The Basics: The Paradox of the Dual Burden – NCDs and CDs

Here’s a fictional allegory:

Thelma lives in a rural area in Tanzania. At age 5, she contracted malaria. Due to broadened availability of health services, Thelma received an artesunate based treatment and, unlike many before her, she survived. In fact, she lived a long, healthy life.

Long enough to reach the age of 55; at which point she developed hypertension and was later diagnosed with Type 2 Diabetes Mellitus.

 

I write this fictional tale here, far removed from the fictional life of Thelma, at my oh-so-trendy standing desk. But fiction or not, it is a scenario that is far too real in many middle and low-income nations. The dual burden of communicable and non-communicable diseases is very real.

Communicable Diseases (CDs): An infectious disease; one transmitted from person to person. e.g. Tuberculosis

Non-Communicable Diseases (NCDs): Diseases that are not transmitted from person to person and generally bare closer relation to lifestyle factors than CDs. e.g. Coronary Heart Diseases

Globally, four of the top 5 causes of death are non-communicable diseases; and the vast majority of the global population lives in low and middle-income nations. But make no mistake, the burden of malaria, HIV and other communicable and tropical diseases remains a force to be reckoned with for many national and regional health systems.

The fact that four of the top 5 global causes of death are all non-communicable illnesses  is a success. It is a success because it is my opinion that the aim of improving global health is increasing the number of healthy life years for the greatest number of people.

Thus, the fact that the majority of the world’s population, including Thelma, now live long enough to develop these arguably lifestyle influenced diseases that occur both later in life and towards the end of an individuals most economically productive years, is a success.

It is vital, however, to understand that none of this is an accident. Cholera, malaria, measles and even polio have not ceased to exist, or occur. It is through consistent, vigilant monitoring, financial investment in the refinement of systems on the part of national governments and associated actors that have kept communicable diseases at bay: they occur, but they do not result in death at the same scale as they did 30 years ago.

Meanwhile, due to globalization and urbanization, amongst the advent of other factors, lifestyles have changed world over. Globally, on average, we are ALL walking less, driving more, consuming a diet higher in saturated fat, sodium and sugar, and living more sedentary lifestyles. These are just some of the many risk factors for NCDs such as Coronary Heart Disease and Type 2 Diabetes (which will no doubt be discussed at length in a future post).

Thus, the emergence of the dual burden. Malaria endemic regions need to remain vigilant in their fight against malaria and despite encouraging numbers, need to maintain funding to maintain progress. Nonetheless, this dual risk and burden mean that investment need also be made in the prevention of NCDs as well as their treatment.

Developing countries today are facing a greater burden than that faced by Europe 100 years ago with regards to Tuberculosis in Sweden and Cholera in England, for example. Today low and middle-income countries are dealing with both old and new; the ailments of the ‘poor’ and the ailments of the ‘rich’, simultaneously. Furthermore, they are dealing with larger populations, different technologies, and regulatory restrictions that the developed world didn’t have to deal with in their fight against widespread NCDs, decades ago.

 

It won’t be easy, but with collaboration, dedication and understanding, it will be done.

 

– Christiana

 

Médecins Sans Frontières Scientific Days 2016

Today I attended the second day of the annual Médecins Sans Frontières / Doctors Without Borders Scientific Day.

I have been thoroughly impressed not only by the entire program this year but also with the dedication to broadening access to healthcare, improving diagnostic systems and achieving the objective of the democratisation of health through the development of accessible and appropriate technologies. E-health, digital health and telemedicine – for far too long it has been assumed that these are not feasible, viable modes for use in low and middle income countries. And this is simply not the case.

I commend MSF and the global health community for their dedication to e-health. I’m excited by the changes in the global health landscape: the world is changing rapidly and (fortunately) we, in health, are keeping up!

Next stop: My first ever TED event tonight!

Yours truly,

Christiana

The Basics: HIV, AIDS and related co-infections

I dedicate this to all those who suffered needlessly, died prematurely, were born free but sick; and felt the pain of not only disease but also isolation and stigmatization.

 

I started this blog with the objective of writing about what I know, and love: global health. I want to write about serious issues in a way that is accessible and relevant. I also want to share my opinions.

