Archive for global-health-academy

The Year of Environment and Health

May 7, 2014 Environment and Health, Health and Wellness Promotion, Human Rights, Intervention Agents and Opportunities, Post-2015, Urbanisation and Health, YoEH 2014 No comments

“A point has been reached in history when we must shape our actions throughout the world with a more prudent care for their environmental consequences. Through ignorance or indifference we can do massive and irreversible harm to the earthly environment on which our life and well being depend. Conversely, through fuller knowledge and wiser action, we can achieve for ourselves and our posterity a better life in an environment more in keeping with human needs and hopes …” Stockholm, 1972

All living things depend on their environment for energy and for the basic requirements that sustain life – air, water, food and habitat. This simple dynamic is not in dispute. However there is a growing body of evidence that suggests the relationship between environment and human health is in fact a reciprocal one, each having complex effects on the other. According to the UN Environment Programme, every human being has the right to a safe, healthy and ecologically-balanced environment…….but what exactly are these complex relationships, and how can we ensure that human rights to a safe and healthy environment are delivered, even under conditions of rapid global environmental change?

Much of our society’s development has depended upon technological advancements in our environment; improvements in agriculture, sanitation, water treatment, and hygiene have had revolutionary effects on health, well being and longevity. While our environment and the natural resources within in it sustain human life, it can also be the limiting factor in improving health, as well as being a primary source of disease and infection. Lack of basic necessities are a significant cause of human mortality. Approximately 1.1 billion people currently lack access to safe drinking water, and 2.6 billion do not have proper sanitation1, so while advancements in managing the productivity of our environment has resulted in access to surplus quantities of food, water and services, for many, this development has not occurred equally across the world.

Our environment can also be a major source of infection. It is estimated that almost one quarter of global disease and 23% of all deaths can be attributed to environmental factors2.  Pollution and other environmental hazards such as food contaminants, over-exposure to sunlight, algal blooms, flooding and drought increase the risk of a myriad of health concerns that include cancer, heart disease, asthma and respiratory diseases, anxiety, stress and depression as well as many other illnesses.   Environmental factors influence 85 out of the 102 categories of diseases and injuries listed in the World Health Report and in 2012, 7 million deaths worldwide were attributed to exposure to air pollution – now the world’s largest single environmental health risk3.   However social and political aspects that affect our environment such as housing conditions, access to education, access to green space and poverty are major influencing factors in the relationship between health, well-being and environment.

On the other hand, policies and processes that are undertaken with the aim of promoting health and well-being can have significantly detrimental effects on ecosystems as well as our human environments. For example, food production requires unsustainably large volumes of fresh water and causes environmental damage from pesticides and fertilizers, soil erosion, animal wastes and carbon emissions from food manufacture and transportation. Disease prevention can also drastically alter environments. For example, malaria was eradicated in many developed nations in the 1950s by draining wetlands and spraying DDT to kill mosquitoes. The destruction of these ecosystems to control malaria, and the addition of persistent and toxic chemicals into the soils and watercourses has had long-term detrimental impacts on these ecosystems at a regional scale. Wide-spread disease prevention on a global scale creates additional consequences for the environment as the subsequent increase in longevity and reduction in human mortality creates further pressures from overpopulation, increased use of fossil fuels, increased land-clearing, water use and agriculture, as well as generating high volumes of pollution and waste. Recently, a socio-economic approach to evaluating the benefits and services provided by ecosystems has provided insight into the threats and challenges that may lie ahead.

The ecosystems services approach provides a framework for decision making, and for valuing the ‘products, functions and services’ ecosystems provide, to ensure that society can maintain a healthy and resilient natural environment, now, and for future generations. For example, The UK National Ecosystem Assessment indicates that the United Kingdom relies on it’s ecosystems for a range of services that include climate regulation, waste removal, pest control, flood protection, food supply, potable water, natural medicine, aesthetics, recreation and tourism, among many others. However, this innovative approach recognises and strives to promote the philosophy that our environment provides much more than material benefits. It states clearly that ecosystems contribute to national security, resilience, social justice, health and well-being, and freedom of choice and action4. Therefore, the degradation of our environment, and the ecosystems it supports can have seriously harmful and far-reaching impacts on society, its governance and the economy.   Primary impacts of ecosystem degradation relate specifically to human well-being: ‘significant and detrimental human health impacts can occur if ecosystem services are no longer adequate to meet social needs’ World Health Organisation Secondary impacts that may result from a decline in ecosystem function can affect jobs, income, local migration and, on occasion, may even cause political unrest and conflict. The Economics of Ecosystems and Biodiversity report estimates that globally, the degradation of our planet’s ecosystems is costing us €50 billion each year.   This figure does not take into account the resultant impacts on national security and social justice, which have wide-ranging impacts on well-being, and the availability and access to food, water and healthcare provisions. Of great concern is the way that the complex relationship between health and environment is evolving due to a culmination of global-scale changes including rapid changes in climate, flooding, drought and fluctuations in temperature, not to mention population growth and urbanisation.

