Archive for Health and Wellness Promotion

The Lancet Commission On Global Surgery

Surgeons have long felt that the importance of surgery has been lost in past efforts to impact on global health issues. The Lancet Commission on Global Surgery seeks to address deficiencies in surgical and anaesthetic care, provide evidence and solutions for achieving health, as well as welfare and economic development through the strengthening of surgical health systems in Low and Middle income Countries (LMIC).

Twenty five commissioners have worked for almost 2 years consulting extensively in over 100 countries in 6 continents. Their report may not please all but is a significant achievement. Surveys, epidemiological studies, estimates, audits and mapping programmes helped to provide evidence and to highlight further disparities in surgical care through 5 key messages at their recent London and Boston launches:

  • 5 billion people lack access to safe affordable surgical services when needed. Nine of ten people in low-income and lower-middle-income countries cannot access basic surgical care.
  • 143 million additional surgical procedures are needed each year to save lives and prevent disability. Only 6% of 313 million procedures that are undertaken worldwide annually, are performed in the poorest countries.
  • 33 million individuals face catastrophic health expenditure to pay for surgical services.
  • Investment in surgical and anaesthetic services saves lives, is affordable and promotes economic growth.
  • Surgery is an indispensible part of health care and should be an integral component of a national health system in countries at all levels of development.

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The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

The Commission’s stated targets for 2030 are daunting:

  • A minimum of 80% coverage of essential surgical and anaesthesia services per country.
  • 100% of countries with at least 20 surgical, anaesthetic, and obstetric physicians, per 100,000 population.
  • 100% of countries tracking surgical volume, a minimum of 5000 procedures per 100,000 population.
  • 100% of countries tracking perioperative mortality.
  • 100% protection against impoverishment from out of pocket payments for surgical care.
  • 100% protection against catastrophic expenditure from out of pocket payments for surgical care.

Some might see these as challenging for some developed countries so how can these objectives be met in developing countries where increasing funding of health care still results in disparities.

We know that targeting specific health care issues through philanthropic support in the developing world has brought about mixed success. Numerous philanthropists and charities have stumbled in attempting to deliver sustainable solutions when investing in facility or service. Outreach programmes from well intended overseas surgical teams may actually impact adversely on the very environment that they hope to support. Essential emergency provision of surgical care may be compromised when, for example, limited facility is set aside for the orchestrated elective missionary surgery. The conditions or surgical pathology targeted or technology being shared may seem entirely appropriate to the visiting team but may be largely irrelevant to the needs of the local population.

Investment in infrastructure may seem to produce a tangible legacy for the donor but it is challenging to maintain such quality facilities when these are seen by some as a source of material to be plundered to support their families in desperate financial need. Furthermore, some initiatives have been been criticized for focusing too narrowly on the capacity of science and in neglecting the importance of economic, social, and political factors. Such surgical initiatives require significant funding and need to be considered in parallel with improvements in public health, education and the health system. Pressurised surgical services dealing with trauma in the developing world might rather welcome greater health and safety regulation, improvements in street lighting, better maintained roads and greater driver regulation.

So where to start? Records often do not exist so reliable surgical audits or death rate statistics for surgery do not exist in LMIC. Investment in information technology is limited in most developing countries but finance is required to obtain key information that would identify clearly the needs of surgical services in the LMIC. GlobalSurg is a collaboration supported by Clinical Surgery at the University of Edinburgh (http://globalsurg.org/get-involved/). The group is currently using an international network of training and qualified surgeons to study variation in outcome of emergency intra-abdominal surgery across various clinical settings. It will determine whether globally relevant quality improvement strategies are needed within acute surgical units. This project would serve to provide much needed information in an area of acute surgical care and will allow development of regional, national and international surgical networks. The group recently published on the benefits of these networks in the Lancet. There is no reason why the group cannot establish key global studies, including the opportunity for randomised trials.

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The Lancet, DOI: 10.1016/S0140-6736(15)60160-X, Copyright @ 2015 Elsevier

Humanitarian and global surgical outreach programmes have been supported by surgical colleagues in Edinburgh at considerable personal social and psychological sacrifice. Such direct support has undoubtedly had significant impact on the lives of those affected by conditions including those arising from complications of obstructed labour. The social stigmata attached to this condition are considerable and the repair transforms the patient’s existence. And yet, the procedure to correct a vesicovaginal fistula is categorized as a ‘can do’ rather than a ‘must do’ surgical procedure. Where should the priorities lie when the challenge is so immense? How can such outreach programmes deliver a legacy in a developing country?

