Panos Briefing No 36 September 1999 DIAGNOSING CHALLENGES Health and the new millennium
‘Health for All by the Year 2000’ was the clarion call of the World Health Organization (WHO) 20 years ago. Great progress has been made in that time: 60 per cent of the global population now have a life expectancy above 60 years, the infant mortality rate has fallen to below 50 per 1,000 live births and the under-5 mortality rate has fallen to below 70 per 1,000 live births. Despite the problems, the wars and catastrophes, humanity in the second half of the 20th century has not merely survived; it has thrived. Yet for many, especially the poor in both North and South, there is less to celebrate. A fifth of the world’s population live in absolute poverty, and as stated by WHO Director-General Dr Gro Harlem Brundtland, “Poverty is the main source of ill health.” As a result around 10 million children and 15 million adults die from preventable causes each year. In some parts of Eastern Europe – where one third of the population is now affected by poverty – life expectancy has fallen below developing country levels. Diseases like tuberculosis (TB) are re-emerging as serious threats. And new diseases are throwing up new challenges. Climate change may bring changes in patterns of diseases like malaria, and increases in skin cancers and cataracts. Changing lifestyles and longer life expectancy mean that diseases of affluence and old age are becoming more common in poorer countries, which are less well equipped to deal with them. This will become more of a problem in the future, as the ‘greying’ of the developing world becomes a reality. Health issues are increasingly acting as a motor for much wider changes in society. A new generation of health issues – not least the AIDS pandemic – have emerged over the last 15 years to shine an unforgiving spotlight on the uglier side of societies the world over. Both HIV/AIDS and the growing attention given to issues of reproductive health and rights have highlighted the links between poor health and inequality. The health situation is affected by individuals and by societies, by governments and doctors, by finance, technologies and environmental changes. The role of information and debate is likely to become increasingly influential: access to information that enables individuals, or institutions, to make their own decisions will be as important as access to debates and ideas that shape people’s behaviour. In particular, this offers a challenge to the supposed medical and scientific certainty that surrounds the subject of health, and the tendency to rely too much on technological solutions. In reality almost every health issue is the subject of disagreement and debate. Public debate is recognised as increasingly important for determining both policy and the management of resources. Individuals and societies will play a major part in any successful and sustainable response to the health challenges of the millennium. A major challenge in most countries – especially in the developing world – is how to finance health care. The total cost of recommended annual spending is around US$22 per person in low-income countries and US$25 in middle-income countries. But governments are actually spending only around US$5 per person annually in low-income countries. Proposals for bridging the gap include charging for services, unsubsidised health insurance, encouraging competition among providers, setting limits on the pay of doctors, and greater reliance on non-governmental organisations (NGOs) and the private sector. The roles of the main international players such as the World Bank and WHO are changing, with commercial companies and NGOs playing an increasingly important part. As a result the question of regulation will become more important, from jobs to factories, from food to medicines. Governments will need to regulate not just environmental polluters, as they do at present, but private health providers and insurers as well.
KEY FACTS
Good news [1]
? Today at least 120 countries (with a total population over five billion) have an average life expectancy at
birth of more than 60 years. The global average is 66 years, compared with only 48 years in 1955; it is expected to reach 73 years in 2020.
? In 1995 a total of 102 countries, with a combined population of 3.4 billion (60 per cent of the global
population), had an infant mortality rate of below 50 per 1,000 live births and an under-5 mortality rate of below 70 per 1,000 live births.
? The spectacular progress achieved in the last few decades in reducing deaths among infants and children
under five is projected to continue. Over 80 per cent of the world's children are now immunised against the six major diseases of childhood (measles, poliomyelitis, tuberculosis, diphtheria, whooping cough and tetanus). Immunisation coverage of infants in 1996 was nearly 90 per cent for BCG and about 80 per cent for DPT3, measles and poliomyelitis. For tetanus toxoid, however, coverage of pregnant women was below 50 per cent of live births in developing countries, which means that half of all babies born there are exposed
? In 1994 at least 75 per cent of the population in the developing world had access to safe water, and 42 per
cent to sanitation services, compared with 61 per cent and 36 per cent respectively in 1990.
? The past decades have seen the final defeat of smallpox, one of the oldest diseases of humanity, which
killed five million people every year in the early 1950s, and the gradual elimination of several others, including leprosy and polio. The eradication of polio will save the world US$1.5 billion annually in vaccination, logistics and personnel costs. [2]
? The number of children born to women of childbearing age (Total Fertility Rate) is now under three, down
Bad news [3]
? Of the more than 50 million deaths worldwide in 1997, approximately one third were caused by infectious
and parasitic diseases, 30 per cent by circulatory diseases, and 12 per cent by cancers. Most of the 15 million deaths each year of adults aged 20 to 64 are premature and preventable.
