Learning from Macron : Why simplified and antiquated assumptions about the world are a direct threat to public health

I went back and watched the French president’s full speech at this month’s G20 meeting in Hamburg, in the original language, in an attempt to gain an understanding of the point he was trying to make. Aware that the noise of the ‘soundbite’ media can often drown a well-intentioned message. I also listened to the original question posed that incited his response. For those of you who don’t know what was said, here is an English translation of the major points raised in the particular answer that caused the contention taken from The Independent.

“The problems Africa face today are completely different … and are ‘civilizational’…. What are the problems? Failed states, complex democratic transitions and extremely difficult demographic transitions

He also referred to the continent as “a land of opportunity”.

It’s by a more rigorous governance, a fight against corruption, a fight for good governance, a successful demographic transition when countries today have seven or eight children per woman…At the moment, spending billions of euros outright would stabilize nothing. So the transformation plan that we have to conduct together must be developed according to African interests by and with African leaders.

Emmanuel Macron / Ed Alcock / M.Y.O.P.

Let’s deal with this in parts.

  1. The Role of Opinion

In my opinion the problem here is exactly that. His statement is based largely on opinion and possibly also some outdated world views. But not on fact.

He was factually wrong. Completely wrong. There are no such states in Africa – where 7 – 8 children are born per woman.

 

  1. The Numbers

I sat down, created a spreadsheet; and using world bank data, carefully compiled a list of all 54 African states (excluding South Sudan, for which there is not yet data) and crunched the numbers.

The average number of babies per woman on the African continent is 4.32.

In terms of countries today that have seven or eight children per woman. There is only one such country in the world today. Incidentally, that nation is Niger: 7.51 children per woman. This is the only nation with an average of 7 or above in the continent. At 1.55 babies per woman, Mauritius has the lowest number followed by Tunisia – 1.97.

Presenting a skewed view of the world is dangerous. Without accurate information, we cannot effectively address REAL problems that exist in the world today; nor fully understand their causal factors. This is not just a development issue: it is a public health issue.

The number of babies per woman, globally, is (unsurprisingly) inversely proportional to infant and child mortality rates. It is therefore, no surprise that Niger, with the highest number of babies per woman, also has one of the continent’s highest child mortality rates at 95.5 per 1000 live births. Compared with Tunisia at 14 per 1000 live births.

This is a vital concept. Parents will have fewer children when their likelihood of survival to adulthood increases. And to frame this issue any other way would be a mistake. When child mortality falls, babies per woman fall too.

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  1. The Point of Democratic Transition

I have yet to fully understand the demographic changes the French president is referring to. (Maybe someone will explain this to me.)

I cannot say I understand the elusion to ‘demographic transition’; outside of my assumption that he is making reference to the tensions created at the Berlin conference of 1884 – 1885, better known as the Scramble for Africa, when European leaders divided the continent between themselves with arbitrary borders, many drawn quite simply with a ruler, with no regard for the ethnic and religious groups living in those areas.

Or perhaps how many of these states were subsequently administrated in a way that was to the complete exclusion of African interests, creating areas of wealth and poverty, new forms of discrimination between ethnic groups, such as in Sudan (now Sudan and South Sudan) or Rwanda, and centres of commerce. Many of these centres placed particularly at ports ultimately leading to the creation of land locked developing countries, today some of the continents’ poorest, with little access to these newly formed trade routes, as opposed to the forms of trade that had existed for centuries.

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  1. Spending Billions of Euros on…. ?

Just to clarify: ‘Western’ nations do not bail out ‘failing’ African economies as they do their own. Furthermore, to speak of ‘challenges facing African economies is to speak of nothing at all.

Africa is the most genetically diverse continent on the earth. A continent of 54 states. The majority of which were colonised; as were India, Bangladesh and what are now the independent states of Peru and Bolivia, respectively. Today, when European nations intervene in African politics these actions are almost exclusively to the benefit of their own interests. Not for the development of African states purely for the benefit of these states. (See: France Operation Serval in Mali 2013)

Nonetheless, I don’t think any of us Africans believe that billions of Euros were to be donated/invested in our economies had the president been aware of our “demographic” profile according to fact, versus fiction. Being a bit of a pet peeve, I have deliberately elected not to address the use of the term ‘civilizational’. The problems with this kind of phraseology are numerous and based on multiple assumptions. Nonetheless, we understand the sentiment being expressed here, so dissecting its misuse would be redundant given the subject matter.

‘Africa today’; to use the same language of the French president, and to acknowledge the validity of his closing remark in this question; will and must develop according to African interests (finally). And in my opinion this will take the continued cohesion within this highly heterogenous continent. And if nations such as France and other members of the G20, all foreign states with the exception of South Africa, wish to be part of accelerating Africa’s continued development, the participation of African leaders who hold the interests of their populations at heart is indeed vital.

