SERIES: Part 5 – Conclusions on Causes and Consequences of Rising Obesity Levels in the UK

I’m back!

And this is the fifth and final edition of my ‘Obesity in the UK‘ series: Conclusions on Causes and Consequences of Rising Obesity Levels in the United Kingdom. Throughout this series, we have explored causes and consequences; physiological, behavioral, economic and social. All references are available upon request.

So, here’s my sum up:

A response to the question of the causes of rising obesity incidence in the United Kingdom principally focuses on the drivers this incidence.

Whilst sometimes framed as a debate on genetics versus environment, the causes are most broadly attributed to these: behavioral and environmental factors, and psychosocial factors.

 

A growing body of evidence shows that behavioral factors outweigh genetic factors. This is an important finding for intervention studies and policy. This series has argued that rising incidence in the UK has been fuelled by multiple, interconnecting causes. Early intervention by government, the World Health Organization and citizens can begin to alter these trends.

However, many studies suggesting that individuals can halt or reverse progression to obesity by food and diet control follow the cognitive model of eating behavior. This model assumes that intentions are a weaker predictor of behavior than attitudes, social norms and even perceived behavioral control.

At an individual level, studies have shown that obesity is associated with low self-esteem and body dissatisfaction in children and adults, affecting work and performance; and in some cases leading to depression, anxiety and other negative psychological consequences. The bias and discrimination reported by overweight and obese individuals has also been explored.

A very important limitation to discuss is the use of BMI. Most of the literature reviewed in this series, and indeed around this subject area, uses BMI to classify overweight or obese status. However, BMI as a classification is occasionally met with criticism. It is not always an accurate measure of risk. It does not account for muscle density, fat distribution or ethnic variations in risk thresholds. The National Institute for Health and Care Excellence (NICE) recommends that in obesity management, BMI is used in combination with waist circumference as centripetal adiposity is often considered a risk factor for a number of cardiovascular diseases.

Furthermore, in many instances, self-reported data was used. It is not uncommon for these to be inaccurate: overestimated height in men and underestimated weight in women.

Individual-level factors can no doubt contribute to consequences on a larger societal level as a greater proportion of the population falls into obesity. The economic costs to individuals can be high; and may be related to prevention, treatment and social adjustments

However, the cost at a national level, in the United Kingdom, may be even greater as obesity and its associated comorbidities incur greater costs to NHS health, support and emergency services.

Although the rising incidence of obesity in the UK and globally is alarming, the phenomenon has precipitated a greater awareness of obesity as a public health problem in the principal global policy formulating body, the World Health Organization and also by the UK government.  The UK has introduced important policy options and strategies.

The rise in obesity has been shown to be multifaceted. The significant contribution of behavioral factors to the rising incidence of obesity suggests an important role for well-defined interventions to manage and reduce obesity levels.

Further research may be needed to better understand the most effective interventions that should be applied. Despite the concern of rising obesity, UK data is promising as it has already been shown that increasing obesity levels in children in particular are responding to the intervention measures.

Let’s see what the future holds!

The “Thinker’s” Guide to becoming a useful citizen of the world.

So this is going to be a very different kind of post. (New month, new me! Right?) I’m going to share some of my ideas about global citizenship; and how I feel about navigating life in both a sensory, intentional and intellectual way. Let’s hope I don’t ruffle too many feathers. But then again, that may or may not be my objective. It’s all light hearted, but in the spirit of (not) striving to create ‘evergreen’ content, I dare say that it is apt. Politically. And indeed, I mean what I say.

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Global citizenship is not a term that I have ever particularly loved.

Rather, it is one that has, perhaps, been thrust upon me. And that I have not felt a specific reason to resist. Conceptually, however, it is important. We live in a world in which hate has no place, but persists. And many of us have the desire to DO something to make it better. “Making an impact” is a vague term.

In my opinion, the first step to becoming part of the solution is extracting oneself from being part of the problem (well-meaning as one may be).

 

So here are my ‘thinker’s’ first steps to becoming a useful citizen of the world:

  1. Question everything you know about the world.

Knowledge is an asset. Misinformation is a liability. It’s easy to take certain information for granted that may not necessarily be grounded in contemporary, statistical or empirical evidence or proof.

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  1. Challenge knowledge you have through your own personal experiences.

How representative are the perceptions you hold based on experience? Seeing may be believing; but remember that the worlds that you have experienced; be it the neighbourhood you grew up in, or stories from major metropoles you have heard, or the village in a country that is low-income by classification, may not be representative.

 

  1. Realise that the world is constantly changing: and in many instances, that change is incredibly rapid.

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Some of our facts may be outdated. And that’s okay. Clinging to them as contemporary truth, however, is not.