? The UNICEF report The State of the World’s Children 1999 estimates that during 1997 there were 11.5
million deaths among children under five, 97 per cent of them in the developing world. Most such deaths are preventable. At least two million deaths a year could be prevented by existing vaccines.
? Every day 3,000 children die from malaria. There are up to 500 million cases of malaria among children and
? As many as 600,000 women die each year of pregnancy-related causes, 99 per cent of them in developing
countries. According to the World Bank, 140,000 die from haemorrhaging, 75,000 from abortions, 75,000 from eclampsia-related complications, 100,000 from infections, 40,000 from obstructed labour.
? One fifth of the world’s population do not have access to modern health services. Over one third of the
world’s population still lack access to essential drugs.
? Poverty is the main cause of ill health. Almost one third of all children are undernourished. The average
African household consumes 20 per cent less today than it did 25 years ago. In the USA an affluent white woman can expect to live 41 years longer than a poor black man. [4]
? Three billion people worldwide – half the world’s population – lack sanitation facilities, which exposes them
? There has been a serious deterioration in public health in the countries of the former Soviet Union and parts
of Eastern Europe, where one third of the population live in extreme poverty. Life expectancy for Russian men is now only 57.6 years, lower than the average for developing countries (64 years). [5]
? Never have so many people had such broad and advanced access to health care. But never have so many
been denied access to health. The developing world carries 90 per cent of the disease burden, yet poorer countries benefit from only 10 per cent of the resources that go towards health.
1 BCG is the tuberculosis vaccine. DPT3 is the ‘triple vaccine’ protecting against diphtheria, whooping cough (pertussis) and tetanus. Tetanus toxoid is the tetanus vaccine given on its own to pregnant women to prevent them and their babies from developing tetanus at childbirth.
CONTENTS 1. THE STATE OF THE WORLD’S HEALTH Determinants of health Tomorrow’s news: eradication On the list Smallpox eradication… with polio to follow? (box) CHANGING PROBLEMS Climate change and health Changing challenges (box) Malaria Lifestyle changes ‘Double burden’ threatening Sri Lanka’s health care system (box) Re-emerging problems Epidemics of blame, diseases of discrimination New diseases The drugs war: what price treatment for people with HIV? (box) Environmental health problems THE MAIN PLAYERS IN THE GLOBAL HEALTH ARENA World Health Organization (WHO) World Bank UNICEF and child health Commercial power The pharmaceuticals industry: promoting health or just their own products? (box) STRATEGIES FOR HEALTH: PAYING THE COSTS OF HEALTH CARE – AND TREATING THE POOR FAIRLY Health in Russia: new system, old challenge (box) Primary health care (box) How countries finance health care Essential drugs (box) Aid (box) Market forces Debt and health spending The Nicaraguan experience (box) Prioritisation Regulation The quality of care Emergency care (box) TARGET GROUPS The poor Children The girl child Women and reproductive health Young people and sexually transmitted infections (STIs) Gender differences (box) Refugees The elderly CONTACTS REFERENCES Visit Panos on the Web http://www.oneworld.org/panos/
Panos Briefings are intended to stimulate informed public debate and may be freely reproduced, in whole or in part, with acknowledgement. The Panos Briefing series is funded by the Swedish International Development Cooperation Agency (Sida), the Norwegian Agency for Development Cooperation (NORAD) and the UK Department for International Development (DFID). This Briefing is part of a series of information activities of the Panos Health 2000 Initiative. The Panos Health 2000 initiative was funded by Swedish International Development Authority (now Sida), UK Overseas Development Administration (now DFID), Oxfam UK, Rädda Barnen, Cebemo (now Bilance) and Memisa Medicus Mundi. The views expressed do not necessarily represent the views of these or other donors to Panos.
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This Briefing was written by Jeremy Hamand, a freelance writer on health and development, with additional work by Peter Poor, Senior Health Adviser to Save the Children UK. The text editor was John Hilary; the Panos Briefings series editor is Heather Budge-Reid.