The World Health Organisation Global Forum on Urbanisation and Health in 2010 highlighted that for the first time in history more people live in urban settings than rural, and that conditions in cities will be among the most important health issues of the 21st century5. Greater urbanisation puts ever increasing pressure on services such as housing and health. Understanding the surrounding environment, the impact that an ever increasing population has on it and how we can develop and increase services with the least impact is key. The use of our natural environment has provided human civilisation with many benefits, but the costs to our ecosystems have been severe and extensive.   As our population continues to grow and our demands for food, fresh water, healthcare, fuel and building materials soar, we must ask ourselves what price we are prepared to pay. What legacy do we want to leave for future generations? Both the Convention on Biological Diversity and the World Health Organisation have made clear that unless we come to understand the relationship between environment and health and address they way we use and manage our environment, then we will substantially diminish the benefits and well-being that future generations can acquire from ecosystems, and severely compromise their ability to meet their basic human rights to a safe and healthy environment.

The Year of Environment and Health is a collaboration between the University of Edinburgh’s Global Health Academy and its Global Environment and Society Academy. It endeavors to examine the key issues in the relationship between Environment and Health through the lens of Global Change.

Join us in a series of public lectures exploring some of the themes discussed above:-

  • Urbanisation and Health
  • Pollution and Health
  • Ecosystem Services and Health
  • Extreme Weather and Health

References

  1. UNESCO http://www.unesco.org/bpi/wwap/press/pdf/wwdr2_chapter_2.pdf
  2. WHO http://www.who.int/quantifying_ehimpacts/publications/preventingdisease.pdf
  3. WHO http://www.who.int/features/factfiles/environmental_health/environmental_health_facts/en/index7.html
  4. Convention on Biological Diversity http://www.cbd.int/
  5. WHO Global Forum on Urbanisation & Health 2010

Catherine Morgan (Global Environment & Society Academy); Lisa Wood (Global Health Academy), University of Edinburgh.

Shining a light on neglected tropical diseases

April 4, 2014 Millennium Development Goals, Neglected Tropical Diseases, Post-2015 No comments

The publication of the second report on Uniting to Combat Neglected Tropical Diseases entitled “delivering on promised and driving progress” marks remarkable progress that has been achieved in the last two years in this field.  In January 2012, the London Declaration on Neglected Tropical Diseases marked commitment from a wide range of organisations and industry to achieving the goals of the WHO roadmap to control, eliminate or eradicate ten of the NTDs.

To mark the launch of the report, on the 2nd April 2014 global leaders convened in Paris to discuss the progress that has been achieved so far.  In this “conversation on progress”, Director-General of the WHO Margaret Chan thanked endemic countries, organisations and industries for their commitment to this cause, and commented that these diseases are no longer neglected as they are “shining a light” on these diseases which shackle over 1.6 billion people worldwide.  Control of NTDs must be a priority in order to achieve the targets of the Millennium Development Goals as they affect the world’s poorest populations.  Since the establishment of the NTD department in the WHO in 2005, effective advocacy has increased the profile of these ancient diseases, and they have been described as a “rags to riches story”.

In the two years following the London Declaration, which was endorsed by thirteen pharmaceutical companies, the drug donation pledges made by these companies have been fulfilled and in some cases surpassed.  These donations allow countries to fulfil and increase the demand for treatment, and have resulted in the scaling up of control interventions as drug supply has been removed as a barrier to the control of a number of the NTDs.  Seventy four countries, representing around two thirds of all NTD endemic countries have now developed national plans for the control of NTDs.  This country ownership is an important factor in the increased commitment to control, eliminating and eradicating these diseases.  Coupled with capacity building and political commitment NTD control can be a success.  The adoption of a World Health Assembly resolution on all seventeen NTDs in May 2013 has been described as a “landmark” in NTD control.  Not only does this resolution confirm country commitment to NTDs, but it marks a change in the way the world is approaching NTD control.  Throughout the history of the WHO, there have been many resolutions adopted which focus on one or more of the NTDs, but the adoption of the 2013 resolution highlights the change to integrated approaches to NTD control.  When we consider the NTDs collectively, they represent an enormous burden on human health, and many opportunities exist to control several of these diseases in combination.

New funding was also announced in conjunction with the report representing increased commitment from a range of partners representing a new collaboration to control soil-transmitted helminths.  This collaboration and funding highlights how multi-partner and multi-sector collaboration is becoming increasingly important in NTD control.

The report highlights that commitment to NTDs has gained momentum since the London Declaration.  In addition, the 2013 resolution on NTDs marks a global pledge by Member States to the control of these diseases that in turn can leverage even more commitment.  In the last two years, the light has begun to shine brightly on these diseases that afflict the world’s poorest and most vulnerable populations.  The control and elimination of NTDs is now recognised as one of the best investments in development.  As the report states “much has been achieved, but much more work lies ahead”.  We must continue to increase commitments and activities to control NTDs.  The report highlights the success and fulfilment of commitments to the ten NTDs included in the London Declaration, but there remain seven of the defined NTDs without such multi-partner pledges of drug donations and increased funding.