True progress requires the involvement of all stakeholders and a comprehensive, representative, contemporary understanding of both the developmental and healthcare landscapes, by all parties. And a poor grasp of these can lead to ill-informed, unpointed, one-size fits all interventions that, despite best intentions, are functionally ineffective.

 

Images: politico.eu, naijamumsonline.com, cnn.com

SERIES: Part 3 – Even more causes of rising obesity incidence in the United Kingdom

This is Part 3 of my Obesity in the UK series. If you missed Part 1, or Part 2, you can find them by following the links. 🙂 Like part two, this part addresses causal factors but with a greater emphasis on some indirect causes.

Beliefs, Perceptions and Stigmatisation

There is evidence to support that a potential driver of obesity is the failure of obese persons, or parents of obese children, to recognize themselves or their child as obese. In short, weight perceptions among obese adults in Britain do not match clinical definitions of obesity. Most obese adults do not describe themselves as obese. Another study of 2976 English children found that a third of parents underestimate their child’s BMI.

As more people in the community grow into the category of obesity, perceptions of “normal” for everyday Britons may be increasingly swayed. Even teenagers, were not immune to this warped self-perception in terms of weight: 39% of overweight teenagers described themselves as “normal”.

At first glance, these findings seem almost counterintuitive. However, in a society that stigmatizes obesity, it is no surprise that many do not wish to recognize themselves as “obese”.

Moreover, overweight and obese individuals who reported experiencing fat stigmatization gained 0.95kg over a year. In an image-obsessed world, many people are experiencing stigmatization due to their weight. Thus, paradoxically, this cruel, “skinny-culture” may be a factor driving more overweight individuals towards obesity.

 

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Socioeconomic status

At first glance, higher levels of obesity among low-income groups may too seem counter-intuitive. However, in the UK, as in many other high and middle-income countries, this is the case.

There is an existing or emerging inverse relationship between income and obesity. Attempts to explain these trends follow the assumption that in high and middle- income nations, the vast majority of the population is able to afford to be adequately fed. Thus, a very negligible proportion of the population will be underweight due to an economic inability to access food. What may be significant in understanding this is how socioeconomic factors drive the types of food that individuals and families consume on a regular basis.

Whilst the prevalence of childhood obesity and overweight in the UK has stabilized in recent years, children from the lowest socioeconomic groups have continued to exhibit increased levels of overweight and obesity in comparison to their counterparts from other socioeconomic strata. The outlook is similarly bleak for low-income adults. This points to the importance of appropriate education on diet. According to the HSE, lower income women exhibited a higher proportion of obesity: 26% – 31%, as opposed to 15% – 18% in the highest income quintiles. Men in the lowest income groups were also more likely to be obese: 29% – 30% were classified as obese, versus 23% – 24%.business-cash-coin-concept-41301

Urbanization is shown to have an effect on diet. In a study examining obesogenic environments, it was found that individuals in the most deprived areas consumed significantly fewer portions of fruit daily; as did those living in densely populated environments. According to the World Bank, in 1985, 78% of people in the UK lived in urban areas, versus 82% today, a percentage that is expected to increase.

Furthermore, energy-rich, processed foods are cheaper to produce and thus cheaper to purchase. Many are increasingly marketed towards children from a young age. These subtle lifestyle changes may be driving many Britons transition into overweight and obesity, resulting in continued increased incidence.

Slightly distinct from the factor of income is that of income inequality. Studies show that national income inequality is associated with higher BMIs within obese populations, lower life expectancy and other negative health and psychosocial outcomes. It is theorized that life near the bottom of more hierarchical societies, such as the USA, results in higher levels of psychosocial stress than in more equal nations, such as Sweden.

Compared to many other high-income countries, the United Kingdom has a very high level of income and wealth inequality. Moreover, the gap growing: between 1985 and 2010 inequality rose by almost 25%, making the UK the most unequal country in Europe.

Thus, growing inequality may be one of the primary factors driving growing waistbands.

The Basics: A beginners guide to acronyms and jargon

It’s been a while since I have published a “Basics” series article.