With this briefing you will find an order form for this and other Panos materials. DIAGNOSING CHALLENGES Health and the new millennium THE STATE OF THE WORLD’S HEALTH
‘Health for All by the Year 2000’ was adopted as a Global Strategy by the 1981 World Health Assembly. This was not necessarily a utopian goal. The original definition used by the World Health Organization (WHO) four years earlier was “the attainment by all the people of the world by the year 2000 of a level of health that would permit them to lead a socially and economically productive life”. This ‘acceptable minimum’ level of health is the measure used by WHO and its member states in achieving this goal. [6] In 1995 WHO launched a Health For All renewal process, and two years later 158 member states (representing 91 per cent of the global population) reported to WHO the findings of progress evaluations on the implementation of the Health for All strategy in their countries. It was clear that substantial, though only partial, progress had been made in achieving the goals of the global strategy. Today at least 120 countries (with a total population over five billion) have an average life expectancy at birth of more than 60 years. The global average is 66 years, compared with only 48 years in 1955; it is expected to reach 73 years in 2020. Over 80 per cent of the world's children are now immunised against the six major diseases of childhood (measles, poliomyelitis, tuberculosis, diphtheria, whooping cough and neonatal tetanus). Immunisation coverage of infants in 1996 was nearly 90 per cent for BCG (the vaccine that protects against tuberculosis), and about 80 per cent received vaccines protecting them from diphtheria, whooping cough, tetanus, measles and poliomyelitis. [7]
However, while overall survival prospects of the world’s population have improved, disparitiesin health levels between and within countries have persisted and in many cases increased. In spite of political commitment by member states and the development of health systems based on primary health care, issues of inequality in health status and access to health care seem not to have been adequately or effectively addressed during the past two decades. Globally, almost one third of all children are undernourished. The average African household consumes 20 per cent less today than it did 25 years ago. In the USA an affluent white woman can expect to live 41 years longer than a poor black man. And during 1997 there were 11.5 million deaths among children under five, 97 per cent of them in the developing world. Most such deaths are preventable. At least two million deaths a year could be prevented by existing vaccines. Despite such statistics, the overall picture of recent decades is one of substantial, if unsteady, improvement. There have been remarkable improvements in human health during recent decades – probably more than at any other time in history. According to WHO, the most important pattern of progress now emerging is an unmistakable trend towards healthier, longer lives. Despite being threatened by two devastating world wars in the first half of this century, and by many other conflicts and catastrophes in the second half, humanity has in general not merely survived; it has thrived. In 1998 WHO sought to inject renewed urgency into improving global health. The World Health Assembly approved a new policy document which incorporated additional elements not previously considered in the WHO Constitution. For example, the importance of a gender perspective and the need to see health as being central to sustainable human development are emphasised. The growing importance of civil society in health governance opens up opportunities for partnership possibilities not foreseen 20 years ago. The policy document confirmed Health For All’s goals as:
? To attain health security for all ? To achieve global health equity ? To increase healthy life expectancy ? To ensure access for all to essential health care of good quality. [8]
WHO believes that the stage has been set for developing and sustaining health systems that are dynamic, effective and able to meet changing health care needs. “Experience of the past 20 years shows
Panos Briefing: DIAGNOSING CHALLENGES 1
that governance is one of the decisive factors in securing implementation of primary health care goals. It is also essential to strengthen the social, political and psychological capacity of people… to participate and be active in decision-making.” [9] Determinants of health
Clean water, good food, shelter, income and education were recognised as crucial elements in healthy living and the reduction of disease (especially infectious disease) long before the advent of modern medicine, antibiotics, vaccines and surgery. Access to these basic rights is acknowledged as a determining factor in improving health, and poverty is acknowledged as the primary obstacle in achieving such improvements. Poverty is strongly linked to poor health in any setting. In the developing world, indicators of health such as infant mortality rates are often more than 10 times higher than in the developed world. Within poor countries the poor get sick and die more often than the rich – but the same holds true for some of the world’s richest countries too. In Britain, where government figures now show two in five children are brought up in poverty, significant differences in children’s health have been identified in different geographical areas. Yet improvements in health have also been documented in most of the poorer countries over the last few decades. It is difficult to attribute this improvement to any single cause. There has been improvement in access to many of the determinants of health mentioned above. Availability of health care, antibiotics, antiparasiticals and vaccines has certainly contributed to this improvement. It is in the combination of improvements that health benefits accrue. One stark exception has been the failure to have any impact on maternal mortality. This remains unacceptably high in the poorer parts of the world. As many as 600,000 women die each year of pregnancy-related causes, 99 per cent of them in developing countries. According to the World Bank, 140,000 die from haemorrhaging, 75,000 from abortions, 75,000 from eclampsia-related complications, 100,000 from infections, 40,000 from obstructed labour. [10] In the UK, despite reductions in infectious disease in the first half of the 20th century, maternal mortality remained high until the advent of antibiotics, blood transfusions, legalised abortion, the effective management of hypertensive disease and the availability of Caesarean section for obstructed labour. It seems that maternal mortality, more than other health problems, is determined by the availability of health care. This would explain the failure to improve maternal mortality in the poorest countries, where access to secondary and tertiary health care is severely limited. Despite the many improvements in the techniques available to treat and prevent disease, improvements in health are slowing down in the poorer countries. In some the health situation is getting worse. The human immunodeficiency virus (HIV) is one cause of this, with associated increases in diseases like tuberculosis. But there are other reasons. Increasing poverty and declining access to many of the determinants of health, including health care and immunisation, together with rising populations and increasing incidence of infectious disease, have all contributed to a much slower rate of progress. Tomorrow’s news: eradication
Several diseases are likely to be eliminated over the next decade:
? Going…
Leprosy is on the point of being eliminated as a public health problem, according to WHO. Of the 55 countries where leprosy is still endemic, only 13 are rated as “the most endemic countries”, and they account for 91 per cent of the estimated 1.15 million cases. They are, in order of prevalence: 2 India, Brazil, Indonesia, Myanmar, Madagascar, Nigeria, Mozambique, Ethiopia, Democratic Republic of Congo, Niger, Guinea and Cambodia. WHO considers that leprosy no longer constitutes a public health problem when the number of cases in a given country falls below one per 10,000 people. [11]
2 Prevalence is the total number of people with a disease or condition (for example, iron-deficiency anaemia), or with malnutrition, or who smoke and so on, in a given year.