World Health Day on the 7th April this year focusses on Vector Borne Diseases. This includes a number the NTDs such as leishmaniasis and sleeping sickness.  We must build on these recent success and increased momentum and continue to combat these ancient diseases while the light continues to shine.

 

 

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Ms Hayley Mableson is in the final stages of completing a PhD from the University of Edinburgh.  Her research to date has focussed on global health advocacy and its application, with particular emphasis on the neglected tropical and zoonotic diseases. 

Preferential Software for the Poor

March 24, 2014 E and M Health No comments

Millions of families who have never accessed the Internet, used landline telephones or even postal service have now begun using mobile phones. Increasingly governments, charities and tech companies see this new infrastructure as an opportunity to re-imagine the way that we deliver health care. While this field is young and riddled with disappointments, some mobile health, or mHealth initiatives have yielded impressive results. For example, inexpensive text messaging programs have improved quality of care for children with Malaria (study), increased adherence to HIV medication (study), and made community-based support as much as 137 times faster and four times less costly (study).

I wish that I could say such studies prove that communication technologies boost health outcomes, but sadly I cannot. Perhaps this field’s most inconvenient truth, observed again and again by practitioners and scholars, is that technologies that are effective in one setting often have very different effects in other settings. It is not difficult to see what makes mHealth so complex; the daily routines by which people make use of technology as well as the technologies themselves are diverse and continually changing. It is more difficult to determine how we might cope with unpredictability and make the most of mHealth opportunities. Currently popular prescriptions include selecting technology that is scalable, fostering collaboration and planning for financial sustainability from day one.

I would like to suggest that we begin by listening to the poor and marginalized individuals who stand to benefit from our work. Listening is a matter of such practical importance that I often think of it as the core competency of the team at Medic Mobile, the mHealth social enterprise I co-founded. We begin by making time for long conversations with people from each of the groups any new initiative might touch. No project moves forward until we have listened long enough to begin seeing the central strengths and constraints of each group from their point of view. Hearing of their daily concerns goes hand in hand with imagining alternative futures, and we always draw sketches of how our collaboration might change their community. By ‘we’ in this case I am also referring to the beneficiaries because sketching and brainstorming is collaborative wherever possible. When we sketch what a future service might look like, we consistently receive more detailed and often more critical feedback than through conversation alone. Making it easier for people all over the world to give feedback on our intentions forces us to listen not only more patiently but also more pragmatically. The number of times we have thrown away old sketches and drawn new ones, always based on feedback, is a reasonable gauge of how well we have listened.

Listening meaningfully is also a great intellectual challenge because appreciating the circumstances of any poor person involves understanding global poverty. The first time that a community health worker in Malawi told me that he had to walk 15 kilometers and spend a third of what he would earn in a typical day just to charge his phone, I understood that an mHealth initiative designed for him would need to reimburse for electricity and use phones which hold a charge for a week or two. Having now heard similar stories from dozens of health workers, it frustrates me how the mHealth community obsesses with fancy smartphones that need to be charged everyday. I have had similar conversations with facility-based staff who lament that the internet is slow, unreliable or absent from their clinics. These are the clinics most in need of support, and yet nothing is more in fashion than to boast that one’s mHealth application is “cloud-based.” International development agencies often write requests for proposals that explicitly call for cloud-based apps because they are deemed ‘more scalable,’ which in turn pressures charities that rely on such grants to write cloud-biased proposals. After many cycles of such investment, it should not surprise us that cloud and smartphone apps are among the most ‘tried and true’ tools in the global mHealth community. Neither should it surprise us that when the ‘best tools’ excel in more urban and middle-income environments, the tools themselves come to incentivize organizations to focus not on the poorest, but on middle-of-the-road needy communities where the tools are likely to be relevant.

To be sure, smart phones and cloud servers can be tremendously helpful in many settings. It seems almost counter-intuitive to suggest that we could ever go wrong by maximizing ‘value for money’ with technologies that are ‘cost-effective’ enough to ‘go to scale’ nation-wide. No one seems to be intentionally marginalizing the poorest. An alternative view may only emerge when we not only listen to the poor, but spend enough time in their company to appreciate that they are subject to a perpetual train of abuses and unfair disadvantages. The most difficult to perceive are the abuses which are nobody’s fault, the suffering which seems inevitable because it flows not from evil people but from patterns of society that have long been taken for granted. Some use the term ‘structural violence‘ to describe such social arrangements that tend to put specific groups in harm’s way. Revisiting this concept has helped me attend to who gets left behind when we design technologies with a utilitarian focus on the characteristics of the average needy community. Many who call attention to structural violence have also argued that the only means of addressing such systemic unfairness is to build a preferential option for the poor. What would preferential software for the poor look like? Perhaps I can explain this most clearly with an example.

