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 His statement is based largely on opinion and possibly also some outdated world views.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

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

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

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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Coming soon: Rethinking Rabies. A Breakthrough in Management?

Rabies is a vaccine-preventable, zoonotic disease of global concern, resulting in over 55 000 deaths annually. Whilst standard post-exposure treatments are estimated to prevent hundreds of thousands of fatalities, these are not without shortcomings. Recent immunological research into novel treatments has revealed promising results.

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More on this later this week. 

For now, have a stellar Monday!

– Christiana

This week: On the Age of Gender Equality

SDG 5: Achieve gender equality and empower all women and girls

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“We need to empower women. Give women a voice in the decision-making process. Give women a political voice where they can champion, for their own welfare. And, of course, for us. United Nations – organizations, agencies – we need to do our part.” – Margaret Chan

Have a great Monday!

– Christiana

 

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.