2 Panos Briefing: DIAGNOSING CHALLENGES Smallpox eradication… with polio to follow?
The eradication of smallpox was one of the major public health achievements of the 20th century. This success was based on a sound understanding of the characteristics of the disease, of the virus which caused it and of the vaccine virus which prevented it. The disease was recognised and feared by all with its disfiguring rash and often fatal outcome. It was highly infectious with a short incubation period, and there was a clear association between contact with an infected person and the onset of the disease. There was no carrier state and the virus did not survive long outside the human body. The vaccine was both heat- and light -stable and did not require refrigeration or a ‘cold chain’ (being kept cold throughout transportation and storage). Only one dose of vaccine was needed. It could be administered safely using relatively untrained workers, without the need for sterile needles or equipment, and therefore without the need for supplies of fuel for sterilisation equipment. Because the infection was able to spread so rapidly, eradication of the virus could not be achieved through routine vaccination from fixed sites in health centres. The strategy used was to contain the infection through careful surveillance and the rapid vaccination of contact cases. By this means the ‘wild’ virus was contained and then eradicated. This strategy required the rapid deployment of trained health workers with supplies of vaccine and the means to vaccinate those in the immediate vicinity of a case as quickly as possible. The active participation of the community was to some extent assured by the fear which smallpox aroused. The end of polio is close, although this disease presents even greater problems for eradication. Only one in a hundred of those infected show signs of paralysis. The rest may not get any symptoms even though they are infectious and capable of passing the virus on. Infected but symptom-free people can travel around the world passing the virus in their faeces without knowing it. The virus can survive outside the human body in cool, dark sewage for several months. The polio virus is much more difficult to contain than the smallpox virus. The vaccine most commonly used for polio must be kept cool as it is destroyed by heat. This complicates its delivery. On the other hand, it is given orally and is very safe, which means that it can be administered by people with very little training. However, at least three doses are required, with an interval of at least four weeks between the doses. Other viruses can interfere with the effectiveness of polio vaccine, and in some cases many more doses are required to ensure protection. Several complementary strategies are used in the eradication programme, including routine immunisation of all infants at every opportunity when they appear at health centres, and also through the use of National Immunisation Days when all children under the age of five years are given a dose of vaccine. This ensures very high coverage, and by ‘flooding’ the community with the vaccine virus the ‘wild’ virus is excluded and eventually eradicated. The mass campaign approach to eradication has been successful and other diseases are also being targeted by this means, including guinea-worm disease and onchocerciasis (river blindness). However, for the management of many diseases there needs to be an accessible health care service available at all times and within easy reach for the majority of people. Mass campaigns can complement and strengthen such services, but cannot replace them. Indeed, they can sometimes undermine existing services, especially in the poorest parts of the world. Our enthusiasm for the eradication of specific diseases must not divert us, or the limited resources available for health care, from the main purpose of ensuring high quality health care for all people and for all of their health problems.
Panos Briefing: DIAGNOSING CHALLENGES 3
? Going…
The world is on the brink of eradicating polio, which involves both halting the incidence3 of the disease and also the worldwide eradication of the virus that causes it – poliovirus, which only affects humans. Polio is one of only a limited number of diseases (others include measles and guinea-worm disease) that can be eradicated. Polio has already been eliminated from the Americas and the Caribbean, and has almost been wiped out in Europe. WHO’s global eradication target is December 2000. Meeting this target would cost an additional US$370 million, but would save US$1.5 billion every year in vaccination costs. [12]
Smallpox used to kill five million people a year in the 1950s, but was completely eradicated from the world nearly 20 years ago in one of the most successful international health campaigns of all time. On the list
Other diseases likely to be eliminated as a public health problem in the coming decades: [13]
? River blindness (onchocerciasis) is a parasitical disease transmitted by the bite of a small fly,
which can cause incapacity and blindness. The Onchocerciasis Control Programme in West Africa has protected more than 34 million people from the disease, and the target date for elimination is 2008. At least 1.5 million people have been completely cured from infection. Control of the disease has opened up 25 million hectares of fertile land for agricultural production, land which was previously deserted out of fear of the disease.
? Guinea-worm disease (dracunculiasis), a crippling water-borne disease which has afflicted parts
of Africa and Latin America for centuries, is close to eradication. Filtering and water treatment to kill the parasite larvae have reduced the number of cases worldwide from 3.2 million in 1986 to 70,000 in 1997.
