo social ou área geográfica onde o indivíduo se moveu.

31infecaonos individuos

Mudanças nos padrões das infecções

Nos últimos 100 anos as doenças infecciosas tem vindo a ser reduzidas e controladas na maior parte dos países. Há uma nítida redução da mortalidade e da morbilidade produzida por doenças infecciosas na maior parte dos países. Algumas das razões para essa alteração tem a ver com as melhorias no abastecimento de água e saneamento, na capacidade de reduzir a incidência da tuberculose, uma melhor cultura na sociedade em relação os comportamentos básicos de higiene, sobretudo na educação das crianças. Regras como lavar as mãos ou tomar banho com frequência tem sido bastante eficientes. No entanto, não existem iguais condições em todos os lados e sítios urbanos. Os locais onde as latrinas são a ceu aberto ou ao ar livres, onde não há águas tratadas, ou onde o consumo de água é feito em locais de águas estagnadas, são exemplos de locais de elevado risco que implica tomar medidas de saúde pública. Por exemplo criar latrinas sem contaminação para o ambiente, ou evitar deitar dejectos para o exterior, ferver as águas para alimentação são medidas eficazes para diminuir os riscos.

Vacinação

Um outro processo de evitar as doenças infecciosas é a vacinação. Há muitas doenças infecciosas que são hoje muito menos incidentes do que no passado pela utilização de vacinas. A primeira vacina foi produzida em 1796 e foi usada contra a varicela. No século XIX surgiram as vacinas contra a Raiva, a cólera, a febre tifóide e a bubónica. No século XX contra a difeteria, a tuberculose, e tosse convulsa. Nos anos 50 contra a poliomielite, e nos anos oitentas, contra a hepatite, A e B, a meningite e contra vários pneumococos. A utilização das vacinas permitiu diminuir de forma acentuada a incidência das várias doenças. Contudo, nem todas as vacinas estão disponíveis em todos os lugares e a sua aplicação não ocorre ao mesmo tempo em toda a população.

Um outro fator que ajuda a combater as infecções produzidas pelas doenças infecciosas foi a descoberta dos antibióticos. Em 1930 os sulfamidas e em 1944 cura da tuberculose. A combinação da vacinação, como prevenção, e dos antibióticos, como terapêutica, levaram a uma forte recessão da incidência deste tipo de doenças, e à erradicação de algumas.

Há no entanto que manter algumas medidas para vigiar e controlar as doenças infecciosas. É necessário manter a vigilância e relatar as suas ocorrências. É necessário saber quem tem e como apanhou a doença. Há que manter com habtio as regras de higiene e sanidade. Lavar as mãos, a educação nas escolas, monitorar a evolução das doenças, observar os comportamentos sociais e manter o marketing social. É necessário estar vigilante e aplicar correctamente as terapêuticas. No campo das doenças infecciosas, o tempo é determinante par controlar o alargamento da incidência das doenças. As doenças infecciosas vão continuar a desenvolver-se no mundo e vão continuar a ocorrer. Uma boa redução das taxas de incidência e mortalidade não implica uma diminuição dos esforços de vigilância.

Impacto da globalização na Saúde Global – VII

O processo de globalização levou a um mundo interdependente. Depois de no século XIX a industrialização e a urbanização terem constituído os modos dominantes de criar crescimento na economia, e de criar processos de melhoria na saúde pública, o século XX viu surgir um modo de organizar a economia e as sociedades diferentes. Vimos as doenças não comunicativas, ditas do progresso, tornarem-se dominantes em todo o lado, ao mesmo tempo que as infecções e os agentes infecciosos viajem muito mais rapidamente. A globalização traz, para a saúde global, vantagens e desvantagens. Como em todas as coisas à que defenda e que critique, quem se entusiasme e quem seja mais cético. No entanto à que analisar o novo fenómeno para procurar as melhores soluções.

Há claras vantagens nos processos de integração económica. A circulação de capitais, bens e serviços, das tecnologias, do trabalho e do saber é benéfico.

Mas também trás inconvenientes. Para além da facilidade de viagem dos agentes infecciosos sabemo que o crescimento económico que a globalização procura catalizar não é infinito e não é necessariamente sempre crescimento. Doenças derivadas de hábitos de vida ou alimentares não saudáveis também se tornam globais, aumentando o risco das populações de cada vez mais regiões a este tipo de patologias. Há vário casos, como por exemplo o aumento da obesidade na população mexicana, nos anos 80, com o crescimento exponencial da importanção de produtos alimentares americanos embalados. Mas também a globalização pode trazer efeitos positivos, como sucedeu na Polónia, onde os níveis de saúde da população melhoraram substancialmente nos últimos quinze anos com melhorias no sistema de abastecimento alimentar. Há também um conjunto de vantagens no campo do conhecimento médico com a globalização. O Conhecimento pode agora ser acessível em todo o mundo.