My first mHealth project was with a rural Catholic hospital in Malawi called St Gabriel’s. We gave phones to about one hundred community health workers so that they could exchange logistical information such as “Mary Banda in Msangwa village might have Tuberculosis and I want you to come test them.” The project was successful enough that many other organizations asked us to replicate it, but they wanted to use more quantitative data in more complex ways than our initial approach to simple prose text messaging. At the time, industry experts referred to durable, inexpensive and long-battery-life phones as “dumb” or “SMS-only” phones because they “couldn’t run apps” that would support forms-based data collection or menu-based decision support. Bucking conventional wisdom, I fixated on the idea of putting apps on $20 phones because it seemed the only way to move beyond the limitations of text messaging without leaving behind communities like St Gabriel’s.

During a trip to Kenya I learned of the popular mPesa mobile banking service. It involved simple menus and worked on the cheapest phones–it was possible! How ironic that the experts in my field had neglected to discuss a technology that 70% of adults in Kenya were using. I learned that mPesa was installed not on the phone itself but on the SIM card, so I began talking to mobile network operators about putting health apps on their SIM cards. I was told again and again that it simply would not be possible unless I were prepared to pre-order a custom batch of 10-50 thousand SIM cards (and my funders said that would be impossible). More than a year later I discovered a small Eastern European manufacturer of paper-thin ‘parallel-SIM’ cards that slide underneath a typical SIM card. Using this technology, we could install our apps on the parallel SIM and keep using ordinary SIMs to connect to the mobile network. Medic Mobile soon began developing a parallel SIM card app called Muvuku, which means ‘to listen’ in Chichewa, one of the indigenous languages of Malawi. Since then we have used it in more than a dozen countries and it has won a few awards. Conveniently, it also works well for programs that could afford more expensive phones and that do have access to electricity and local smartphone suppliers. It was harder and took much longer to develop than an Android app though. It was only worth the effort because of a commitment that has more to do with who we are than it has to do with maximizing impact or going to scale. While we’re open to working in any setting that would benefit from our support, we design our core technologies in partnership with, and to suit the circumstances of poor and marginalized communities.

What does it mean to make preferential software for the poor? I do not mean to argue that the solution lies with any one technology or in dealing with any particular constraint, be it electricity, usability, adaptability or local availability and appropriateness. Rather, it means standing with the poor, spending time in their company and appreciating their strengths and constraints—as they see them—before attending to technical or financial concerns. I believe this matters because engineers and economists too often advocate for their expertise in ways that make the aspirations of the poor seem impossible, or even a waste of resources. In recent decades we have heard that HIV prevention is ‘cost effective’ but treatment is not and that patients who do not respond to the cheaper classes of Tuberculosis drugs are ‘untreatable.’ Today many still argue that poor community health workers can volunteer while their bosses receive comfortable salaries and that the ‘dumb phones’ which have proliferated all across the African continent are not ‘smart’ enough to extend the highest standard of medical care. These social fictions stem from a poverty of imagination about what is possible. They stem from a traditional deference to the expertise of foreign technical elites over the lived experience of beneficiaries. To be sure, spending time in the company of the poor will not render all problems easily solvable. But listening patiently and with a deep sense of humility is a decent place to start.

 

Isaac Holeman, Medic Mobile 

Isaac Holeman is a designer and a scholar striving for global health equity. Through ethnography and innovation, his work is about seeing through the eyes of the poor and marginalized and responding pragmatically. He has pursued this work as a cofounder of the mHealth social enterprise Medic Mobile, as an Echoing Green Fellow and as a Gates Cambridge Scholar.

Maternal and infant health in Malawi

March 17, 2014 E and M Health, Health and Wellness Promotion, Intervention Agents and Opportunities, Maternal & Infant Health No comments

For the last 15 years women in rural Malawi have been experiencing high rates of maternal and new-born illness and death due to preventable complications of childbirth. Three main factors precede the majority of poor maternal and new-born health outcomes: firstly a delay in making the decision to seek care, secondly a delay in getting to an appropriate health facility, and thirdly a delay in receiving appropriate care within the health facility.