? Measles – which still kills around one million children every year in developing countries – is due
to be eradicated worldwide through immunisation.
? Lymphatic filariasis (elephantiasis), one of the most painful and unpleasant of all tropical
diseases, still affects over 120 million people in 73 countries in Africa, the eastern Mediterranean and South-East Asia. It can be controlled by a yearly dose of two drugs, and eradication is possible by 2020.
? Sleeping sickness (African trypanosomiasis), spread by the tsetse fly, should soon cease to be a
public health problem, although recently cases have doubled again in some countries.
? Chagas disease, another form of trypanosomiasis which affects 16-18 million people in 21
countries of Central and South America, is expected to be eliminated by 2010.
? The blinding disease trachoma affects 150 million people and has blinded six million who are
alive today, but should be eliminated by 2020 through the use of long-lasting antibiotics.
CHANGING PROBLEMS
There are fundamental changes afoot in health and health care. There will be changes not only in the way health care is provided, but also in the kind of health problems needing treatment. Changes in the funding of health services, new technology, increasing expectations, population profiles, migration, climate and lifestyles all contribute to a host of new challenges. These come on top of a continued lack of funds for health care worldwide, and problems such as HIV/AIDS, which will remain a major health issue for decades to come. This rather pessimistic picture is despite some of the good news, such as the expected fall in the burden of infectious diseases from 49 per cent to 22 per cent between 1990 and 2020. Infectious disease will remain near the top of the health agenda, especially as new infections emerge and old ones become resistant to current treatments.
3 Incidence is the number of new cases of a disease or condition in a given year.
4 Panos Briefing: DIAGNOSING CHALLENGES
In 1990 the three leading causes of disease burden4 were (in order) pneumonia, diarrhoeal diseases and perinatal (birth-related) conditions. The three causes projected to take their place by 2020 are heart disease, depression and road traffic collisions. By 2020 non-communicable diseases such as heart disease and cancer are expected to account for seven out of every 10 deaths in developing countries, compared with less than half today. [14]
Changing challenges
? Changing lifestyles: non-communicable diseases (mainly cardiovascular and neuro-psychiatric
diseases and cancers) are expected to increase from 36 per cent of global disease in 1990 to 57 per cent in 2020, partly because of increased smoking in developing countries. [15] There is also likely to be an increase in the incidence of stress-related problems often found in the North but becoming an increasing problem as lifestyles change in the South.
? New bugs: New epidemics and drug-resistant bacteria will become prominent problems.
Antimicrobial resistance is an emerging public health issue as a rapidly growing number of bacteria become resistant to an increasing range of antibiotics. [16]
? Ageing populations in both North and South will change the nature of health demands. By 2020
there will be more than one billion people aged 60 and over living in the world, more than 700 million of them in developing countries. This may well be coupled with an expected decline in childhood mortality from infectious disease; fewer births, longer lives and higher incidence of age-related diseases could all change the health priorities for nations.
? Increasing environmental health problems around issues such as toxic waste, pollution, industrial
production and environmental degradation: health risks from toxic chemicals such as lead, cadmium, mercury, DDT and polychlorinated biphenyls have been brought under control in most developed countries, but generally not in the developing world. Exposure of children to lead and persistent organic pollutants are of particular concern.
? There is both a perceived increasing need for, and resistance to, government and international
regulation, covering everything from worker safety to food production, from health insurance schemes to doctor/nurse job distinctions.
? Increasing numbers living in absolute poverty and outside the reach of national services and
unable to enter the health care marketplace: well over a billion people are deprived of basic consumption needs. There are 76 doctors per 100,000 people in developing countries (only 14 per 100,000 in the least developed countries), as against 287 per 100,000 in industrialised countries. [17]
? Prevention is better than cure – and certainly cheaper. Many diseases and disabilities can be
prevented by immunisation, proper nutrition and environmental improvements, but prevention costs money now even if it saves it later.
? Collapsing state health systems: in the poorest countries state health care systems are in crisis.
Typically, lack of funds means access and coverage are very limited, the quality of services is low, and health staff are inadequately trained, poorly paid and without reliable supplies. [18]
? Road traffic collisions: for men aged 15-44, these are already the largest cause of ill health and
premature death worldwide, and the second largest in developing countries. The high toll of road traffic collisions in developing countries has received little attention from public health specialists.
? War: since 1945 so-called ‘conventional’ weapons have directly caused the deaths of more than
230 million people and the disablement of millions more. In recent years approximately nine times as many civilians as military personnel have been killed in war. An estimated four million children have been disabled during the past decade because of armed conflict, many of them from injuries caused by landmines. [19]
? Violence and accidents: in 1993 at least four million deaths (three million of them in the
developing world) resulted from accidental or intentional injury, including 300,000 murders. In Latin America and the Caribbean there are over 1,000 violent deaths every day. Violence, currently 19th in the leading causes of disability, could rise as high as 12th place, and suicide could climb to 14th place. [20]
4 The burden of disease is usually measured by the disability-adjusted life year (DALY) indicator. This represents the years of healthy life lost either through premature death or as a result of living with a disability. Adding these two numbers produces a single measure: the DALY. The total number of DALYs in a population in any given year indicates that population’s disease burden for that year.