 

 I’m pissed off. I have noticed a trend of reporting on HIV & AIDS in terms of morbidity and mortality that seems not to draw a distinction between these two related but independent conditions.

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immunodeficiency Syndrome

The attention on HIV and AIDS has simmered down in mainstream media. Indeed, major progress was made in slowing the rate of new infections, AIDS deaths and treating the co-infections with which HIV is associated. But it still irks me every time I HIV and AIDS used interchangeably. I am equally annoyed by the frequent misinterpretation of HIV & AIDS data that leads not only to misunderstanding of disease process but also an underestimation of the progress made by governments, NGOs and major international governing bodies, notably the World Health Organisation.

 

Human Immunodeficiency Virus (HIV) is a virus that can be spread by a number of infection modes. The epithelial linings of the vaginal and anal cavities make them particularly vulnerable to exploitation by the virus. Intravenous infection by the sharing of needles is another way that the HI virus can gain access to the host by the circulatory system. Mother to child transmission also persists as a concern in many regions.

 

HIV can remain latent, showing no symptoms for up to 10 years before progressing to AIDS (in the absence of treatment). Some people progress rapidly from HIV to AIDS. These individuals are called fast progressors. A small percentage of individuals never progress to AIDS, but I will not focus on this in this article, as this is a small minority of patients.

 

HIV currently has no vaccine; and its ability to change its surface proteins and integrate itself within the DNA of the host makes it very hard to develop one.

 

Nonetheless, with antiretroviral treatment (ART) an individual can live a relatively normal, long and healthy life. In fact, some studies have shown that HIV positive patients on antiretroviral treatment tend to live up to two years longer than the average national life expectancy. This may be due to their constant medical monitoring.

 

Once an individual has progressed to AIDS, however, in the absence of any form of ART, their prognosis is poor and death is virtually inevitable.

This brings me to the interpretation of HIV & AIDS data. People die of AIDS. People do not die of HIV. HIV deaths are always associated with comorbidities. The suppression of the immune system caused by HIV makes HIV positive individuals far more susceptible to a range of infections: from cryptococcal meningitis to Tuberculosis and pneumonia.

Some of these are particularly difficult to treat in HIV positive patients.

Moreover, due to the characteristic of latency in HIV, it is common that patients present at clinic and hospital with the confection, unaware of their HIV positive status. This produces new challenges, particularly in the case of Tuberculosis, especially multi-drug resistant tuberculosis. Often the drugs associated with treating these infections, with their long and complicated treatment courses, have a negative interaction with the initiation of ART. There is much debate about when and how to start treatment for HIV and TB in such a way that minimises risk of mortality to patients. Most recent research has shown that the time to start ART after MDR treatment is dependent on how poorly the individuals immune functioning is at the time of presentation; measured by CD4 T-lympocyte count.

This is a topic that will be explored in a later article in detail however I hope that this article has made the distinction between HIV and AIDS clear. I also hope it explains what are sometimes referred to as ‘HIV deaths’ and that even nations with a high population of HIV positive individuals, through the utilization of ART, heavy monitoring and treatment of coinfections in HIV positive individuals, informed by current research, can still achieve a high life expectancy and reasonably high quality of life for its citizens.

 

Cheers, Happy Friday!

The End of An Era: 2015 Millennium Development goals round-up

The World at 2000

 

In September 2000, leaders from each of the 189 UN member states assembled to decide the United Nations’ Mission for the next 15 years. The “Millennium Summit”, unlike any meeting before it, was to set the stage for global development in the form of eight Millennium Development Goals (MDGs).

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The preceding decades had seen wars, epidemics and crises that caused devastation on a scale unrivalled in recent history. It had also seen the establishment of the League of Nations, and later, the United Nations: an organization poised to mediate, delegate and ensure peace, stability and sustainable development globally. In the famous words of former United Nations Secretary General, Dag Hammarskjöld, “The UN was not created to take mankind to heaven, but to save humanity from hell.”

 

In this spirit, eight Millennium Development Goals were developed. Each goal was defined with set targets and indicators. They were to eradicate extreme poverty and hunger; achieve universal primary education; promote gender equality and empower women; reduce child mortality; improve maternal health; combat HIV/AIDS, malaria and other disease; ensure environmental sustainability and develop a global partnership for development.