Context of ICT implementation at Diamphwe and Mtenthela health centres 

The absence of patient data for decision-making at health facility level remains one of the greatest weaknesses of the Malawian health, which is characterised by antiquated, paper-based systems and a reliance on mothers to hold their own paper-based records, known as ‘health passports’, as well as that of their infants. Implementing electronic health information systems (eHIS) across hospital and community care has potential to reduce birth complications by ensuring that the right information about the right patient is available to the right people at the right time and place. Enabling information to flow between community-based and hospital-based care settings may enable more informed decision-making about high risk cases in need of referral for specialist management, leading to improved maternal and new-born health outcomes. Since 2009, there has been significantly increased commitments to and investments in the strengthening of eHIS at Nkhoma Hospital in Malawi. This is being done through integration of information and communication technology (ICT) in the running programmes of at Nkhoma Hospital and it’s surrounding health centres to increase the quality and effectiveness of development interventions. The ICT solution being implemented is AfyaPro, which has seven (7) modules: patient registration, patient billing, diagnosis and treatment, medical laboratory, reproductive and child health, inventory, and HIV-ART. Beyond installing AfyaPro, efforts have been to strengthen eHIS through a change management process aimed at facilitating ICT ownership, increasing ICT competencies and assisting with institutional integration of ICT at the health facilities. The first stage of implementation involves replacing the paper registers that are currently used in antenatal and delivery care with electronic data capture using AfyaPro. The electronic data is linked to the health passport through a bar code system, as well as being retrievable through name, year of birth and village. Electronic patient data are stored securely in a local and central database and accessible at the referral hospital and the other health centres. In the continuum of care, if a woman is referred from her primary health centre to the referral hospital, or transfers to another health centre, her file is directly available at the referral site, improving quality of patient care.

So far, computers and other hardware have been installed at Nkhoma Hospital and health centres. Health workers have been trained in the use of computers, Afya Pro applications, as well as change management. There is now need to study how the electronic health information system impacts quality of care and health facility management, and ultimately maternal and new-born health outcomes.

 

Nkhoma Safe Motherhood Scale Up Programme

The main aim of the Nkhoma Safe Motherhood Scale Up Program is to increase family planning and referrals, and the utilization, timeliness, and quality of reproductive health services, while building partnerships and advocating for reproductive health and rights to reduce maternal and new-born deaths in the Nathenje Health Area. Nathenje Health Area’s main referral hospital, Nkhoma Hospital, is surrounded by five health centres: Matapila, Nathenje, Chimbalanga, Diamphwe and Mtenthela and they all work together in this program. The Nkhoma Safe Motherhood Scale Up program covers Traditional Authority (TA) Mazengera in 22 group village heads. To achieve its goal the program uses many activities that have been clustered under the following strategies to address the three delays (delay in seeking health care, delay in accessing health care, and delay in service provision):

 

Strategies to increase in family planning methods and referrals

  1. Strengthening community structures to act on modern family planning
  2. Women empowerment
  3. Youth empowerment/Mobilization
  4. Strengthening community structures to take family planning to communities
  5. Strengthening quality assurance in the health facilities

Strategies to increase referrals

  1. Empowering the community to organize transport for referrals
  2. Strengthening communication systems
  3. Strengthening quality assurance in the health facilities

Strategies to increase women using health care facilities for skilled delivery and reproductive health care on time

  1. Strengthening community structures to act MCH/MNH/SRHR issues
  2. Women empowerment
  3. Maternal death audits

Strategies to improve quality and quantity of reproductive health services

  1. Improving skills and attitude of health providers
  2. Ensuring adequate resources to conduct sexual and reproductive health
  3. Improving availability of information

Strategies to build partnerships and advocate for SRHR issues

  1. Advocating to church leaders on SRHR issues
  2. Lobbying for SRH issues (patients rights, human resources and infrastructure)
  3. Developing networks with local/national government and NGOs
  4. Mobilizing and distributing information, education and communication materials

Church leaders have been invited to various meetings and have been trained in issues relating to SRHR. There is need to follow up on the advocacy with the church leaders to identify specific actions taken. The project provides a leading role in a local and national network, called Uchembere Network.

There is an exchange programme established for health providers, so they can experience work in the maternity ward of the hospital or another health centre. There is need to further develop this strategy to improve skills and attitudes of the health providers.

Each facility maternal death is audited, yet community-based maternal deaths are rarely reported. There is need to develop a mechanism for capturing all community-based maternal deaths, and subsequently conduct an audit.

A community bicycle ambulance system has been developed and use of bicycle ambulances are being monitored by the community and the project. A wireless communication system set up among the health centres and Nkhoma Hospital is being maintained. There is need to further develop the voice over internet protocol communication system to be able to share document, picture and video among the health facilities. There is also need to evaluate the sustainability and cost-effectiveness of the bicycle ambulance system.

Community structures such as Area Development Committees in the Traditional Areas have been strengthened. Women’s groups in the 22 villages have been set up to empower women. Training of youth from churches in the catchment villages has mobilized them. Community based distribution agents have been trained and are being supported to take family planning methods closer to people’s homes. A quality assurance system ensures a team from Nkhoma Hospital supervises the health centres, and staff from the health centres learn from each other. There is need to evaluate these strategies increase access to family planning methods.