The target set by the Commission that 100% of countries should have at least 20 surgical, anaesthetic, and obstetric physicians per 100,000 population is formidable. We have experience supporting surgical training in Malawi which produces some 100 medical graduates per year. However, for a population of 17 million people, there are currently only some 15 trained surgeons in practice since many move overseas when they are exposed to the opportunities that exist for well-trained doctors in the developed world. The Lancet Commission requirement by 2030 is projected at 60 specialists per 100,000 population. It is difficult to imagine where the additional 10,000 or so specialists will emerge for Malawi without substantial investment.

Scotland has a strong tradition of investing in education on Africa. Gordon Brown as UN Special Envoy for Global Education, and through the Office of Gordon and Sarah Brown, has promoted and initiated education programmes in Africa. Edinburgh University has invested strongly in postgraduate educational initiatives that have benefited LMIC. The huge success of our own surgical distance learning programmes has allowed us to support more trainees from these countries.

Our surgical Masters programmes currently have over 450 students enrolled in 40 different countries. In 2009, the Scottish Government and J&J/Ethicon supported the University of Edinburgh and the Royal College of Surgeons of Edinburgh to deliver free postgraduate educational support to training surgeons in Malawi. Since then, the first three students have graduated from the three-year distance learning course which supports the educational and professional needs of the young training surgeon. Six more Malawian trainees are currently in the programme. Surgical trainees have been supported without the need to remove them from the area of greatest need. The programme content adds value to their in-the-workplace training and allows the young surgeon to attend to local service needs. We are also aware that educational resource has been extended to medical assistant practitioners who are a vital link in the surgical care chain.

The Lancet Global Commission has ensured that surgery can no longer be overlooked as a health need for the world’s poorest people. The Commission has set itself ambitious targets but no one initiative will address the current unmet need. Better global surgical and anaesthesia care will only be realised through increased investment in human and physical resources. Early and urgent domestic and external investment in surgical and anaesthesia care is needed to realise these returns. Our group sees itself as being in a strong position to invest in the postgraduate education of the surgical workforce in these countries.

Similarly, research, monitoring, and assessment will have to play an increasing and crucial part in the future of global surgical and anaesthesia care. There is a paucity of scientific rigor around implementation science, and an absence of globally accepted surgical metrics which have contributed to past neglect of surgical and anaesthesia care within global health. A commitment to better understand the problems and solutions should be a priority for those dedicated to improvement of surgical and anaesthesia care worldwide. We will continue to invest primarily in the training surgeons in these LMIC through postgraduate education. In this way, we should empower the very body that can engineer change locally so that we might yet see some practical light at the end of a very long tunnel.


Professor O James Garden, Regius Professor of Clinical Surgery and Honorary Consultant Surgeon, University of Edinburgh

Why it is critical to genotype the causative agents of tuberculosis

Sun Tzu, a Chinese military philosopher in the 6th century BC, said “ if you know your enemy and yourself, you will not be imperiled in hundred battles”.

If not taken in literal terms, it would suggest that learning more about the humanity and livestock’s arch enemy Tuberculosis (TB), with whom we have been battling for millennia, can only arm us all the better for the fight.  As part of this battle, The University of Edinburgh has long been contributing to the research and development arm of the World Health Organisation’s “Stop TB Global Strategy”. 

The WHO has achieved the 2015 Millennium Goal of halting and reversing the incidence of the disease.  Despite this great acheivement, in 2013 alone the WHO registered 9 million cases of TB, half a million of which succumbed to the disease.  Horrifyingly this latter number loosely translates to four super jumbo jets crashing every day for the entire year.  Going forward to 2035, the WHO has set yet more ambitious goals to end the global TB epidemic with corresponding targets of 95% and 90% reduction in TB deaths and incidence respectively.