I am grateful for the interest I have received on this humble blog of my musings in areas from economic development to novel treatment modes and health policy. Some of the feedback I have received has been concerning my occasionally excessive use of jargon and acronyms. My intention with this blog was to provide accessible insights that are both relevant and beneficial to peers within this interest and subject area as well as others who are simply interested in discussion about statistical trends in healthcare or the role of pharma in public health. Some of these terms are explained further in other articles within “the basics” section of this blog – I have linked those articles where relevant. 🙂

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So here’s my growing list of acronyms and jargon for clarification:

AIDS: Acquired Immunodeficiency syndrome

ARVs: Antiretrovial drugs for the treatment of HIV

BMI: Body mass index – (Healthy BMI is generally accepted to be 18.5 – 24.9)

BRICS: Brazil, Russia, India, China, South Africa – large, growing middle-income nations

CDC: Centers for Disease Control and Prevention

CDs: Communicable Diseases

COPD: Chronic Obstructive Pulmonary Disease

DALY: Disability Adjusted Life Year

FDA: United States Food and Drug Administration

GWAS: Genome Wide Association Study

HIV: Human Immunodeficiency Virus

MAb: Monoclonal Antibody

MDG: Millennium Development Goals

NCDs: Non-communicable Diseases

NGO: Non-governmental Organization

NTDs: Neglected Tropical Diseases

OECD: Organisation for Economic Co-operation and Development

PEP: Post-exposure Prophylaxis

SDG: Sustainable Development Goal (based on the United Nations 2030 Agenda for Sustainable Development)

T2DM: Type II Diabetes Mellitus

TB: Tuberculosis

WHO: World Health Organization

 

 

SERIES: Part 2 – Causes of Rising Incidence of Obesity in the United Kingdom

This is Part 2 of my Obesity in the UK series. If you missed Part 1, you can find it here.

So back to Causes.

Among other factors, rising incidence of obesity in the UK can be explained by behavioral theories relating to changes in physical activity and eating behavior.

Basic weight gain is most commonly caused by excess energy consumption for expenditure. Rising incidence of overweight and obesity on a population level, however, is more complex. Whilst there are individual physiological and genetic factors resulting in obesity, one may infer that obesity trends are a result of multiple direct and indirect factors including social, political and economic factors affecting our behaviour. Some of them are introduced here.

Environmental Obesogenicity

Environmental factors of societal and market forces driving eating behavior within the population are an area of increasing interest. An obesogenic environment is one where the food and activity environment may drive individuals towards obesity progression. Plenty can be said about obseogenic environments and I will write about this particular aspect more pointedly in future.

Physical Activity and Inactivity

Similarly, It is well understood that appropriate physical activity is a means of effective weight management. It has been argued that the cause of weight gain pertaining to physical exercise is not only low levels of physical activity, but also by high levels of physical inactivity. Sedentary behaviour in itself is linked to co-morbidities.

One theory for increased incidence of obesity considers decreased levels of energy expenditure. An example of this is a change in shopping behavior. Greater accessibility and affordability of services such as online grocery shopping and delivery positively impact the lives of many people, e.g. disabled and elderly, but many modern conveniences have come at a social cost to health.

A greater proportion of the working population in the UK is employed in occupations conducive to levels of relative inactivity. Improved transport services, urbanization, affordability of vehicles and even mobile internet access have made life more convenient, de-necessitating much of our passive physical activity. As early as 1984, a US telephone company estimated that an additional phone extension in the household saves approximately 1.6km of walking annually.

It has been found that children were more likely to be obese for each additional hour of sedentary time. Low levels of activity have been shown to be the most prominent risk factor for weight gain. This trend of increased sedentary behavior may form part of the forces driving obesity incidence in the UK.

Eating Behaviour

Genetics & Physiology

A number of studies have explored the genetic bases of obesity. In particular, twin studies and Genome-wide association studies (GWAS). Results of the Twins Early Development Study (TEDS) show a strong heritability of adiposity and waist circumference as do GWAS. However, these explain less than 3% of BMI variation in children and adults.

Furthermore, it is unlikely that genetic factors are central to rising obesity incidence, as these have not changed substantially, relative to the short time frame of rising prevalence discussed earlier.

 

 

There is no doubt that the causes of rising obesity are complex, multiple and multifactorial. Thus, this article has a Part 2: More Causes of Rising Incidence of Obesity in the United Kingdom

Today’s Agenda: World Health Assembly General Elections

Today I report to you from the Palais du Nations in Geneva where a secret ballot is currently being held for the new Director General of the World Health Organisation.

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Margaret Chan’s decade tenure has drawn to an end. Dr Chan will leave a strong legacy without a doubt, as did many before her. And today’s events and outcomes may have a profound role in defining the next 10 years in global health and indeed, the direct of leadership for the bulk of the SDG era.

World Health Organisation (WHO) Director

Who will it be?