 

 Paul Kawale 

(Director Community Health,  Nkhoma Hospital, Malawi and PhD Student, University of Edinburgh)

https://www.facebook.com/pages/Nkhoma-Hospital/263372044008

http://www.linkedin.com/pub/paul-kawale/30/787/66

Thinking about the post-MDG era

December 23, 2013 Measuring and prioritising health interventions and impact., Millennium Development Goals, Neglected Tropical Diseases, Post-2015 No comments

In 2015, the current eight Millennium Development Goals (MDGs) will expire. Results will be mixed, some will be met and some will not. What is clear, however, is that the MDGs have shaped the way we think about development, and our priorities and approaches to alleviating poverty.

The MDGs gave new prominence to the health issues affecting the poor; although their focus was restricted and derived from a top-down process of deliberation, rather than informed by inclusive analysis and a thorough prioritisation of development needs. Subsequently, the narrowly focused and largely sector-specific MDGs left gaps in coverage and failed to realise synergies between the foci covered by the goals (education, health, poverty, and gender). MDG 6 in particular—“combat HIV/AIDS, malaria and other diseases”—sidelined many of the communicable and non-communicable diseases that perpetuate the cycle of poverty in developing countries. And yet, the very act of naming HIV/AIDS and malaria raised the profile of these diseases immeasurably, stimulating increased funding, focused policy and dedicated institutions and programmes.

In response to the narrowness and specificity of the MDGs networks, alliances and lobby groups have emerged to argue for other priorities, perspectives and approaches. One of the most vocal examples – and the focus of the article – is the alliance arguing for Neglected Tropical Diseases (NTDs), a cluster of diseases of the bottom billion that are underserved with regards to research, treatment and control, to be included in the set of Goals that will replace the MDGs after 2015. At the moment it is looking increasingly likely that NTDs will be name-checked and specifically included in the “new” MDGs. This will be no mean feat.

The case for including NTDs in the post-2015 agenda has been building since their omission from MDG 6, which served as a call to arms for a group of concerned stakeholders, who have since contributed to a series of landmark initiatives that have placed NTDs firmly on the international agenda.

One “advantage” that the NTDs may have in a more enlightened and nuanced post-MDG era (with regards to development as well as to health), is that, by their very nature, they “undermine healthy lives” and cut across and threaten to undermine multiple silos of MDGs. This suggests a potentially fruitful bifurcated approach where focusing on NTDs can help make concrete inroads into reaffirmed or tweaked post-2015 MDGs, or NTDs can be used to articulate a set of goals that do not represent silos as targets to be met, but rather represent the strengthening of the institutions we need to manage the complex social, economic, environmental, and health systems that interact to shape future development.

Controlling NTDs in a post MDG era

MDGs and NTDs: Reshaping the Global Health Agenda

INZI Project (Investigating Networks of Zoonosis Innovation)

 

James Smith

Professor James Smith, Director, Global Development Academy, University of Edinburgh

Emma Michelle Taylor

Dr Emma Michelle Taylor, Research Fellow, INZI Project, Centre for African Studies, University of Edinburgh

 

 

 

 

HIV/AIDS: into the third decade

December 1, 2013 Cycles of Disease and Illness No comments

1981 saw the first description of AIDS cases in the USA. There are now over 100,000 people living with HIV in the UK and around 34 million people worldwide. In 2011, an estimated 1.7 million people worldwide died from HIV related causes. In the UK, around 1 in 5 patients living with HIV are not aware of their diagnosis; more efforts should be done to identify them so that they can benefit from antiretroviral treatment and improved health. Treated early, patients with HIV can look forward to an almost normal life span.

Despite extensive research, there is no effective vaccine for treatment or prevention of HIV infection. Treatment is effective and is required lifelong as at present there is no cure.  Antiretroviral therapy fails to cure HIV infection because latent proviruses persist in resting CD4+ T cells.

Although the international response to HIV epidemic has not been rapid, more than half of people eligible for ART in low and middle income countries were receiving ART for the first time in 2011.

Lifelong therapy means that patients are exposed to potential drug toxicity for a prolonged period. People with HIV are living longer; the proportion of patients aged 50 and older are an increasing proportion of the population of persons living with HIV in the UK. Older people with HIV/AIDS face both HIV/AIDS-related and age-related co-morbidities, such as hypertension, chronic pain, hepatitis, and arthritis, which are associated with poorer physical, mental, and social wellbeing.

The global HIV epidemic is one of the most formidable challenges to life and human dignity; it undermines social and economic development worldwide. Efforts at eradicating HIV must be maintained by finding a cure for those who are already infected and an affordable and effective vaccine to prevent new infections.

 

Professor Clifford Leen

Consultant Physician Infectious Diseases (Western General Hospital) Professor Infectious Diseases (Edinburgh University)

 

CLS Leen (6x4)

mHealth and User Centered Design in low resource settings

October 28, 2013 E and M Health No comments

Walk into almost any corner store in India, Pakistan, Zambia, Mexico, or Tanzania and you will find cell-phone top-up cards for sale. Corner stores and markets and even street vendors understand that mobile phones mean business. There are now more than six billion wireless subscribers in the world, and more than 70% of them reside in low- and middle-income countries. The Global System for Mobile Communications Association (GSMA) reports commercial wireless signals cover more than 85% of the world’s population, extending far beyond the reach of the electrical grid.

