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

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 Basics: Causes of Death

In the past I have written about how non-communicable i.e. non-infectious diseases make up four of the five global causes of mortality. I have also written about how this is, on the whole, a good thing. This article, although based on strong epidemiological data, is heavy laden in opinion.

The objective of this article is to provide a basic outline of the major causes of death. Everyone dies. And on more than a few occasions, I have heard the comments that all, in their own way, suggest that reducing mortality from specific disease causes is merely an exercise in pushing mortality from one disease cause to another; largely based on funding and location.

I wholly disagree with this sentiment.

It is my opinion that a major objective of improving global health is, beyond widening quality healthcare access for all, increasing the number of healthy life years lived by individuals and populations. In this regard, it is preferable to die of a stroke at older age than the next major influenza outbreak within the next five years, or tuberculosis, or pneumonia, or a lower respiratory tract infection. Moreover, the risk factors for most non-communicable diseases are generally modifiable.

The global reduction in childhood illnesses has been huge, although there is still much work to be done, particularly in Sub-Saharan Africa. Case in point: Diarrheal diseases are no longer amongst the top 5 causes of death. (Can you believe that easily treatable, diarrheal diseases were, until recently, amongst the top 5 causes of death?)

I’m glad we no longer live in that world. And whilst cancers, diabetes and cardiovascular diseases are a major force to be reckoned with within the next 15 years of the SDG era, and likely beyond, based on current trends, we are all projected to live longer. And to me, that says ‘improvement’. Even HIV positive individuals, adherently monitored on Antiretroviral Treatment, are living longer: according to some studies, as long or even up to two years longer than average life expectancy.

Most recent estimates place the top 10 global causes of death as follows:

  1. Ischaemic Heart Disease
  2. Stroke
  3. COPD
  4. Lower Respiratory Tract Infections
  5. Trachea, Bronchus and Lung Cancers
  6. HIV/AIDS
  7. Diarrhoeal Diseases
  8. Diabetes Mellitus
  9. Road Injury
  10. Hypertensive Heart Disease

This is important. It is not important to memorize this list, per se, as they are constantly changing. But it is important; as understanding disease profiles and trends is invaluable to understanding the current, global health landscape.

In future articles I discuss the major problem this poses to health systems, economic development and economic stability for individuals and communities, particularly in low and middle-income settings.

For now, have a stellar Thursday!

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

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

Here’s a fictional allegory:

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

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

 

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

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

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

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

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

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

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

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

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

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

 

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

 

– Christiana

 

Médecins Sans Frontières Scientific Days 2016

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

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

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

Next stop: My first ever TED event tonight!

Yours truly,

Christiana

The Basics: HIV, AIDS and related co-infections

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

 

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

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

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immunodeficiency Syndrome

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

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

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

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

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

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

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

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

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

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

 

Cheers, Happy Friday!

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

The World at 2000

 

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

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

 

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

 

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

 

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

 

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

 

The World Today

 

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

 

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

 

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

 

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

 

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

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

 

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

 

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

 

MDG 4, 5 & 6 Progress Scorecard

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

The World Tomorrow

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

 

 

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

 

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

 

 

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

 

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

 

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