Cheers,

Christiana

SERIES: Rising incidence of obesity in the United Kingdom – Introduction

In the past three decades obesity in the United Kingdom has increased three-fold, emerging as one of the UK’s most prominent public health challenges. Obesity is largely a lifestyle and behavior associated condition, although there are also some genetic factors.

Obesity is measured by a standard anthropometric measurement of known as Body Mass Index (BMI). The terms overweight and obese are usually classified as increased weight-for-height. The figure below classifies the BMI ranges used to define BMI status. (Do you know your BMI?) BMI is calculated by dividing the weight in kilograms by the square of the height in meters. (Or googled)

BMI INDEX FOR GLOBAL HEALTH BLOG

An individual whose weight is two or more times the ideal weight is classified as morbidly obese.

Recent studies show steady increases in obesity incidence both nationally and internationally. Indeed, today we live in a world where more people are clinically obese than those suffering morbidity or mortality due to starvation.

Globally, the percentage of people classified as overweight or obese increased in both men and women from 28.8% and 29.8% in 1980 to 36.9% and 38.0% respectively. Child overweight and obesity also increased. In 2013, World Health Organization adopted a target of halting the rise in child obesity by 2025.

The primary reason obesity is a public health concern is because it is a risk factor for other non-communicable diseases (NCDs) such as Type II Diabetes Mellitus (T2DM), hypertension and coronary heart disease (CHD). Morbid obesity, considered the most serious stage of obesity, can leave patients at the highest risk of mortality related to their obese status.

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Throughout this series I will outline the causes and consequences of rising obesity incidence as identified in empirical studies and literature. All sources are available upon request.

Likely due to methodological challenges, much of the available data on obesity in the UK and elsewhere discuss prevalence and not necessarily incidence. However, understanding disease prevalence and its nuances is useful in interpreting both causal and consequential factors of incidence.

 According to Health Survey for England (HSE), in 2013, 26% of men and 24% of women were classified as obese; 41% of men and 33% of women were classified as overweight. Scotland and Wales had similar findings.

The UK has seen increases in obesity in children for several years. In 1995, 11% of boys and 12% of girls were classified as obese. By 2005, these numbers were 18% and 19% respectively. These increases have since leveled off: to 16% of boys and 15% of girls in 2013.

The prevalence of obesity is significantly higher in some groups. Children were more likely to be obese if they lived in an urban area. Whilst 22% of boys and 21% of girls from the lowest-income families were already obese.

Rising incidence of obesity is a problem

The major problem presented is the co-morbidities with which obesity is associated. Obesity is a major risk factor for many NCDs, thus causing and contributing to a high proportion of morbidity and mortality.

Type 2 Diabetes Mellitus (T2DM) is strongly correlated with obesity. The detrimental effects on an individual living with obesity and T2DM are multiple-fold. Rising incidence of obesity in children is well correlated with incidence of childhood T2DM. Expectedly, in terms of reducing the risk of cardiovascular diseases, particularly coronary heart disease, greater reduction in adiposity results in greater risk reduction. With the exception of LDL cholesterol, fat loss in obese patients improves blood pressure, glycemic control and lipids.

T2DM is simply hyperglycemia resulting primarily from a resistance to insulin but also from impaired insulin secretion. Clinical studies have shown the metabolic effects of high sugar, particularly fructose. These sugars mediate fatty liver and insulin resistance in humans. In a typical Western diet, the majority of fructose comes from sugary, soft and fruit drinks, often resulting in significantly elevated levels of fasting glucose and thus, high levels of insulin, leading to resistance.

Obesity also has a role in worsening nocturnal hypoxia in obstructive sleep apnea syndrome (OSAS). It has been theorized that oxidative stress and inflammation caused by OSAS is a major factor causing cardiovascular morbidity and mortality in obese patients.

This series will explore the causes, consequences and some potential solutions to rising obesity incidence in the UK. The significant contribution of behavioural factors to the rising prevalence and incidence of obesity suggests an important role for well-defined interventions to manage and reduce obesity levels. It is clear, however, that the burden and cost of the consequences of obesity justify the need for the United Kingdom to aspire to meet its own targets and those set by the World Health Assembly.

Cheers,

Christiana

Challenges Facing the South African Pharmaceutical Industry

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As some of you may already know I am a firm and unapologetic believer that the partnership of NGOs, national and international health governance with the pharmaceutical industry, rather than its exclusion, is vital to the effective treatment of disease globally.

From my first experiences at intergovernmental organizations at the age of 16, I came to appreciate the importance of medical research in global health. I have interned at the World Health Organization on two occasions but my experience at Tropical Diseases Research in particular, working with an infectious diseases specialist, designing educational tools for community healthcare workers on the use of a rectal artesunate drug for infants with severe malaria, I realized the need for innovation in the design of drugs and drug delivery systems.