Panos Briefing: DIAGNOSING CHALLENGES 5 Climate change and health
Changes in climate are thought to affect the incidence5 of diseases such as malaria and dengue. Dengue, a mosquito-borne disease, currently threatens 1.8 billion people. An estimated 50 million people are infected annually, and the disease causes about 25,000 deaths. A temperature rise of 1-2 degrees centigrade could result in an increase of the population at risk by several hundred million, with 20,000- 30,000 more dengue deaths a year by 2050. A recent study by the World Resources Institute in conjunction with WHO experts predicts that by 2020 – if current trends in greenhouse gas emission continue – there will be 700,000 extra avoidable deaths annually because of additional exposure to atmospheric particulate matter (PM) produced by the burning of fossil fuels, with 80 per cent of these deaths occurring in developing countries . The health effects of PM include cardiovascular and respiratory illness. The researchers calculate that up to eight million PM-related deaths worldwide in the first 20 years of the 21st century could be prevented by the implementation of a climate policy designed to reduce carbon emissions significantly. They have concluded that regardless of how or when greenhouse gases alter climate, reducing them now will save lives worldwide by lessening particulate air pollution, and that the beneficial effects of reduced particulate pollution appear to be far greater in rapidly developing countries than in developed countries, although they are substantial in both regions. [21]
Some effects of global climate change and stratospheric ozone layer depletion (a separate but coexistent problem) could be beneficial. For example, in areas with relatively cold climates an increase in ambient temperature could result in a decrease in cardiovascular mortality. But most effects are expected to be adverse. For example, stratospheric ozone depletion increases incidence of skin cancer, cataracts and immune system damage, although scientists calculate that excess mortality from increases in skin cancer would be much less than that expected in malaria deaths resulting from climate change. [22] Malaria
The first two major health campaigns that Dr Gro Harlem Brundtland announced when she was appointed Director-General of WHO were against malaria and smoking – issues to which WHO had not previously given top priority.
? Malaria is the single largest disease in Africa and a primary cause of poverty. Every day 3,000
children die of malaria. Every year there are 300-500 million cases among children and adults – most of them in Africa – and at least two million deaths.
? Treatment and eradication have become more difficult and more expensive because of
antimalarial drug resistance in mosquitoes.
? 30 million tourists and business travellers from non-endemic countries visit malaria-endemic
? Rural communities are particularly affected. In rural areas the rainy season is often a time of
intense agricultural activity, when poor families earn most of their annual income. Malaria can make these families even poorer. In children, malaria leads to chronic school absenteeism and there can be impairment of learning ability. Urban malaria is increasing due to unplanned development around large cities, particularly in Africa and South Asia.
? More than any other disease, malaria hits the poor. Malaria-endemic countries are some of the
world's poorest. Costs to countries include costs for malaria control and lost workdays – estimated to be between one and five per cent of gross domestic product (GDP) in Africa.
? Recent scientific studies based on mathematical models indicate that a global mean temperature
increase of 1-2 degrees centigrade would enable mosquitoes to extend their range to new geographical areas. This would lead to increases in cases of malaria along with several other infectious diseases – especially in populations living just outside the areas where these diseas es currently occur.
? The proportion of the world's population at risk from malaria could increase from around 45 per
cent to 60 per cent by the year 2050. The estimated number of annual deaths from malaria would rise from its present level of 2-3 million to anything between 3.5 and five million. There is already some evidence that malaria incidence is increasing in a number of highland regions, for example in Kenya, in a manner that is compatible with recent regional warming – although other ecological factors may also be involved. [23] 6 Panos Briefing: DIAGNOSING CHALLENGES Lifestyle changes
The way people live affects their health – both for better and for worse. As living standards improve, the diseases of poverty and deprivation may recede but the diseases of affluence increase. Overconsumption of high-fat foods and sweet drinks, smoking, drinking and drug abuse all bring their own health problems. Advertising can encourage unhealthy consumption patterns. Promoting more healthy eating and reducing obesity, especially among children, would bring considerable health gains. Taxation of unhealthy alternatives can also contribute.