 

  1. Accept that the everything in the world is incredibly nuanced.

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There is rarely right and wrong, black and white. Most situations are remarkably complex: inherently so and additionally by virtue of the multiple external factors that influence and manipulate them. As a rule of thumb, if anything – an epidemiological trend, a political action or the funding of drug development seems easy to understand – you may have an accurate conceptual understanding but you almost certainly have not yet had the opportunity to understand the full picture.

Challenges arise when we, or those we elect, do not have a broad and comprehensive understanding of a situation. Sometimes, it is not necessarily in their interest to do so. (It is important to recognise all the stakeholders and attempt to understand the factors that inform their agenda.) But a genuine lack of understanding can result in poorly designed, imprecise solutions that do not prove effective; or misallocation of resources.

My hope is that this will be food for thought.

It’s a foggy Wednesday in London, from whence I write. So it is surely an act of true altruism for me to end this blog post, as always, by wishing you a stellar day!

– Christiana

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 Demographic 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

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”.

Rethinking Rabies: A Breakthrough in Management? – My comments on the literature

Let’s talk about disease 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. Published in the Journal of Infectious Diseases, the research paper this article comments on has been described as groundbreaking. (I dare say, most notably by those enchanted by the spell of the [magical] monoclonal antibody: still one of the coolest cocktail party topics in immunology.)

 

The article by van Dolleweerd et al can be found here.

Overview

So let me break it down. Dog bites make up 99% of rabies virus (RABV) transmission from animals to humans. RABV infection usually results in death from the onset of clinical symptoms. Endemic in some regions, rabies is a concern in over 100 countries, particularly in Asia and Africa. Primary prevention is vital to combatting rabies globally. The World Health Organization (WHO), working with governments and NGOs, strongly recommend widespread canine vaccination as the most effective means of rabies prevention.

Secondary prevention treatment of suspected cases is Rabies Post-exposure Prophylaxis (PEP): a combination of the rabies vaccine and rabies immunoglobulin (RIG). Unfortunately, RIG preparations can be costly, varied or even contaminated, particularly in lower resourced settings. Furthermore, immunoglobulins lack the epitope specificity of monoclonal antibodies (mAbs), often resulting in adverse reactions.

A major new research breakthrough to replace RIG is a cocktail of mAbs, particularly including the engineered, plant-expressed, chimeric mAb, E559, shown to successfully neutralize RABV in-vivo. This article highlights the latest scientific findings, reviewing the relevance for future management of suspected rabies virus infection.

 

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Limitations of PEP

Currently, survival post exposure to RABV is based solely on the administration of PEP. Classified by WHO as a Neglected Tropical Disease, RABV has been shown to disproportionately affect impoverished communities. Furthermore, RIG is often subject to environmental challenges associated with storage and contamination.

Polyclonal serums such as RIG, from vaccinated donors, are subject to the risks associated with the use of human blood-derived products, such as potential transmission of infectious agents if appropriate measures are not observed and unpredictable availability of donors. They are also susceptible to batch-to-batch variability. The majority of virus specific antibodies contained within the serum are non-neutralizing, with a small percentage being pathogen specific. Moreover, only human and equine polyclonal immunoglobulins, HRIG and ERIG respectively, are available.

The exciting development and benefits of new monoclonal antibody preparations to replace RIG is that they are highly effective due to their epitope specificity, neutralizing a range of RABV isolates, with minimal adverse effects.

A little lost?

 

The bottom line is that Rabies Virus disproportionately affects impoverished communities and PEP as treatment is effective but easily compromised, as human/horse blood derived products can be, particularly where storage infrastructure is variable.

 

Monoclonal Antibodies for Treatment

Monoclonal antibodies (a.k.a mAbs for to coolest of us) remain a new frontier for modern therapeutics. In 1986, the United States Food and Drug Administration (FDA) approved the first monoclonal antibody drug, Muromonab-CD3, to prevent organ rejection in kidney transplant patients. Today, almost 30 mAb drugs have been approved, with many more undergoing clinical trials.

Derived from a single cell line, a hybridoma, produced by the fusion of a single B-lymphocyte clone and a myeloma cell; mAbs have the advantage of greater specificity than polyclonal antibodies, derived of multiple B-cell lineages. These mAbs directly neutralize rabies virus glycoprotein (RVG) by inhibiting RVG binding at viral receptors as well as inhibition of attachment and fusion at the plasma and endosomal membranes, respectively.

A major advantage in the development of rabies treatment using mAbs has the potential for widening access in endemic areas. Earlier research into mAbs for treatment of RABV, human mAbs, showed promising therapeutic results in in-vitro neutralization of particular RABV strains. Moreover, in- vivo experiments in hamsters found that two human mAbs showed equivalence to HRIG in preventing rabies virus. Where this approach was found lacking, however, was cost- efficiency.