I don’t believe that big pharma is the enemy. I believe the industries of biotechnology and pharma are an invaluable resource; and that the market failures we encounter at scale are primarily a function of the market forces that govern every industry in our world today.

The fact is that the profitability of drugs and vaccines has been a primary driver in the development of the life saving treatments available today. As for those that have fallen through the ‘gaps in the market’, so to speak (see: Antimicrobial resistance; Alzheimer’s, Malaria), I will write on this in future.

  1. HIV: South Africa is doing pretty damn well dealing with the burden of disease

South Africa is a BRICS nation: the growing, middle-income giants of the world. It was the first nation in the world to make Antiretroviral treatment free to all HIV positive individuals at the point of presentation in 2001. Moreover, today, it’s virtually impossible to visit a clinic or hospital in South Africa without being tested for HIV – this means that infections are detected more rapidly than ever.

The result of this is excellent ARV coverage, bearing in mind that this is a lifelong treatment, and HIV positive individuals today live as long as the general population. What this also means is that the nation still has the second highest HIV infection rate globally. Not because management has been poor; but because unlike in many smaller African economies, a sizable proportion of HIV positive patients diagnosed in the mid 2000s survived. This is my measure of success. Moreover, free condoms are infamously everywhere and the South African education syllabus focuses on teaching children about HIV transmission; all this alongside endless television PSAs and government subsidized projects aimed at educating the broader population in this respect.

That said, for Pharma, there has been a decline in new infections. The local pharmaceutical company, Aspen, holds the government ARV tender and the greatest market share in the South African pharmaceutical industry currently.

Opportunity: HIV co-infections present a potential area for growth. The re-emergence of Tuberculosis and certain forms of meningitis present an opportunity for drug development and incremental improvement upon current treatments.

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  1. Litigation: Pharma vs. Government

It’s this battle again. Multinational drug companies are constantly in litigation against the SA government; particularly after the introduction of the 1997 Medicines and Related Substances act.

One thing that has to be understood about South Africa is that, unless you are a South African, you may never fully understand South Africa.

We do overkill like nobody else. But for good reason. Our history of discrimination, dehumanization and suppression of our 90% non-white population means that many of our laws and constitutional requirements are very much shaped towards the complete protection of our population; and rightly so.

That said, our department of health has fought tooth and nail to ensure that drugs are available to the South African people cheaply, ethically and affordably.

Drug companies looking to break into / establish growth in the South African drug market have a lot of regulatory hoops to jump through; some of which may not be ideal for their bottom line – which make smaller, more loosely regulated, faster growing African economies more attractive.

Opportunity: South Africa has a huge growing middle and upper class who are privately insured and willing to pay top dollar for the highest standard of medical treatment. Assuming a firm has taken the potential legal climate into account in calculating their risks and opportunities; South Africa can be a highly profitable market.

  1. An excellent Segway: Generics

The market for generic drugs is massive in South Africa, particularly through the public sector. The highest growing pharmaceutical company in South Africa (by a long shot) is Mylan: a multinational firm that specializes in generics in South Africa (good move).

Moreover, since 2014, new drug compounds have reduced as a contributor to growth in the pharma industry. Price and volume changes are currently the two major areas driving growth in the industry. In my view, in the long term, this is not a sustainable model for growth: prices can only increase so much and South Africans have approximately 2 children per woman which indicates linear population growth and caps the extent to which volume can drive revenue.

Opportunity: In terms of market share, there is still room for growth in the generic drug market.

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  1. Dual burden of disease

I have discussed this topic at length. South Africa is a perfect example of a nation facing the dual burden of communicable and non-communicable diseases. No, malaria has been fully eradicated. But Tuberculosis is a real and verifiable risk and diabetes and COPD are equally so.

Opportunity: See point 2.

  1. Supply chain: Cutting out the middle men?

The drug supply chain from manufacturer to point of dispensing to patient can be rather confusing. Manufacturers typically dispense their drugs through four major routes: independent couriers, wholesalers, distributors or directly to the three major points of dispensing, pharmacies, hospitals and clincs and grocery stores.

I was in Tel Aviv last December and was surprised that I could not purchase any analgesic drug (Tylenol, Panadol, Nurofen, etc.) at any major grocery store. In all of the countries I have lived in, these over the counter drugs were readily available in grocery stores and I had not realized that this is a relatively unique feature globally.

Opportunity: The primary problem with South Africa’s drug supply chain for the pharmaceutical industry and its consumers is that it becomes expensive and these are costs that may (or may not) be transferred to buyers. Streamlining this is an opportunity in itself; and a sector that manages to form valuable partnerships to successfully linearize this process may be able to drive profits.