'Double burden' threatening Sri Lanka's health care system
A recent phenomenon has begun to worry Sri Lanka’s development planners and health managers: the emergence of non-communicable diseases as major causes of illness and death. Paradoxically, the system is having to cope with these diseases – including heart diseases, strokes, cancers and diabetes – while at the same time dealing with a host of communicable diseases that are aggravated by poverty and underdevelopment. The situation underlines the need to shift from a mainly curative approach to a preventive one in health care. During the past few decades Sri Lanka has achieved remarkable progress in its health care delivery and coverage, leading to a steady decline in death rates and to an overall improvement of people's health and living standards. The infant mortality rate – at 16.5 per 1,000 live births – is better than that of many wealthier countries, and very few mothers die in childbirth. Unfortunately, while these achievements are impressive they are not sufficient to ensure good health for all. Communicable diseases continue to affect a large number of Sri Lankans, keeping them away from school or work. No reliable statistics are available on overall sickness rates, but productivity experts see this as a major problem. Against this backdrop the emergence of non-communicable diseases is forcing the health care system to fight on two different fronts. Already these diseases are among the top 10 causes of hospital death. Ischaemic heart disease is number one: with 3,109 deaths in 1996, it alone was responsible for more hospital deaths than all communicable diseases combined. Strokes, other forms of heart disease and cancer are also among the top six killers. Other lifestyle conditions are increasingly having an impact on the well-being of individuals and communities. These include dependence on drugs and alcohol, sexually transmitted diseases, child abuse and suicide. Road traffic collisions take an increasing toll on life and limb. Mental disorders have also shown a marked increase, with more cases being reported and more people seeking treatment than ever before. "With all these factors to cope with, it is quite clear that we are not going to achieve health for all by the year 2000," says Professor Ravindra Fernando, a medical researcher and President of the Ceylon College of Physicians. He points out that this calls for a major reorientation of the mainly curative approach currently adopted by the system. But only 17 per cent of the total health budget in 1996 was spent on community health services, which play a major role in preventive health care. A further complication is the gradual ageing of the Sri Lankan population: the shifting of the demographic pattern from predominantly young to middle-aged. A United Nations report last year said Sri Lanka's population was ageing faster than anywhere else in the world, but noted that the country was grossly unprepared to meet the burden of looking after its elderly. Thus one of Sri Lanka's major challenges is how to add life to the years, and not just years to life. Nalaka Gunawardene, Panos Features, April 1999
Panos Briefing: DIAGNOSING CHALLENGES 7 Tobacco
“I am a doctor. I believe in science and evidence. Let me state here today: Tobacco is a killer.” – Dr Gro Harlem Brundtland [24] Smoking already kills four million people a year. The major focus of the epidemic is now shifting to the developing countries. By 2020 tobacco is expected to cause more premature death and disability than any single disease, surpassing even the HIV epidemic, and is expected to increase its share of the total disease burden worldwide from 2.6 per cent in 1990 to just under nine per cent in 2020. In a collaborative effort WHO, the World Bank and UNICEF have launched the Tobacco Free Initiative. Part of the campaign involves setting up an International Framework Convention of Tobacco Control, which will be concerned with harmonising taxes on tobacco products, smuggling and tax-free tobacco products, advertising, sponsorship, international trade, package design and labelling, and agricultural diversification. WHO plans to organise world action to accompany national tobacco control initiatives. With the support of UNICEF and the World Bank, WHO aims to counteract the tobacco habit which is extensively communicated through the media, the entertainment industry, and most directly through the marketing and promotion of specific products. The world tobacco market has grown markedly during recent years and the direct foreign investments made by transnational corporations in developing countries have also increased, said Dr Brundtland at a seminar in October 1998 to launch the initiative. Tobacco control cannot be achieved only through the individual efforts of governments, non-governmental organisations (NGOs) and some media advocates. “We need an international response to an international problem,” declared Brundtland. Effective legislation reduces tobacco consumption. Five years after the introduction of the Evin Law of 1991 in France, which banned cigarette advertising, created smoke-free public places and increased prices, cigarette consumption had fallen by 16 per cent. [25] Re-emerging problems
Many low-income countries do not have adequate resources for essential health services. This is also increasingly the case in more prosperous countries, even if to a lesser extent. For some countries, particularly in Eastern Europe, people’s health is declining. One result is that diseases formerly under control are now becoming more common again.
? Tuberculosis (TB) Tuberculosis (TB) kills more young people and adults than any other infectious disease in the world today. It is a bigger killer than malaria and AIDS combined and kills more women than all the combined causes of maternal mortality. It kills 100,000 children each year, and it is increasing rapidly in the developing world. It is estimated that between now and 2020 nearly one billion people will be newly infected, 200 million will get sick and 70 million will die from TB if control is not strengthened. This year more people will die of TB than in any other year in history. New outbreaks are occurring in Eastern Europe, where TB deaths are increasing after almost 40 years of steady decline. The biggest burden of TB is in South-East Asia.
? TB kills two to three million people each year. ? TB accounts for more than one quarter of all preventable adult deaths in developing countries. ? Seven to eight million people around the world become sick with TB each year. ? Between 1993 and 1996 there was about a 10 per cent increase in TB cases worldwide. ? 1.6 million TB cases per year occur in sub-Saharan Africa, three million per year in South-East
Asia and 0.33 million per year in Eastern Europe (0.36 with Turkey).