Knowing your enemy

In order to achieve this mighty aim, now more than ever, it is critical for the definitive diagnostics to not only reveal the mycobacterial species but also the genotype.  The majority of cases of human TB are caused by Mycobacterium tuberculosis, however a small, but significant geographically-limited, proportion is due to Mycobacterium bovis the causative agent of bovine tuberculosis. The latter is what is commonly referred to as zoonotic tuberculosis. The current statistics shows that when considered as a proportion of the global TB burden, zoonotic tuberculosis accounts for a small proportion however, if reported in absolute terms it translates to between 95,000 and 150,000 cases of which 15% succumb to this disease form globally. It is noteworthy that 9 out of the 22 high-burden TB countries are responsible for ~70% of the global zoonotic TB cases.

Vaccination as a defence against infection

In general, vaccination is an effective method of controlling infectious diseases.  The BCG vaccine, developed agianstM. bovis, is the most widely administered TB vaccine in the world.  However its varied efficacy globally has always been a challenge to the TB control strategy.  If the endemic population of infective bacteria is different from that contained in the vaccine, this can lead to vaccine failure.  Vaccines that target a narrow range of phenotypes may not offer sufficient prevention against infections in settings where multiple different strains of the infective agent may be present.

This is particularly relevant to areas where several different strains of M. bovis are prevalent, and where the TB burden is correspondingly high. It is also reasonable to argue that some of the TB treatment failures in these areas are likely due to species and genotypes un-accounted for in the treatment protocols.  Thus it is critical to document the diversity of M. bovis, and use this data to increase the phenotypic range in novel vaccines, thereby improving patient immunity.

Sequencing the genomes of the bacteria that cause TB

The currently documented genotypes of M. bovis in high-burden settings lack “granularity” because they are based on PCR methods that target less than 0.005% of the genome.  It is therefore likely that niche and host-specific polymorphisms that are critical for population-based vaccine implementation, are left unused in determining these genotypes.

This disparity in genotype diversity and breadth of target phenotype is likely part of the reasons why the efficacy of BCG vaccination is lowest in Africa.  A solution to this comes in the form of whole genome SNPs based genotyping, which offers high definition genotyping power capable of revealing subtle niche and host specific diversity.

Large international collaboration fighting the disease

Researchers from the University of Edinburgh are now part of a large international collaboration that will sequence and genotype 254 isolates of Mycobacterium bovis from eight African high burden countries.

They will be working alongside colleagues from eight African research institutions, and from the United States Department of Agriculture, Colorado State University, the University of Georgia, the University of Tromsø, theNorwegian Veterinary Institute, and the Norwegian University of Life Sciences.

The new data the team generates will be made freely available for researchers and industry involved in TB vaccine, diagnostics and therapeutics development.  By piecing together more and more information about the strains of Mycobacteria causing TB in different areas, researchers will generate the ammunition needed to finally defeat TB.


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                    Adrian Muwonge (DVM, MSc, PhD), Research Fellow, Roslin Institute, 

                   Edinburgh Infectious Diseases, University of Edinburgh, UK

 

 

 


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Unhealthy investments

I have been involved with the fossil fuel divestment movement over the past year, both with the University and through Healthy Planet UK, after coming to terms with the enormity of climate change and the need for urgent action. As a medical student I am compelled by a similar duty of care towards our ecosystem, on which our health depends, and am called to respond to its current symptoms of distress. Divestment offers a way to treat one of the root causes of these symptoms – the continued burning of fossil fuels – through moving investments away from the fossil fuel industry whose business model relies upon burning reserves which currently hold over five times that which is safe to burn if we are to stay below the 2 degrees celsius limit of global warming[1] Akin to the health sector leading divestment from the tobacco industry, there is a similar narrative in the response to the health threat of climate change further weighted by tactics utilised by the fossil fuel industry to thwart climate mitigation policy and mar public perception of the reality of climate science[2]. UK universities hold around £5.2 billion worth of investments through their endowment funds in the fossil fuel industry[3]. However, divestment is not simply a matter of money, most divestment decisions have been driven by a moral case. It rests on a simple principle -if it is wrong to wreck the planet, then it is wrong to profit from that wreckage. For the medical tradition investing in fossil fuels can be seen to contradict the fundamental principle to “first do no harm”. So far 21 universities, 35 cities, 65 religious organisations and numerous other organisations from around the world including the British Medical Association have committed to divesting from fossil fuels[4].