No entanto, a globalização e o seu sistema de crises cíclicas traz vários problams. Por exemplo as políticas de ajustamento estrutural, levadas a cabo em países como por exemplo a Rússia nos anos noventa, levaram a claras deficiências no financiamento dos sistemas de saúde pública, com reflexos na saúde da população. Também na China, com a crescente mercantilização da saúde, regista-se uma tendência para uma diminuição dos indicadores de saúde.  Há no entanto paíse, como sucedeu na Tailanda, que resistiram às políticas de austeridade, e que mantiveram, contra a pressão das organizações internacionais, o financiamento ás serviços de saúde, mantendo e melhorando os seus indicadores. As várias organizações internacionais acabaram por considerar os efeitos negativos das reformas que propuseram, nomeadamento a limitação ao acesso aos serviços de saúde, com a introdução de taxas moderadoras, ou por um insuficiência no financiamento do sistema.

Há um outro importante impacto da globalização no sistema de saúde global que deriva da livre circulação de pessoas. Os pessoal médico e qualificado no campo da saúde é mais facilmente atraído ara regiões mias seguras e melhor remuneradas, o que cria dificuldades de cobertura em diversas regiões do mundo. É necessário um código de ética para assegurar a distribuição de pessoal qualificado por todas as regiões.

Um outra tendência da globalização, com efeitos na esfera da saúde global, é a tendência cada vez maior da investigação ser financiada por findações e empresas privadas. Nem sempre há uma coincidência entres os interesses globais e os interesses do mercado e das corporações. Isso é susceptível, por exemplo, de introduzir distorções nos processos de investigação, favorecendo uns em detrimento dos interesses gerais.

A globalização também tem produzido alterações noutros sistemas com resultado que tem impacto nos sistemas de saúde global. Por exemplo, na agricultura, a predominância do mercado e da produção extensiva em regime de monocultura, não só está a diminuir a diversidade da base alimentar e a destruir ecosistemas, como introduz lógicas que destroem recursos das populações. Por exemplo a produção de sementes através de processos de produção industrial ou a tendência do mercado para previligiar a produção de carne, levará, nesta caso, mantendo-se o crescimento previsto do consumo, a um impossibilidade de recursos para satisfazer a procura. Isso já está a ser visível, por exemplo ao nível dos recursos marinhos. O ambiente é outro sector onde a globalização também produz efeitos com reflexos na saúde global. A degradação do ambiente tem um reflexo na saúde pública. Por exemplo, o processo de transferência da industrias poluentes para países mais pobres, para aproveitar uma mão-de-obra mais barata, tem efeitos negativos nesse paíse, que já por sí são mais frágeis em termos de sistemas de saúde pública, introduzindo novas pressões que implicam a mobilização de mais recursos.

Mas por outro lado a globalização pode ser uma oportunidade para corrigir as distorções e conseguir alcançar condições para uma maior equidade na saúde global.

Sabemos que o crescimento económico, por si só não gera uma melhor saúde global. É necessário que o crescimento económico se faça com equidade. O mercado por si só não resolve os problemas das sistemas sociais. É necessário criar também alguma ação colectiva para criar equidade. O mercado gera assimetrias que é necessário ir corrigindo. É necessário que os podere públicos tomem uma série de medida para corrigir os mercado.

As medidas de ação podem ser, por exemplo, criar consciência da consumidores saudáveis e dar incentivos ás industrias de produção de bens alimentares saudáveis. Uma sociedade com saúde é mais produtiva, e uma população com um trabalho estável consome mais no mercado e com mais responsabilidade. É necessário criar condições para que a população aceda a uma alimentação saudável através do incentivo às industrias de produção de bens alimentares saudáveis.

A globalização criu uma superfície onde é mais fácil navegar. Mas por vezes a superfície é inclinada. Há que manter a superfície plana e equitativa. Sem isso não é possível alcançar uma melhoria nos indicadores da saúde global. Para isso é necessário criar um compromisso global e corrigir as assimetrias do mercado. É necessário assegurar que as instituições globais estão ao serviço da equidade e da justiça. É necessário que os diversos pasíses tenha consciência das armadilhas das dívidas externas. É necessário não confiar nos mercados financeiros. Sabe-se que ao menor sinal de fragilidade dum mercado, que os investidores desaparecem. O mercado financeiro é um mercado muito volátil e tem um risco muito elevado de sustentabilidade. É necessário proteger alguns serviços do mercado. Serviços como a água, o saneamento, a produção de alimentos, o ambiente, a saúde básica e a educação constituem serviços básicos que devem ser assegurados. É necessário ter em consideranção que o mercado é imperfeito.