  1. Reputation

Whilst South Africa is not the recipient of any foreign aid; a number of its geographical neighbors are. In fact, South Africa is the largest contributor of foreign aid to other African states globally.

Nonetheless, pharma doesn’t have the best reputation down south. One reason for this, rarely covered by the foreign media is the leakage of drugs sent to states meeting the criteria, back into the ‘West’.

An example is an OECD scheme to sell drugs to the 49 poorest states. These drugs are sold at either the cost of production plus 10% or at a price reflecting 80% off the average ex-factory price in OECD member states. This is an excellent aid initiative for those states that benefit from this based on World Bank and IMF standards.

Unfortunately, more recent investigations by Belgian customs authorities uncovered large quantities of GlaxoSmithKline products destined for Africa being sold in the European Union. This doesn’t help the already less than favorable view that many already hold of the pharmaceutical industry, not to the exclusion of Southern Africa.

Have a banging Friday

Cheers, peace and love,

Christiana

On Booze, Babies and Birth defects:

A brief commentary on Foetal Alcohol Spectrum Disorders

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Foetal Alcohol Spectrum Disorders (FASDs) are a group of disorders of global concern. Entirely attributed to prenatal alcohol exposure, affected individuals suffer a lifetime of physical, psychological and social consequences. Foetal Alcohol Syndrome (FAS), has a global prevalence of 2.89 per 1000 live births, with some regions as high as 55.42 per 1000 live births. FASDs are preventable but there seem to be significant gaps in knowledge and practice.

In its 2014 Global status report on Alcohol and Health, the WHO emphasized the importance of strengthening capacity for prevention of FAS and the spectrum of associated disorders. As with many diseases of global concern, a variety of cultural, population and behavioral factors result in certain regions being more profoundly affected than others. FASDs are no exception. Some of the highest prevalence of the disorders globally is seen in South Africa, Canada and Croatia.

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The discussion on FASDs is part of a broader discourse. For the most part, the consequences of the harmful use of alcohol are well understood and documented. Most recent data from a systematic literature review estimates the global prevalence of FAS at 2.89 per 1000 live births. The prevalence of FASDs, however, including other disorders within the spectrum is estimated to be far higher.

The World Health Organization (WHO) estimates that 3.3 million annual deaths occur as a result of the harmful use of alcohol, accounting for 5.9% of preventable deaths worldwide.

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As shown above, after Alcohol use disorders, Foetal Alcohol Syndrome is the most significant cause of death or Disability, measured in Disability Adjusted Life Years (DALYS), attributed to harmful alcohol use. Unlike most health effects and consequences resulting from alcohol consumption, such as Alcohol-use Disorders and liver cirrhosis, FAS does not directly affect the individual. Instead it affects the foetus. Furthermore, unlike almost all other alcohol-attributable diseases, FAS is entirely attributed to alcohol exposure. This relationship between the alcohol consumption of the mother and the adverse, irreversible effects on the infant raises a number of ethical issues in preventing, measuring, interpreting and regulating the factors related to the condition.

DALYs are years of healthy life lost to disease due to disability. One DALY equates to one year of healthy life lost.

Whilst not always considered the most useful measure of morbidity in terms of disability, in conjunction with other indicators, it is generally accepted as a useful metric for understanding health status change and, from a broader perspective, the effectiveness of policy and intervention. In this regard, FASDs are unique. They are not acquired at some point in life as is the case with pancreatitis or accident related injury. In essence, every year of the affected individual’s life is a DALY.

Quality Adjusted Life Years (QALYs), as a metric, are also not immune to criticism. QALYs measure the quality of life provided by healthcare interventions. To its credit, this measure combines both qualitative and quantitative measures of patient’s life quality. In terms of FASDs, however, QALYs are a poor measure. FASD patients require lifelong medical and social intervention to thrive – this is a high level of resource allocation for a condition that can only be monitored, perhaps ameliorated, but never treated.

FASDs are important because they present an important social as well as public health problem in many communities. A major challenge lies in identifying appropriate intervention programs aimed at reducing alcohol intake by pregnant women who are at greatest risk of giving birth to infants with FASD.

In South Africa, the Western and Northern Cape regions have the world’s highest recorded rates of FASDs. Heavy alcoholism within certain groups remains very much commonplace, particularly in the nation’s rural areas. High levels of alcoholism and binge drinking behavior have their centuries old heritage in the dop system, directly translated to mean “tot” or “shot”, whereby Dutch colonists paid farm workers on vineyards entirely or partially in cheap alcohol.