As global health NGOs join governments, health care, and donors begin to build the foundations for a cancer control strategy in places such as sub-Saharan Africa, we need to incorporate mobile health strategies and monitoring mechanisms to unleash the potential of those six billion mobile users to further awareness, advocacy, and behavior change goals.

A 2011 WHO report on mHealth states: “The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.” If we intend to
improve access to cancer control strategies known to be effective such as HPV and Hepatitis B vaccines, and cervical cancer screening, into our global mission to fight cancer in low and middle income countries then the use of mHealth will certainly form part of the tools to accomplish those goals.

Most patients in sub-Saharan Africa walk away from the clinic visit with a cell phone in hand, but lack access to resources about treatment, work-related issues, and transportation to receive the treatments. If they are fortunate enough to have access to treatment, they may have no way to communicate problems or questions as health facilities could be miles away by foot from where they live. Mobile technologies could help bridge the gap for patient support services. As a global health community, we should support adequate resources for more research and development of effective mobile strategies to urgently address cancer and other other non communicable diseases, the cause of 63% of global deaths.

There are few global foundations underwriting programs to support the understanding and development of mHealth in cancer interventions. If foundations, governments and private individuals were made aware of the
potential impact that mobile based Cancer applications could have on their dollars already invested in health services there is little doubt that they would get behind the deployment of such technology.

Medic Mobile is partnering with the University of Edinburgh on the creation of a series of courses focused on mHealth and User Centered Design in low resource settings.

 

Jay Evans, Regional Director , Asia for Medic Mobile
Jay Evans TH

 

 

 

 

Twitter: @jaymedicmobile

 

The potential impact of technology on health delivery: NCDs

October 16, 2013 E and M Health No comments

 

“The number of mobile subscriptions in use worldwide, both pre-paid and post-paid, has grown from fewer than 1 billion in 2000 to over 6 billion in 2012 (current world population estimates are near 7 billion)” (1)

Facebook has reached more than 1 billion active users and every minute, 48 hours worth of content is uploaded to YouTube  (2)

During this last decade we have had to make two fundamental shifts in our thinking about NCDs:-

Firstly that NCDs are also a major health challenge in low and middle income countries – gone are the days when NCDs were seen as the disease of rich countries and infectious diseases as the disease of poor countries.

Secondly that NCDs only affected the middling to older aged population.   NCDs affect everyone and transforming the NCD world picture demands a life course approach to policies and interventions if the burden is to be reduced in any significant way.

A new report from NCD Child entitled “Young people and NCDs: Harnessing the culture of technology”(2) highlights the link between the exponential rise of mobile phones, the use of technologies  and a younger generation more tech-savvy than any generation that has gone before, and argues that   “A life-course approach to prevention (primary, secondaryand tertiary) that pays greater attention to adolescence and acknowledges major cultural drivers of change in young people’s attitudes and actions is central to mitigating the effects of NCDs in individuals, communities and societies now and in the future.”  Harnessing this in the battle with NCDs is a priority.  We desperately need new ideas, new plans and new tested and trialled interventions to improve young peoples’ health through mobile technology.

” We need to communicate what NCDs are, and why they matter to a global audience of young people – the generation who must solve this issue ” Dr Alessandro Demaio, NCDFREE

A white paper produced by mHealth Alliance in 2010 (3) highlighted some of the barriers and gaps to making mHealth widely available, such as security of patient information and policy etc and that “Governments need to develop a strategic eHealth framework in which mHealth is an integral component in order to provide mHealth implementers in the NGO and private for profit sectors more guidance when implementing projects to ensure alignment with their eGovernment, health information systems, and other relevant policies and aims to leverage technology for public good” (3).

This latest report (1)  highlights not only the availability of mobile phones worldwide and shows that this is continually increasing, but also looks at the some of the key barriers to full implementation – patient privacy and security of patient information.  Mobile technology has the ability to help greatly in the drive for health equality and we need to capitalise on this – however we also need to ensure that the barriers are addressed for maximum worldwide benefit.    There has been some success to date and harnessing the young and tech-savvy in the battle with NCDs is another excellent step which is easily transferable to other disease areas.  However the question now is how else do we continue to maximise this particular technology as an added value in health delivery globally, ensuring that barriers are cleared, gaps are filled and it becomes an integral part of health policy and delivery?