Por outro lado é necessário aproveitar as vantagens que a globalização oferece. A livre circulação de conhecimento e das tencologias são um benefício da humanidade. É necessário construir pontes para o conhecimento para partilhar soluções inovadoras.

Por exemplo a inovação reversiva, que é constituída por inovações em processo aplicados em muitos pequenos ou médios países podem levar a implementar soluções de baixo custo e de maior rendimento em outros países.

Por outro lado é também necessário apoiar os países mais pobres a implementarem mais rapidamente os seus programas de saúde e de desenvolvimento económico. Estes países não podem ficar dependentes do assistencialismo e da caridade. Há que ter programas adequados. Para isso é necessário construir uma parceria global para valorizar os modos de vida saudáveis e os sistemas de alimentação saudáveis. É necessária atuar de forma aberta nos problemas sociais e combater as diferentes formas de pobreza. Criar um compromisso global é dominar os impactos da globalização e aproveitar as suas vantagens.

Economia da Saúde e Equidade – (Saúde Global VI)

O primado da equidade na Saúde Global é uma questão do senso comum, tal como o é a ligação entre o crescimento económico ou o desenvolvimento e a existência dum sistema de saúde eficiente. Neste pequeno texto procuramos abordar a relação existente entre a economia e a saúde pública (global) e pensar de que forma é que a equidade se refleta no desenvolvimento duma Saúde Global.

A questão da equidade é um tema que vale a pena pensar em primeiro lugar. Em 1999, quando foram estabelecidos os ODM, as questões da Saúde e do acesso à saúde foram separadas em vários objetivos: A Saúde das grávidas, das crianças, a redução da pobreza, o combate à má-nutrição. Todas elas constituem determinantes para diminuir a mortalidade e assegurar uma maior igualdade entre os seres humanos. Quando hoje estamos a avaliar os resultados dos ODM, temos que reconhecer, que em relação aos vários objetivos previstos nos ODM se registaram avançao consideráveis. Mas também temos que reconhecer que ainda há lugares (espaços) onde há problemas. Ou melhor, onde os indicadores não diminuíram de forma tão acentuada. Ao mesmo tempo também podemos verificar, que mesmo no interior de espaços onde se registaram fortes diminuições das taxas de incidência dos problemas a resolver, existem grupos dentro de espaços (regionais ou nacionais9 onde essa diminuição também não é tão intensa. Em suma nestes quinze anos foram atingidos bons resultados através duma diminuição significativa dos macro indicadores. Contudo, entre os mais pobres e nas regiões mias pobres do mundo, a tendência de diminuição é menor, verificando-se mesmo em alguns casos algum aumento.

Como é que estas questões podem ser resolvidas no âmbito dos ODM, ou dos futuros ODS. Uma das questões que está na agenda de discussão é a relação entre a equidade e o desenvolvimento, seja da economia, seja dos sistemas de saúde pública.

A equidade tem sido fundamentalmente abordada como a procura de uma ausência nas disparidades no acesso aos sistemas de saúde. Contudo, a questão da equidade deverá passar a ser colocada, não em termos de acesso ou cobertura do sistema de saúde, mas como uma das questões chave na construção dos determinantes sociais na resolução dos problemas da Saúde Global. Equidade não é apenas uma questão de existência do sistemas ou da sua acessibilidade, é também uma questão que implica a redução das desigualdades sociais.

O desenvolvimento económico é tradicionalmente visto como a solução para resolver os problemas dos sistemas de saúde global. Há uma convicção que aumentando a riqueza num dado território, essa riqueza se distribui pela sociedade, sendo aplicada na resolução dos seus problemas sociais. No entanto, como podemos verificar a partir das análises sobre os indicadores de saúde nos países mais desenvolvidos, não basta trabalhar sobre os indicadores para resolver os problemas da saúde global. Nos países mais desenvolvidos é necessário atuar sobre os determinantes sociais.