 

  • Three of the eight MDG targets were met ahead of the 2015 deadline. Five were not. However, tremendous progress was made on all fronts and the breadth of commitment of all the actors involved was unmistakable. Now, post 2015, it is imperative that the world, all of us, reflect on the successes of the new millennium. And that as global citizens, we continue support our governments and hold them accountable. To whom are nations accountable? Countries are accountable to their citizens alone; and achieving sustainable development on national and regional levels requires action, involvement, innovation and an integration of efforts across ministries and sectors.

 

Seventeen Sustainable Development Goals, with 169 targets, were declared at the General Assembly in September 2015. The aim of the 2030 Agenda for Sustainable Development is to build on the work of the MDG era, advance towards new development aims and additionally pursue accelerated progress.

 

It is my hope that in this SDG era, an even more integrated approach to development will be taken, particularly in terms of global health, towards ensuring the universal delivery of primary healthcare within the frameworks of both economic and social development.

 

The World Today

 

Naturally, my interest here leans towards the objectives of health. The countries with the greatest challenges in relation to the health in the past 15 years are low income countries, and to some extent middle income countries; nations that experienced civil war and conflict; and those that have experienced natural disasters. These tended to be particularly vulnerable because in many of these cases, health systems and other necessary infrastructures required to deliver healthcare had been weakened.

 

A good example of how conflict can affect services and make nations vulnerable to disease is the way in which the Ebola epidemic that transpired in Sierra Leone and Liberia. The weakened nature of these two nations healthcare infrastructures made them more susceptible to wide spread outbreak than another nation in the same region with far greater resources and a better established healthcare structure, such as Nigeria, who very successfully managed to contain Ebola, in major cities, despite its vast and dense population.

 

Nonetheless, today, the number one cause of death globally is ischemic heart disease: subtracting more healthy years from more people than any other health issue. Not Tuberculosis, nor malaria.

 

Today, nations developed and developing are experiencing the burden of non-communicable diseases. Sadly, in many places, this burden is growing. In the SDG era, this paradigm shift in global public health has also been taken into account to ensure an appropriate response to today’s global health risks and disease.

 

At the time when the MDG goals were conceived, poverty levels were high, education in many parts of the world was dismal, and there were alarmingly high levels of maternal and child deaths as well as ever increasing mortality and morbidity rates associated with HIV/AIDS, malaria and TB. The goals were an exceptionally useful political tool to bring the global community together with a common goal and purpose. The MDG process was able to galvinate much-needed political will from governments, necessary UN arms, non-state actors, development partners and citizens throughout the world. The MDGs became a rallying point for global change. The banner under which every member state, ngo, and concerned partner could stand united towards a common goal. Eight, in fact.

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Notwithstanding, the realities on the ground were an enormous challenge. From the very onset, the MDGs came under great scrutiny. Some argued that like a long list of New Year’s resolutions; written with the best, although ambitious intentions; they would either never fully come to fruition or simply be forgotten by the new millennium’s proverbial ‘February’. Today, however, 9.5 million HIV positive people have received antiretroviral drugs since 2012 and child mortality has almost halved; with six million fewer child deaths in 2012 than in 1990.

 

In the midst of these great strides, great challenges persist globally. Case in point: 600 children having died of AIDS-related causes in 2012 alone. It is important to bear in mind that almost all of the MDG targets have either a direct or indirect impact on health. Improving education for women and girls has not only a profound impact on national wealth, but also on the health and survival of children and infants. For every additional year of primary education in reproductive-age women’s education there is a 9.5% decrease in child mortality.

 

Furthermore, in 2005 an amendment was made to MDG 5, “improve maternal health”. MDG 5b was a commitment to the expansion of access to reproductive health and family planning services and an extension of MDG 5, the improvement of maternal health. A point that also appears amongst the 2030 SDGs, and a sign of our rapidly changing world.

 

MDG 4, 5 & 6 Progress Scorecard

 

For those in the global health community, the focus has been largely on goals 4, 5 & 6: reducing child mortality, improving maternal health and combatting HIV&AIDS, malaria and other diseases respectively. Whilst the SDG era will call for greater integration and collaboration of efforts, the MDG global health outcomes are as follows:

 

 

  • MDG 4 – Child Mortality: Over 40 nations including Brazil and Madagascar are on target to reach MDG 4 by 2015, over 20 nations are off target, including Kenya and Afghanistan.