 

Dr Liz Grant, is Deputy Director of the Global Health Academy at Edinburgh University

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References

(1)      Patient privacy in a mobile world a framework to address privacy law issues in mobile health

http://www.mhealthalliance.org/images/content/trustlaw_connect_report.pdf

 

(2)     NCD Child – Young people and NCDs: Harnessing the culture of technology

https://www.dropbox.com/s/ylubv2umqbzn8kx/2013%20Issues%20Paper_FINAL%2024%20June%202013.pdf

 

(3)     Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper.

http://cghed.ei.columbia.edu/sitefiles/file/mHealthBarriersWhitePaperFINAL.pdf

 

October 10th 2013 – World Mental Health Day: Time for Action

October 10, 2013 Mental Health No comments

Today celebrates World Mental Health Day, an initiative to raise awareness about mental health disorders worldwide, which was instigated by the World Federation for Mental Health and the World Health Organisation over two decades ago.  The theme this year is ‘Mental Health and Older Adults’.

Worldwide, the ageing population is increasing, with the current population aged 60 years and over expected to expand to 2 billion by 2050, as lifetime expectancy continues to rise.  As a recent report, published by the World Health Organisation “Mental Health of Older Adults: Addressing a Growing Concern” identified, mental health problems are often under-recognised in this age group.  Depression is common, accounting for 9.17 million Disability Adjusted Life Years (DALYS).  Dementia is recognized as a public health priority and by, 2050 it is estimated that 115 million people will be affected, of which over 50% will be in low and middle-income countries (Yasamy et al, 2013)

People living with mental disorders (PLWMD) face many challenges in accessing appropriate care worldwide, and this is exacerbated in low and middle income countries (LMIC), where it is estimated 90% of those individuals suffering from a mental disorder do not receive treatment (Patel et al ,2010).

Stigma, the negative attitudes and labelling that occur based on prejudices and misinformation about mental illness, has serious consequences.  Older adults, whilst respected in some communities, in others face significant stigma.  This is the case in some parts of Malawi, for example, where older adults may be perceived as witches, and subsequently ostracized and even victimized within their local communities.  This is an area that some Governments are starting to recognize requires action (http://www.nyasatimes.com/2013/08/24/elderly-not-witches-says-malawi-pres-banda).

Elder maltreatment has been defined by the World Health Organisation as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust that causes harm or distress to an older person”.  It is estimated to affect 4-6% of older adults in High Income Countries (World Health Organisation, 2011).  In low and middle-income countries, the situation is less clear.

Dementia, is not just a problem that affects the older adult population, and particularly in sub-saharan Africa, the spectrum of HIV-associated neurocognitive disorders may affect up to 50% of people living with HIV/AIDS.

Perspectives from the mental healthcare field in a low income country:

How does the epidemic of mental disorders translate to experience in everyday psychiatric practice in a low-income context?  In my work in a psychiatric institution in one of the poorest countries in the world, Malawi, we are faced with challenges in offering basic levels of care to individuals who have often gone for many years without treatment.  The result is that they often arrive in a life-threatening condition, in some cases exacerbated by their neglect within general healthcare services, in part due to the stigma they face even within the healthcare profession.  Whilst we are fortunate to have a reasonable supply of medication within our hospital, provision of other important aspects of care, such as intensive nursing, occupational and rehabilitation and social therapy are limited.   On discharge from hospital the level of community care provision is sparse, often represented by a single monthly clinic that has no supplies or resources for providing psychological or social therapies.  In this context, there is a need to improve training and education of primary healthcare professionals in basic interventions for mental disorders.  Even within a specialist hospital, we have few nursing staff who have undergone specialist mental health training, and many have not chosen to be deployed to work in this area.

World Mental Health Day has an important role to play worldwide, by raising public and professional awareness of these issues, in the hope that we will move towards a brighter future in which individuals experiencing mental distress and mental illness, are able to access appropriate care and treatment in a non-judgemental and supportive way, that is tailored to their needs and respects their basic rights.  We still have a long way to go, but I am hopeful that World Mental Health Day will continue to be one of the many small steps required to raise awareness of the needs of people living with mental illness, one of the most vulnerable groups in society, whether in low-, middle- or high- income countries.

 

Dr Selena Gleadow Ware is a Consultant Psychiatrist and Lecturer in Mental Health at the College of Medicine, University of Malawi and Visiting Honorary Lecturer at Edinburgh University where she facilitates the module on Global Mental Health.

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References

Patel V, Maj M, Flisher AJ, De Silva MJ, Koschorke M, Prince M; WPA Zonal and Member Society Representatives. Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry. 2010 Oct; 9(3):169-76.

World Health Organisation (2011) Elder Maltreatment. Factsheet No. 357 http://www.who.int/mediacentre/factsheets/fs357/en/

World Health Organization. Dementia, A Public Health Priority, 2012, World Health Organisation.  http://whqlibdoc.who.int/publications/2012/9789241564458_eng.pdf

Yasamy, WT., Dua, T., Harper, M., Saxena, S. Mental Health of Older Adults: Addressing A Growing Concern.  2013. World Health Organisation.  http://www.who.int/mental_health/world-mental-health-day/WHO_paper_wmhd_2013.pdf

World Mental Health Day: Mental Health Foundation

http://www.mentalhealth.org.uk/our-work/world-mental-health-day/world-mental-health-day-2013/?view=Standard

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