Van Dolleweerd et al, successfully cloned and engineered a plant- produced candidate monoclonal antibody, E559. The chimeric antibody, an isoform of E559, was equally effective as commercial HRIG in a hamster model.

Comparing two monoclonal antibody production platforms in plants to murine hybridoma-derived platforms; the paper found that whilst plant- derived vs. mammalian-derived mAbs have different half-lives, there is no difference in rates of RABV neutralization.

Moreover, decreasing production costs by improving the productivity of cell lines and developing transgenic tobacco plants as well as tobacco cell cultures to express E559 has made the use of mAbs in treatment of disease, even in the poorest settings, a feasible alternative to existing secondary prevention models for RABV.

Whilst the use of mammalian mAbs is virtually not viable in lower resourced settings; the promise of tobacco plant- derived RABV neutralizing mAbs presents the possibility for greater accessibility as well as production capacity in rabies-endemic regions.

How relevant are these developments in the future prevention of Rabies Infections?

The high levels of efficacy of PEP made it the main post-exposure treatment for RABV for decades. In this respect, concerns surrounding access and cost were primarily addressed in three ways: developing models of categorization of levels of exposure for treatment allocation; broadening availability of the less costly equine RIG, despite increasing scarcity; and the modification of administration modes: particularly from intramuscular to intradermal.

In this respect, the introduction of monoclonal antibodies to the RABV prevention debate was met with initial skepticism. MAbs, although newer and highly promising, were infamously expensive to produce. Further, their use requires higher levels of skills and technology. This resulted in a view that mAbs would only be useful in regions where administration of standard PEP is highly feasible and rabies exposure is relatively rare. This background underlines the significance of cheaper, plant-derived, potential mAbs to replace RIG.

However, RNA viruses, such as RABV, lack mechanisms to prevent the emergence and proliferation of mutant strains under exposure to highly specific monoclonal antibodies. Thus, to be effective, an immunoprophylactic needs to be able to neutralize a range of RABV isolates: an integral quality of any effective mAb treatment for RABV.

In this regard, more scientific research in this direction going beyond E559 is required. A single mAb is unlikely to provide sufficient protection across a broad range. Initiating the use of plant-derived mAbs, as demonstrated by van Dolleweerd et al, is the first step in dismantling the prohibitive frameworks within which mAb treatments have long existed. This will pave the way, for better results and broader opportunity for mAb use in response to RABV exposure; and also for mAbs in treatment of other neglected tropical diseases globally.

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Have a banging Thursday!

-Christiana

 

Reference: “Engineering, expression in transgenic plants and characterisation of E559, a rabies virus-neutralising monoclonal antibody.” – van Dolleweerd et al, July 2015

 

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

Reflection: On Sitting, Standing and Sedentary behavior

(a.k.a. Thoughts on my personal apathy and our collective ‘laziness’)

This is a reflective piece. And as such, it will be more personal than most of my writing. But true to form, it’s based on some pretty solid (albeit somewhat terrifying) science. You have been warned.

I’ll be honest. I’ve read the studies. There is a growing body of evidence that independent of diet and exercise, sedentary behaviour, being generally inactive, in itself, is a pertinent health risk.

Studies have found that independently, consecutive hours of sitting, at a desk, for example, is a major risk factor for disease. This means that regardless of whether you ride your bike to work, eat raw vegan everything (with kale), and hit the gym for an hour, daily; spending 5-6 hours at work, sitting in a chair, is a risk factor for a number of illnesses. In particular, cardiovascular diseases.

Think about this: it is easy to understand that a pack-a-day smoker who still manages to do daily, vigorous exercise and keep a healthy diet is still at risk of smoking-related illness, regardless of how admirably healthy the rest of their lifestyle may be. Similarly, ‘sitting’ has been dubbed by many as “the smoking of our generation.” (Lol: Fear-mongering alert. I should probably be taking this more seriously.)

‘Sedentary Behaviour’, as it is called, is measured in METs, a measure of metabolic activity. Light activity measures roughly 2.5 METs, standing 2.9 METs. The threshold for sedentary activity is 1.5METs or less.

Thus, all across the world’s trendiest work spaces from London’s Islington to Silicon Valley, employers are installing standing desks: keeping employees on their feet. Literally. And, I must admit, yours truly, too, has converted to using a (makeshift) standing desk, from time to time. Not necessarily because of the health benefits, but because it makes me feel like the kind of forward thinking, conscientious individual I would like to view myself as.

To be completely honest, thus far, I’m pretty apathetic towards changing my personal activity levels.

Unfortunately, it is this kind of apathy at personal and community levels that fueled the continued use of asbestos, even after the risks were well understood. It’s this kind of apathy that persists in the debates for environmental conservation and reform. And, it is likely this kind of apathy that continues to drive global overweight and obesity levels at the unprecedented rates of recent years.