Furthermore, it is reported that on many farms in the Cape provinces of South Africa the use of alcohol as a form of partial remuneration still exists covertly. Current legislation in South Africa prohibits dop, but the legacy of a culture of heavy alcoholism lives on: today some of my beloved country’s rural areas prevalence of FAS is as high as 10.2%.

Foetal Alcohol Syndrome is diagnosed using criteria of facial abnormalities, including smooth philtrum, reduced palpebral fissures and even cleft lip and/or palate. Often infants suffer impaired cognitive development. Those affected by FAS often experience brain dysfunction, mental impairment, psychological disorders and learning disabilities. Furthermore, it often goes undiagnosed for several years. There is no cure for FAS.

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Foetal Alcohol Spectrum Disorders in particular, distinct from the syndrome, tend to be poorly diagnosed. Particularly where health workers are not very familiar with the condition. Nonetheless, the long-term consequences of FASDs, including pFAS, ARBD and ARND, have a profound impact on the intellectual and social development of the individual.

Although no formal international guidelines on primary, secondary and tertiary prevention of Foetal Alcohol Spectrum Disorders exist, a handful of regional and national studies have investigated prevention methods used in certain areas with an aim to better understand the effectiveness of these varied approaches and how they may be implemented at a larger scale. Indeed, one study showed that merely gaining access to prenatal care resulted in a significant decrease in alcohol use during pregnancy, a luxury to which many women globally, particularly from lower socioeconomic backgrounds, have little or no access

Nonetheless, I would argue that it is the culture of frequent and/or binge drinking that perpetuates prenatal alcohol exposure; perhaps even to a larger degree than ignorance, misinformation or apathy.

Images: whattoexpect; WHO; FASlink; 

Seven lessons I learned from Professor Hans Rosling: A Tribute

Last week we lost one of the greatest statisticians of our time. A clinician who informed scholars and audiences world over; and a researcher whose work on economic development and global health changed the way we view our world. Personally, too, I have lost a role model, Dr Hans Rosling of the Karolinska Institute.

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Nonetheless, Dr Rosling’s memory, influence and legacy remain with us.

He inspired me; and my serendipitous exposure to his work played a major part in making me who I am today. Not only did Dr Rosling’s work in the fields of public health and economic development inform audiences world over, but his dedication and contribution to informing professionals, pharmaceutical companies, public health workers and laypeople across the globe will not soon be forgotten.

So, in tribute, this article will memorialize the seven major lessons I learned from listening to and reading the work of Professor Hans Rosling.

 

  1. “We live in a one hump world”

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Figure 1: Asian countries, including Australasia are shown in pink; African nations in blue; Americas in green and European nations including Turkey, in yellow. The y-axis represents population.

 

The long-term readers amongst you will know that I am a proud South African. A member of the BRICS – the large, emerging, middle income powers of the world. The “nearly theres but not quite”, to some.

Using data and the excellent visuals generated by his Gapminder foundation’s revolutionary software; Dr Rosling demonstrated to us how so many of our traditional views on wealth and wealth distribution are in fact outdated.

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Figure 2: For comparison, the graph above represents the world in 1975. Over 50% of the world’s population lived in extreme poverty, and the vast majority of these were in Asia. There was a clear disparity between wealth in the traditional west and the rest.

 

The vast majority of the world are not only out of poverty, but earn almost the same amount of money as measured by US$/day, regardless of where they live. Understanding this is vital to interpreting our world and understanding healthcare challenges.

 

  1. Let’s stop using the terms “Developing and Developed” to describe nations

In the same vein, on occasion, Professor Rosling mentioned that the terms developed and developing are not particularly useful in describing the world we live in today. Many of these terms are understandably established along political lines and regional categorizations. Nonetheless, their use is of minimal benefit.

We live in an incredibly rapidly changing world; the most peaceful two decades in recent history in terms of war with the highest global life expectancy. Globalisation, decolonization and the slight dismantling of national and geopolitical protectionist trends in recent decades have opened opportunities for previously suppressed and disadvantaged nations world over. It is my hope that what we are witnessing in this digital and globally connected era is the beginning of the democratization of trade, health and wealth. 

 

  1. Humans never lived in ecological balance with nature: they died in ecological balance with nature.

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The world is getting better; not worse.

There has never been a better time for human life and civilization in known history as now. Today, globally, we live better than ever before**; longer than ever before; have fewer children whose chances of survival to reproductive age is the highest rate in recorded history.

If you didn’t know this, you’re not alone. Not only does fear mongering sell; but parents and teachers inform young people based on their experience of the world as it was when they were young, including ideas that their teachers and parents imparted to them.

 

  1. Population growth is inevitable

Professor Rosling is arguably best known for his views, supported by statistical projections, on population growth.