 

Medical institutions and the health community have a unique awareness of climate change through its current and future impacts on human health, but also through the potential immense health co-benefits of tackling climate change such as reducing the disease burden of air pollution, which has been attributed to 2000 premature deaths annually in Scotland[5], and encouraging active travel through reducing our reliance on fossil fuel guzzling cars. This gives an important dimension to the divestment dialogue and the engagement of medical schools and health organisations is sure to be very valuable. On the 3rd February, Healthy Planet are publishing their report “Unhealthy Investments”, co-authored with MedAct, The Climate and Health Council, Medsin and the Centre for Sustainable Healthcare. This will be a crucial step towards further engagement on fossil fuel divestment from the health sector. It will involve a panel of expert speakers to discuss the question of whether organisations which work to improve health should continue to invest in fossil fuel extraction and production companies. Should the health sector be taking more of a lead in this issue? There is certainly great potential in engaging with the process and evaluating how best our pension and endowment funds can be invested towards a healthier and more sustainable future.

 

More information on the report launch can be found here: http://www.eventbrite.co.uk/e/unhealthy-investmentsshould-health-organisations-divest-from-fossil-fuels-tickets-15237083527


 

References

[1] http://www.carbontracker.org/

[2] http://www.greenpeace.org/usa/en/campaigns/global-warming-and-energy/polluterwatch/Dealing-in-Doubt—the-Climate-Denial-Machine-vs-Climate-Science/

[3] http://peopleandplanet.org/fossil-free

[4] http://gofossilfree.org/commitments/

[5] http://www.foe-scotland.org.uk/air-pollution


 

 

Eleanor Dow – Medical student at the University of Edinburgh and coordinator of Healthy Planet UK, a network of students raising awareness of the links between climate change and health.

http://www.healthyplanetuk.org/

 

Global mental health – its time to pull together

The recent report from the UK’s All-Party Parliamentary Group on Global Health and Mental Health (MH) is very welcome. Not only does it describe the parlous state of MH services in many parts of the world, it presents an evidence-base for global action. It is important to acknowledge, for example, that patients can be caged, chained or subjected to abusive traditional approaches and that Western mental health services are not all bad. The report summarises the growing body of research showing that there are cost-effective solutions to mental health problems that even the poorest countries could implement and benefit from. These include improving social and economic environments, integrating mental health into general health care, using trained and non-specialist health workers to provide culturally appropriate community care, increasing access to self-help and empowering people with mental health problems to support and advocate for themselves and each other.

Further, and more specifically, the WHO (1) have previously shown that interventions such as psychosocial and antidepressant treatment are ‘very cost-effective’ interventions for panic disorder and depression throughout the world, and that psychosocial treatments plus older antipsychotic and mood stabilising drugs are ‘cost-effective’ for schizophrenia and bipolar disorder.

Another report released in November, from the Overseas Development Institute (2), gives a complimentary perspective – mental (ill) health does not receive due policy attention due to stigma and a lack of coherence across the mental health community. The time has come for the mental health community to work together to achieve shared goals such as reducing stigma and increased funding for MH services across the globe.

 

 


Professor Stephen Lawrie, Head of Psychiatry, University of Edinburgh


 

1.Chisholm D, on behalf of WHO-CHOICE. Choosing cost-effective interventions in psychiatry: results from the CHOICE programme of the World Health Organisation. World Psychiatry 2005; 4: 37-44.
2. Mackenzie J. Global mental health from a policy perspective: a context analysis. Overseas Development Institute 2014.

What are the long-term consequences of deworming programmes?

Dr Francisca Mutapi, University of Edinburgh

What happens afterwards? This apocalyptic question is one that is integral to all forms of intervention in human and animal diseases. This is particularly important in cases where the intervention occurs at a national scale. My research group has been asking this question in relation to the current global efforts to control worm (helminth) infections which significantly impact on the health and development of children. Specifically, we work on bilharzia (urinary schistosomiasis) an important, but neglected infectious disease caused by the blood fluke Schistosoma haematobium. Although we hear occasional reports of tourists infected during visits to resorts in endemic areas, bilharzia is typically a disease of poverty due its association with poor sanitation and unsafe water. People become infected when they come into contact with the infective stage in freshwater after it has been released by freshwater snail- hence the other name of the disease- snail fever. The disease affects over 100 million people, mainly in Africa.  Children carry the heaviest burden of infection; as a result, they experience bladder and kidney disorders, stunted growth and poor development.