The industrial revolution came and went. World over, fewer people are toiling on their feet in rigorous, manual labour and vocations. Increasingly, we are employed in occupations that are not conducive to high levels of activity. And this is increasingly true across the board – from high to low income nations.

More of us are sitting at a desk – (perhaps typing out a blog post) – slouched over our laptop or generally writing, receiving and rewriting e-mails; some place where the only opportunity for mobility is a trip to the photocopier or the restroom.

Despite my personal apathy, it was fairly easy to bring myself to write on the topic of sedentarism. The reason for this is clear; and it is demonstrative of one of the fundamental problems in health psychology as it pertains to global health.

On a personal level, such changes in lifestyle and habit seem almost unattainable. The mere concept that something as mundane (or even virtuous) as ‘sitting’ may be as bad for our health as researchers are saying is rather hard to digest. Nonetheless, for those of us like you and I who take an interest in public health, we do realize that at a population level this is, or could be, a problem; the gravity of which may be larger than we care to admit.

Another barrier to change is the opportunity cost of change. How will I reorganize my life to minimize sedentary time? And is it really worth it? Are we really that convinced? How conclusive is the data anyway? (Oh my goodness I will be freaking miserable.)

Our increased levels of sedentary time, though often reflective of positive outcomes in economic growth and technological development, indeed pose a major global health risk. Whilst there is still some debate as to the molecular biological forces driving unfavorable health outcomes, the correlational studies have shown clear association.

Unfortunately, hoping that tens of millions of at risk individuals the world over will read this blog post or even be exposed to the studies that I have referred to is a pretty long shot.

Dealing with non-communicable diseases is hard. We continue to see this with obesity. Sufficiently informing the public of health risks in order to facilitate behavioural change, without jeopardizing economic growth, and fostering the development of health positive behaviours on a population level, is a hard task. Moreover, getting people to care may prove to be even harder.

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(Source: americaninfographic.com)

So here are more of my signature, health-related, fictional allegories: How do you tell the self-employed, Burmese fabric maker, who has always seen purchasing an automated vehicle as a sign of financial success and stability for her family, that she is better off riding a bicycle? This is essentially an exercise in changing entire cultural views.

How do you convince the Togolese steel worker who, whilst forming part of the working class perhaps, aspires to one day make enough money that his family can eat meat with their dinner every night. How do you create the kind of paradigm shift that shapes, informs and changes culture sufficiently that at a population level, in discrete and distinct communities world over, people understand that this form of improvement in circumstance, and possibly subsequently, eating behavior, may pose a risk to his family? Not necessarily only for him, but for his children; who are now less likely to work on the steel mill and more likely to reach a level of education that secures them the kind of higher paying but less physically demanding occupation that demands protracted periods of relative sedentarism.

ACTION

I believe that the answer is multiple-fold. The broadening frontiers of prosperity need to expand with health ideologies and beahviours that are conducive to long, healthy life – wherever life is lived. Whilst the threat of communicable diseases still exists, advancements in health and access to healthcare mean that the majority of these are steadily on the decrease. Indeed, in many regions, health services are dealing with the dual burdens of both communicable and non-communicable diseases. In my opinion, the threat of disease associated with inactivity is real; and with mean life expectancy rising globally, it is relevant in high, middle and low-income nations.

The Sustainable Development goals make great provision for non-communicable diseases. However, unlike its predecessor, the document is fairly (deliberately) vague about which NCDs are of particular concern. This is an opportunity. From a global health standpoint, will the risk of continued and increased sedentary behavior require mass action? Is the funding available? If YES to the former but NO to the latter, can funding be garnered? If this health risk is deemed worthy of global concern, this will require agreement. Global agreement. Acknowledging the existence of the problem and the need for action. (Sounds like an AA meeting already)

Secondly, once consensus is reached there will be a need for widespread community-based education that is appropriate to the social context. What we are suggesting are major shifts in lifestyle. One-size fits all approaches in any capacity are likely to be a waste of time and resources.

Ultimately, on a personal level, you (and your rear) will choose. The decisions that you make on a daily basis have an irrefutable impact on your health, health outcomes and life expectancy.

On a public health level, however, there is a need for the expertise of allied health professionals and health psychologists, who can aid in implementation of high quality policies and programs; and, vitally, community-based health workers, who genuinely understand culture and community, and work on effecting change without overwhelming populations (nor producing the same kind of apathy this knowledge elicited in me).

Have a stellar Friday!

Christiana

 

Read more:

“Are workplace interventions to reduce sitting effective? A systematic review” – W.J Brown et al, 2010

“Too Much Sitting: The Population-Health Science of Sedentary Behavior” – N. Owen et al, 2010