Global health security, collaborating to stop epidemics

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Just three little words, “global health security”, but they represent such depths of meaning. A hundred years of modern scientific enquiry into infectious diseases such as yellow fever, malaria, and now zika. The wake up call of SARS and swine flu, where viruses with dramatic results leapt the species barrier. The galvanising effect of West Africa’s Ebola epidemic on the WHO, the international NGO and donor community and on governments. The concern over emerging and re-emerging infectious diseases, so many of them zoonotic in origin.

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Universal health coverage gains momentum in 2016

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WHO definition: Universal Health Coverage (UHC) means everyone can access the quality health services they need without financial hardship.

This year it seems that organisations, governments and citizens everywhere are answering the call to UHC, whose annual awareness day is December 12th.

From this year forward, UHC is seen as central to improving health systems, improving economies, and ensuring global health security. The G7 group countries, the primary source of funding for Low and Middle-Income Countries (LMIC), met in Ise-Shima Japan 2016 and made UHC their umbrella concept. Through this, they seek to improve health systems and global health security.  Of the 17 SDGs agreed by the United Nations, just one is directly health-related but it is “achieving UHC”.

Judith Rodin, (President Rockefeller Foundation, has observed that “25 of the wealthiest nations all have some form of universal coverage, as do some middle-income countries including Brazil, Mexico and Thailand and lower-income nations, such as Ghana, the Philippines, Rwanda and Viet Nam, are working towards achieving UHC.”

Rather than talk about why we need UHC, I thought I’d talk  about what is actually proposed by middle-income and lower-income countries (LMIC) to fulfil UHC and what the NGOs, donors and global health community championing UHC would like it to encompass.

What is UHC?

UHC systems vary from country to country: there is no one size fits all.  It very much depends on the minimum health outcomes a government wants to achieve and how much of its GDP it is prepared to spend. The main variables being the level of care delivered, who delivers it, who receives it and how it is funded. 

UHC of itself does not mean universal access to health services nor care for all diseases. It’s about providing a basic level of health services (“Essential Packages of Health Services”) to as much of the population as possible.

The first UHC system was the UK’s National Health Service set up in 1948.

The USA has a non-universal system of health coverage.

What do LMIC see it as?

Over time,  as far as I can see, these basics for a cost-effective UHC have emerged:

  • government regulation, legislation and taxation
  • primary health care
  • vaccination programmes for children (for LMIC this is organised through GAVI, the Vaccine Alliance)
  • maternal healthcare (pregnancy)
  • health insurance to finance (public tax, private insurance or a mix of both)
  • financial protection: pooled funds to reduce out of pocket payments amongst the poorest and vulnerable  

Much of the information that now follows is derived from  the RSTMH 2016 Chadwick memorial lecture "Neglected Tropical Diseases in the Time of Blue Marble Health and the Anthropocene Epoch", given by  Professor Peter Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine, Texas and President of the Sabin Vaccine Institute. 

 

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One Health working will improve health and well-being of us all: plant, animal, human and ecosystem!

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    Pastoralists, Mongolia. Image courtesy of Esther Schelling, Swiss TPH.

 One of a series of blogs written by CABI editors for One Health Day on November 3rd 2016
 
It's always nice to meet up with a CABI author at a conference especially when they are giving a talk around a theme dear to CABI‘s heart,  namely “One Health”: the concept of working across the interface of animal, plant, human  and environment  to achieve health  & development  which is sustainable and fair. CABI has been gathering, managing and generating research information across all these sectors since 1912.  We know “its all connected”.

The conference was the RSTMH biennial meeting [Cambridge UK, Sept 12-16th, 2016], and the author in question, Esther Schelling, co-editor  of CABI’s  book One Health: The Theory and Practice of Integrated Health Approaches [2015].    To read a  free e-chapter, use this link.

In One Health beyond early detection and control of zoonoses Esther talked about her long-time project with nomadic pastoralists in Chad and a rift valley fever (RVF) control project in Kenya.  She drew attention to the need for:

  • more interdisciplinary studies to include an evaluation of One Health working
  • involvement of social scientists
  • engagement of key stakeholders

And tellingly she provided a cost-benefit analysis to society of controlling zoonoses when the disease is in its animal host before it infects human beings. 