Current global initiatives from Partners of Parasite Control including the World Health Organization (WHO), Bill and Melinda Gates Foundation, UNICEF, Schistosome Control Initiative and the World Bank are advocating regular school-based de-worming interventions to reduce the development of morbidity, promote school-child health and improve cognitive potential of the children. Children are treated with the antihelminthic drug praziquantel. Over the past decade, there has been a concerted global effort to control bilharzia, galvanised initially by the Millennium Development Goal (MDG) 6 to combat HIV/AIDS, malaria and other diseases by 2015 and the World Health Assembly resolution 54.19 to treat at least 75% of all school-age children at risk of schistosomiasis by 2010. The most recent schistosomiasis resolution, World Health Assembly resolution WHA65.21 passed in 2012 is advocating for the elimination of schistosome transmission and the WHO Schistosomiasis Strategic Plan 2012-–2020 sets out its vision of for a world free from schistosomiasis. This represents a real drive at the global scale not previously seen, to control this important disease of childhood.

Millions of school children in Africa are currently being treated with this drug resulting in significant health improvements. In several countries where the control programmes are currently being implemented, they are typically running for 5 years. The questions we are asking is what will happen to 1) the children who have been treated, 2) the rest of the population that has not been treated and 3) the parasites? The overall, long-term outcome of these treatment programmes for human health is believed to be good- but what evidence do we have for this? In my research group, we are interested in the long-term consequences of praziquantel treatment. Our studies and those of others have shown that the effects of praziquantel treatment go beyond the transient reduction of infection intensity and morbidity. Treatment with the antihelminthic also reduces future pathology and induces immune responses protective against re-infection by the parasites. What will be the effect of the 5-year treatment programmes on the host immune system and overall health?  Experimental studies of the regulation of the immune system suggest that treatment of helminth infection results in susceptibility/worsening of immune disorders (explained through the hygiene hypothesis). What is the relevance of these studies to human helminth infection? What are the long-term health implications in children treated through these national treatment programmes? Similar to malaria, people exposed to schistosome parasites develop natural acquired immunity to the parasites following repeated infection with the parasites. What is the consequence of praziquantel treatment on schistosome immunity and disease, decades after cessation of the control programmes? Providing answers to these questions is critical for informing strategic planning for ministries of health and prioritisation of resources as well as formulating /directing global health policy.


These really interesting scientific questions and the potential impact of the findings for human health are the drivers of research for Dr Francisca Mutapi and her group, the Parasite Immuno-epidemiology Group, at the University of Edinburgh.

 

 

The health & environmental impact of global health research

“How does one cross the Atlantic in an environmentally-friendly way?” I asked myself.* A few weeks earlier I had been challenged by a fellow student who had attended a university-run course “Carbon Conversations”. I then began to reflect on the health and environmental impact of my global health research and to consider ways in which I might reduce my climate change burden. Struggling to find a satisfactory answer to my question, I approached a local sustainability advisor who explained that the alternatives to “door-to-door” air travel were likely to involve significant time costs and/or financial costs. No feasible alternatives. It was a disappointing response, especially after reflecting on the potential global health cost of spending over 20 hours on aeroplanes for my research. Could a solution be found to minimise the global health impact of overseas travel which remains essential for many studying and working in global health with limited time and restricted budgets?

It is widely accepted that high carbon usage and emission contributes to global climate change. Studies have reported that the likely direct health impacts of global climate change include those associated with an increase in heatwaves and a rise in vector-borne diseases such as malaria. Indirect health impacts may include sanitation problems secondary water shortages and malnutrition due to a rise in food costs as a result of reduced food production. People living in less developed regions are predicted to experience the greatest direct and indirect health impacts of climate change.