The “population growth is the problem” argument has always been a personal pet peeve. But I’ll write more on this in future.

The global population will likely reach 11 billion before reaching a plateau. This is not because more people will be born; but rather that the additional 3.5 billion people are already alive.

Dr Rosling often demonstrated this in a very accessible way with the use of plastic or Styrofoam boxes. He referred to this concept as the global population ‘fill up’.

In short, today very few people die between infancy and the age of 65. Thus, as we are having only enough children to roughly replace ourselves, the population will not grow from new births: it will grow from later deaths. The global population fill-up of adults.

“We have reached the age of Peak Child” (2014)

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  1. The future will be dictated by love, not fear.

Child mortality is the primary driver of fertility rates. The number of babies per woman only decreases when the chances of child survival increase. When families are uncertain of the chances of survival of their children, they will have more children. Today, the global average number of babies per woman is 2.4. In Vietnam, the average number of babies per woman is 1.7. In Bangladesh, 2.14. In Yemen, 3.83 and 2.34 in South Africa.

Many make assumptions about fertility rates based on the world as it was in the 1970s. Rich countries had long life and small families whilst poor countries had shorter lives but larger family. This simply is not the world we live in: the world we live in is changing rapidly; and continues to do so.

Dr Rosling spoke on how most young couples today have access to some form of contraception; and with time and changing social norms; family values have started to shift towards an increased importance of how well one’s children are doing as opposed to how numerous they are. This is how love will dictate the composition of families, rather than fears based on child and infant mortalities.

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  1. We need to use useful metrics

A good example of a metric that is commonly used to discuss global disease profiles is the percentage of adults within a particular population living with HIV.

This is not a particularly useful metric. In a nation such as South Africa, Antiretroviral Treatment is free to any person or persons presenting themselves at a clinic or hospital. Moreover, whilst highly costly, budget provisions have been made for on-going counselling and lifetime maintenance of treatment and management of disease including co-infections. Thus, a large proportion of HIV positive individuals have been able to receive the treatment to live a long and healthy life. Indeed, provided that there are newly infected individuals, the number will continue to rise, and this is only a sign that those who contract HIV are surviving: not progressing to AIDS or succumbing to other infections.

This is an example of a middle-income country. Contracting HIV in a low-income country can be very different. Often, people who contract HIV in low-income, very low income or some land locked developing states, do not survive unless they have the personal funding to give them access to treatment. In some instances, free treatment is made available for periods of time but without the consistency vital to antiretroviral therapy. Such a nation may have a lower percentage of infected individuals due to survival rates. Thus, this metric is not particularly useful, nor encouraging.

I might suggest more useful metrics to communicate the same data in a stronger way. Perhaps “% HIV positive patients on ART for >2 years”; or “% HIV positive patients progressing to AIDS”

 

7. Healthcare spending is more important than GDP in dictating national public health outcomes

Wealth does not need to precede health (see: Vietnam; Cuba), but it sure does help. Strategic allocation of resources both between and within nations can act as a major driver of positive health outcomes even at a relatively low GDP, middle-income nations can create conditions to ensure long length of life.

The challenge faced by many of such nations that are winning the fight against communicable disease is the dual burden created by the fast emergence of a range of non-communicable diseases coexisting alongside traditional disease profiles. I have written about this in the past here.

These governments face the challenge of the incredible financial challenge of dealing with NCDs such as cancers, cardiovascular diseases, kidney failure and diseases of old age such as Parkinson’s disease and Alzheimers. Thus, time will tell if strategic efforts in prevention of these in many nations will yield useful results, or if, indeed, a third paradigm shift will occur in the management of NCDs in low and middle-income nations.

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*All graphs used were taken from Gapminder.org, the foundation started by Professor Rosling and his son, Ola Rosling, dedicated to the democratization of economic and health data and statistics.
**As measured by the percentage of the global population percentage currently living under “extreme poverty”.

Hans Rosling: A Tribute

Such sad news, the death of such a great man. May his legacy and influence live on. As a clinician, as a statistician who informed scholars and audiences world over, and a researcher whose work on economic development and global health changed the way we view our world. It’s hard to lose a role model but I can’t help but feel he was lost too soon. RIP Dr Hans Rosling.

I feel that it’s apt to share one of his oldest (but still my favourite) TED talk. He was a clinician and statistician whose research and accessible insights changed the way we view the world, and our understandings of the complex relationships between development and health.

The Best Stats You’ve Ever Seen

This weekend I will be posting the top seven lessons I learned from Dr Rosling over the years, in the hope that these are the concepts he might wish not to be forgotten. Find that article here.

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