Those cost-benefit analyses made a deep impression on the delegates, many of whom were involved in zoonotic neglected tropical diseases. Perhaps for the first time they were appreciating the added benefits and synergies that a transdisciplinary approach between science, society, humanities and medicine could bring.

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Why Latin America is nearer elimination of rabies than Africa

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"World Rabies Day" is September 28th. Copyright: CC, Global Alliance for Rabies Control   
   
Rabies: a contagious and fatal viral disease of dogs and other mammals, transmissible through the saliva to humans and causing madness and convulsions. Rabies is fatal once symptoms appear.

Latin America is doing far better at managing, controlling and ultimately eliminating rabies from the region. Africa is failing to make the same gains and a rethink is required: can the lessons learned in Latin America be  applied or adapted to Africa?

At  the biennial RSTMH meeting “Challenges in Disease Elimination” held in Cambridge [September 12-16th, 2016], Katie Hampson [University of Glasgow] described the Pan American Health Organisation (PAHO)'s surveillance & management framework operating in Mexico and Brazil,  and devised to support the elimination of rabies in 25 PAHO countries. She also described the work of Tanzanian colleagues who have developed a “pragmatic approach to surveillance” for the African setting where resources are constrained.

Current situation of rabies control in Latin America vs Africa

The short answer is that in Latin America, PAHO, which exists to “strengthen national and local health systems and improve the health of the peoples of the Americas”, has concentrated on vaccinating the dog population against rabies and interrupting transmission. African countries have no similar regional support structure for their health ministries and rely on post-exposure prophylaxis (PEP)  of humans bitten by dogs, to achieve a form of control of rabies. PEP vaccination only saves lives if the bitten person has timely access to a well-stocked clinic, and the money to pay for the shots. In remote and rural areas, this can lead to grim choices: which child do you treat if you only have money for one?  We heard at the RSTMH of an African mother with several children bitten by the “family dog”, who having travelled a great distance to reach the vaccine, was then faced with that very choice.

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The recognition of Mycetoma: much needed attention finally given to long neglected tropical disease (NTD)

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Image: Woman in the West Indies with mycetoma caused by a fungal organism
CDC/ Dr. Lucille K. Georg

From Harpur Schwartz, an economics/global health student from Connecticut College, USA,  interning with Cabi’s Global Health team.

While tuning in to the live broadcast of the Sixty-ninth World Health Assembly taking place at the World Health Organization (WHO) headquarters in Geneva, Switzerland, mycetoma reached the discussion floor. At the risk of sounding naïve, I’m going to tell you that I had never heard of mycetoma – although a quick google search revealed images resembling elephantiasis. As a student studying global health, I was a little disappointed with myself; I mean I have at least heard of the other neglected tropical diseases (NTDs). But if mycetoma was unfamiliar to me, how many other people had never heard of this disease? I have provided answers to some basic questions I had about mycetoma in case you too are unfamiliar with this disease…

What is mycetoma?

The World health Organization describes mycetoma as, “… a chronic, progressively destructive morbid inflammatory disease usually of the foot but any part of the body can be affected”. This disease is caused by a bacterial (actinomycetoma) or fungal (eumycetoma) infection where the organism enters the body through a minor trauma or a penetrating injury (i.e. commonly a thorn prick). It is believed that the infection enters the body after this pricking occurs, but there are no concrete studies determining transmission. A good video on it can be found here in Global Health Now's Spotlight on Mycetoma by Amy Maxmen.

Is there a cure?

In terms of treatment, curing actinomycetoma using antibiotics has about a 90% success rate. The use of antifungals to treat eumycetoma has a success rate of about 35%, but in 2016 a new antifungal agent, fosravuconazole, will be the subject of the First Clinical Trial in Mycetoma conducted by Drugs for Neglected Diseases Institute (DNDi). Because the disease takes a slow, relatively pain-free progression, mycetoma is at its most advanced stages once it is diagnosed. It is at these later stages when amputation becomes necessary.

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Neglected tropical diseases: the future is multidisciplinary and ‘one health’

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A new society has been born – the International Society for Neglected Tropical Diseases. The society’s reason for existence is to provide a space where people from different disciplines can meet and develop new ways to control neglected tropical diseases (NTDs). I went to their inaugural conference. The talks were many and varied as was the audience: there were experts in anthropology, communication and education, microbiology and molecular biology, health workers in the field, and last but not least – veterinarians.

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