Hard policies are already being implemented by national and global bodies to reduce carbon emissions through initiatives such as improving rail networks and increasing taxes on fuel and high-emission vehicles. Could “softer” approaches at a local level be effectively employed by individual members of the working and studying global health community in order to tackle the problem of climate change which threatens to have a negative health impact on many populations? It is certainly never too late to consider this suggestion. It was only in 2013 that the UN Development Programme for Europe and Asia for the first time assessed the carbon footprint of one of its global health projects. We know that travel and transportation are important contributors to the climate change problem, and that many staff and students in global health are likely to travel for work purposes. Perhaps responsible travel is an approach and practice that could be promoted more widely and emphasised more strongly within the global health community.

Practically speaking, adopting this approach might mean that within academic departments of global health, individuals who plan to travel would be encouraged to consider and attempt to address the issue of climate change when writing project proposals, funding applications, dissertations, and theses. For example, a postdoctoral researcher applying for funding to attend a global health conference in Brussels might choose to budget for the additional time and financial cost of travelling to Paris by ferry and train. At the same time she could be offset these extra costs against savings made by booking more modest accommodation. Similarly, a PhD student involved in global health data collection in Asia might include a reflective paragraph in his thesis acknowledging the health impact of climate change due to travel. He could also describe the challenges encountered and steps taken to reducing the travel-related carbon emissions associated with his research.

Finally, we need to consider not only the immediate costs of changing our travel habits, but also the longer-term global health costs of not taking action to promote a low carbon future worldwide. Time and money are important and even when both are limited, global health workers and students can still explore and consider more responsible ways of travelling. If we choose to spend years studying and working to improve global health today, let us also choose to leave a shrinking carbon footprint that will have not have a significant negative impact on global health tomorrow .

 


 

Dr Anne Aboaja

Dr Anne Aboaja, is a Global Health PhD Researcher, Psychiatrist and Member of the Global Health PhD Network at the University of Edinburgh


 

Foot note

*When I asked this question, I did not have in mind ticking a box during an online airline booking in order to offset my carbon emissions. Instead I entertained the idea of spending a couple of weeks on a low-cost transatlantic crossing followed by a scenic, and possibly bumpy, road trip on public transport to my destination, sensibly using the time to read and critically review journal articles, write papers for publication, practise language skills, and creatively think through research problems encountered. Unrealistic? Maybe. Maybe not. In the spirit of sustainable global health? Definitely.

 

 

Hepatitis E Virus – An Emerging Infection in Scotland?

 

Globally, liver disease caused by hepatitis A, B, C, D and E viruses is estimated by the World Health Organisation (WHO) to cause the death of around 1.4 million individuals annually. On World Hepatitis Day, 28 July 2014, the WHO underlines the recent resolution of its World Health Assembly directing its 194 Member States to ensure they have national policies in place to address the challenge of viral hepatitis in a manner that builds on local, national and international expertise and experience with a view to combat the hepatitis viruses successfully.

Worldwide, hepatitis E virus (HEV) is an emerging infection with a current estimate of around 20 million infections occurring annually – with >3 million acute cases and around 57,000 deaths (WHO data). The virus is transmitted primarily through the faecal-oral route causing mostly asymptomatic infection but HEV acquisition may also develop into overt hepatitis and fulminant hepatic failure. Although HEV prevalence is highest in East and South Asia, it is now clear that the infection is a global challenge that does not require travel to such high prevalence areas. Instead, autochthonous (locally acquired) hepatitis E is now a recognised component of UK HEV epidemiology with an increase in HEV cases having been observed in the British nations. In particular, recent collaborative research between NHS Lothian and the University of Edinburgh has highlighted the situation within the Lothian health board. Equally, Health Protection Scotland (HPS) has observed a substantial national increase in laboratory reports of HEV infection rising from 15 cases in 2011 to 95 reports in 2013. Although no HEV outbreaks have been reported in Scotland, greater awareness of autochthonous HEV has led to a general increase in HEV testing with identification of cases.

As a result of the above, NHS Scotland is collaborating closely with the University of Edinburgh and other Scottish research institutions with a view to forge a national approach to the prompt identification and management of HEV infection as well as delineating some of the research required to further our understanding of the virus and its pathogenesis thereby supporting the WHO in its efforts to combat viral (HEV) hepatitis.

 

Ingólfur Johannessen, Specialist Virology Centre, Department of Laboratory Medicine, the Royal Infirmary of Edinburgh (University of Edinburgh)

The Year of Environment and Health

“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 needsWorld 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.

Maternal and infant health in Malawi

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