Durante muito tempo considerou-se, por exemplo, que bastava aumentra o PIB num país, para isso se reflectir no aumento da esperança média de vida. E efectivamente isso acontece até certo ponto, considerando-se uma valor médio entre os 3.000 e 5.000 U$. A partir dessa valor o impacto do crescimento do PIB tende a ter uma menor relação no aumento da esperança de vida. No entanto, a curva de crescimento tende a ser ligeiramente superior nuns países do que noutros. Nos países onde se verifica uma menor distância entre os mais ricos e os mais pobres, a tendência para o crescimento da curva é maior do que nos países onde a diferença entre ricos e pobres é mais acentuada. No caso do Japão, onde a distribuição da riqueza nacional é mais equitativa, a esperança de vida é maior, do que nos Estados Unidos, onde essa distribuição é menor. Significa isso, que, nos EEUU a esperança de vida é maior nos mais ricos do que entre os mais pobres. Há uma evidência sobre o impacto da distribuição de riqueza na sociedade.

Em “The Spirit Level” de Key Pickett e Richard Wilkinson” abordam a questão da equidade nas sociedade e do impacto sobre a distribuição da riqueza na fomação dos indicadores sociais. Nas sociedade mais desiguais os diferentes indicadores sociais e os determinantes sociais dão indicações de que há um esforço social que é canalizado para apoio aos mais pobres e para a resolução de problemas que a desigualdade gera. O sistema de saúde global reflecte esses problemas sociais, em questões de saúde, saúde mental e mesmo obesidade.

O Relatório sobre o Desenvolvimento Humano , de 1993,  ou o Relatório da OMS sobre a Macroeconomia e Saúde , de 2001, demonstram que a Saúde não e apenas um produto do desenvolvimento, mas que existe uma relação bidireccional entre os dois e que existe uma relação entre a equidade nas sociedades e a sua capacidade para alcançar melhores níveis de desenvolvimento económico.

É evidente que é necessário que se invista no crescimento económico para aumentar a riqueza social que permita canalizar recursos para os sistemas de saúde pública. Mas o inverso também é verdadeiro. È necessário investir nos sistemas de saúde pública para potenciar o crescimento económico. Melhorar a vida e a saúde das pessoas é aumentar os ativos da sociedade. Com mais ativos há possibilidade de produzir mais riqueza.

A demonstração de que sociedades mais iguais tem desempenhos na saúde publica mais elevados é também a demonstração de que o crescimento global da economia também é assegurado por sociedades mais iguais. A construção de sociedades mais equitativas é uma prática que deve ser incluída nos determinantes sociais dos sistemas de saúde global.

A ideia de equidade social está também ligada à ideia de sociedades mais justas. Sociedades mais justas, durante muito tempo, foram pensadas como sociedades que desenvolviam igualdade de oportunidades. Assegurando, pensava-se, o acesso aos sistemas de saúde, de educação ou outros serviços sociais, cada uma dispunha de condições para construir o seu caminho. Sendo certo que entre os seres humanos há quem aproveite melhor as oportunidades que num dado momento estão disponíveis, não deixa de ser verdade que a sociedade não pode pensar que a questão da equidade se resume a assegurar um mesmo ponto de partida. Na verdade, no processo de desenvolvimento há grupos socias que são marginalizados e excluídos. São pessoas que estão em dificuldades para aproveitar as oportunidade. Ora, no processo de desenvolvimento todos são úteis. Quem não participa nos processos sociais de forma ativa, constitui um entrave ao desenvolvimento do conjunto. Dessa forma, a questão da justiça social deve também pensar na equidade horizontal e na equidade vertical.

Equidade horizontal, relaciona-se com o conceito de igualdade para todos. Tratamento igual para todos e acessibilidade para todos. A equidade vertical, parte da necessidade de desenvolver acções específicas para grupos específicos da sociedade. O processo de desenvolvimento coloca certos grupos em desvantagens que devem ser compensadas através de ações. Todos devem participar. É necessário das acesso a todos, mas também é necessário que todos tenham oportunidades de ter acesso. Assegurar a participação de todos nos processos, é uma ação do sistema global de saúde, mas também dos demais sistams sociais, como por exemplo a educação, a habitação, o saneamento e a cultura.

Em suma não basta criar condições de acesso universal. É também necessário criar oportunidades de acesso universal, com condições ajustadas a cada grupo. A construção de serviços de saúde adequados é uma forma de trabalhar os determinantes sociais que os indivíduos necessitam para agir. Não é apenas a acessibilidade que interessa atingir, mas a capacidade dos indivíduos de agirem. De se tornarem autónomos. E de desempenharem o seu papel na sociedade.

Por fim, ainda nas questões sobre a equidade, é também necessário assegurar uma equidade intergeracioanal. Não basta nos dias de hoje, usar os recursos disponíveis para resolver os problemas de hoje, sem pensar nos recursos que as gerações futuras necessitam para resolver os seus problemas. A equidade não é necessário apenas entre a sociedade, mas também entre gerações.