 

  • MDG 5 – Maternal Mortality: Only 18 nations including Morocco and Ecuador are on target to reach MDG 5 by 2015, 40 nations are off target for this goal, with many others showing some progress.

 

  • MDG 6 – HIV/AIDS, Malaria, TB, etc: Over 30 nations including Uganda and Sri Lanka are on target to reach MDG 6 by 2015. Over 50 nations including India, Ukraine and Mozambique are currently off target.

 

Some countries did not meet their targets within the original timeframe. What has become apparent is the importance of health systems strengthening in the realization of these outcomes.

 

A great deal needs to be done particularly in the low-income nations in Africa and Asia to ensure that levels continue to be improved. Access to healthcare services, universal healthcare (the dream!) has not only to do with the availability of these services, which is absolutely essential, but also with adequate road networks and public transport infrastructure – even to the world’s most remote communities. Indeed, most of the world today lives in urban settings. Nonetheless, where there are people living in remote rural areas, forested areas and periurban settings, they too need to be able to access safe, adequate and quality healthcare services.

 

Education also plays a vital role in this respect: community level healthcare workers in parts of East Africa, for example, have been shown to have a remarkable impact in dealing with severe malaria in infants. Where, in this case, there is often a full day’s walk in the blistering heat to the nearest clinic. Hence, healthcare workers at the community level help to tide over the crucial time period between the culmination of symptoms – usually the child losing consciousness – and arrival at a healthcare center.

 

Education, in terms of health seeking behavior can be the fundamental difference between life and death. Accessible, affordable, quality healthcare will encourage people to attend clinics and hospitals sooner; but so will a change in attitude towards seeking medical attention. It is my belief that greater consideration of the economic and developmental economic aspects that influence health and healthcare will yield exponential results in the SDG era.

 

The World Tomorrow

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Data is a truly invaluable resource for policy-makers to aid in interpreting reality, understanding causality and recognizing trends. Through the analysis of data, policy makers can facilitate strategic decision making to respond to the needs of our current world in a contemporary and region specific manner, as opposed to employing “one-size fits all” methods. The role of the World Health Organization, and the United Nations at large, is to work with member states to develop strategies that are right, workable and appropriate for them. Strategies based on evidence: that yield results in the short to medium term, and also the long term.

 

 

There is no longer a stark contrast between the wellness and illness of north and south, east and west, rich and poor, developed and developing. No longer are non-communicable diseases an affliction of the west and communicable the affliction of the rest: many developing countries are experiencing rapidly increasing levels of non-communicable diseases, often grappling with both of these combined.

 

Nonetheless, to a certain extent this can be regarded as a global health victory. The rise in non-communicable diseases in many developing nations is a symptom of success in tackling communicable illnesses: she who contracts tuberculosis at 25, receives adequate treatment and lives another healthy and fulfilling 25 years has lived long enough to develop hypertension at 50.

 

 

Thus, I take my hat off to all the silent hero developing states, such as Vietnam, that have allocated their resources to fostering more robust healthcare systems that have dealt positively with communicable and infectious diseases, road accidents and other formerly major causes of death globally.

 

The SDG era will deal with a brand new beast – pressing forward to the goal of universal health coverage whilst dealing with a brand new set of challenges, including mental, nutritional and age based health concerns. Watch this space for a more detailed discussion on the SDGs as pertaining to health.

 

One thing is for sure: healthy life for all is not only a right, it is a necessity. And the latest and most comprehensive global partnership agenda may be the first step towards a healthier, brighter future that global health fanatics (such as yours truly) have only seen in their wildest dreams.

 

A Brief Introduction

I’m Christiana: a 23 year old, Geneva and London based global health and development enthusiast. With a background in medical sciences and economics; and as a current MSc candidate in the field of drug development; I use this blog to explore and record my personal musings on issues surrounding drugs, health, policy and development.

It is my hope that through my writing I can share my passion and contribute to the global discourse on matters of health and development.

Christiana Onyebujoh