8 Panos Briefing: DIAGNOSING CHALLENGES
HIV is accelerating the spread of TB. HIV and TB form a lethal combination, each speeding the other's progress. One third of the increase in the incidence of TB in the last five years can be attributed to HIV, and by the end of 1999 an estimated 15 per cent of TB cases will be attributable to HIV. HIV weakens the immune system: someone who is HIV -positive and infected with TB is 30 times more likely to become sick with TB than someone infected with TB who is HIV-negative. At the same time, TB is the leading cause of death among people who are HIV-positive. It accounts for almost one third of AIDS deaths worldwide, 40 per cent of AIDS deaths in Africa and 40 per cent of AIDS deaths in Asia. In Africa HIV is the single most important factor determining the increased incidence of TB in the last 10 years. Poorly managed TB programmes are threatening to make TB incurable. Until 50 years ago there were no medicines to cure TB. Strains that are resistant to a single drug or even a combination of drugs have now emerged. Up to 50 million people may be infected with drug-resistant TB. There is no cure affordable to developing countries for some multidrug-resistant (MDR) strains, defined as resistant to the two most important drugs, isoniazid and rifampicin. MDR-TB is caused by inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period because they start to feel better, doctors and health workers prescribe the wrong drugs or the wrong combination of drugs, or the drug supply is unreliable. Drug-resistant TB is more difficult and more expensive to treat, and more likely to be fatal. In industrialised countries TB treatment costs around US$2,000 per patient, but rises more than 100-fold to up to US$250,000 per patient with MDR-TB. Movement of people is helping the spread of TB.Global trade has increased six-fold and the number of people travelling by air has increased 17-fold since 1960. In many industrialised countries at least half of TB cases are among foreign-born people. In the USA one third of TB cases are among foreign-born people. The number of refugees and displaced people in the world has increased nine-fold in 20 years. Untreated TB spreads quickly in crowded refugee camps and shelters. It is also difficult to treat mobile populations. As many as 50 per cent of the world's refugees may be infected with TB; each year 17,000 get sick with the disease. As they move, they may spread TB. Other displaced people, such as homeless people in industrialised countries, are at risk. In 1995 almost 30 per cent of San Francisco's homeless population and approximately 25 per cent of London's homeless were reported to be infected with TB. [26] Epidemics of blame, diseases of discrimination
A new generation of health issues has emerged over the last 15 years which have shone an unforgiving spotlight on the uglier side of societies the world over. The rapidly escalating HIV/AIDS pandemic in particular has sparked further epidemics of discrimination, blame and prejudice in almost every country in the world. Discrimination against people with AIDS, against whole countries and peoples associated with AIDS, against those accused of harbouring or spreading HIV have been almost universal reactions. The virus has tended to flourish alongside poverty, gender inequality and other forms of discrimination and social exclusion. By the end of 1998, according to new estimates from WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the number of people living with HIV had grown to 33.4 million, 10 per cent more than just one year previously. The epidemic has not been overcome anywhere. Virtually every country in the world saw new infections in 1998. More than 95 per cent of all HIV -infected people now live in the developing world, which has likewise experienced 95 per cent of all deaths to date from AIDS, largely among young adults who would normally be in their peak productive and reproductive years. The multiple repercussions of these deaths are reaching crisis level in some parts of the world. Whether measured in terms of declining child survival and life expectancy rates, overburdened health care systems, increasing orphanhood or financial losses to business, AIDS has never posed a bigger threat to development.
Panos Briefing: DIAGNOSING CHALLENGES 9
According to new UNAIDS/WHO estimates, 11 men, women and children around the world contracted HIV every minute during 1998 – close to six million people in all. Ten per cent of newly infected people were under the age of 15, which brings the number of children now alive with HIV to 1.2 million. Most of them are thought to have acquired their infection from their mother before or at birth, or through breastfeeding. While mother-to-child transmission can be reduced by providing pregnant HIV -positive women with antiretroviral drugs and alternatives to breast milk, the ultimate aim must be effective prevention for young women so that they can avoid becoming infected in the first place. When it comes to HIV infection, the pattern of men generally having more sexual partners than women means that the percentage of women contracting the virus is rising faster than the percentage of men. While women accounted for 41 per cent of HIV-positive adults worldwide in 1997, they now represent 43 per cent of all people over 15 living with HIV and AIDS. Altogether, since the start of the epidemic around two decades ago, HIV has infected more than 47 million people. And although it is a slow-acting virus which can take a decade or more to cause severe illness and death, HIV has already cost the lives of nearly 14 million adults and children. An estimated 2.5 million of these deaths occurred during 1998, more than ever before in a single year. HIV/AIDS has, perhaps more than any other disease, raised profound questions of lack of access to drugs, with many arguing that medicine has little to offer such health problems. There is as yet no vaccine or cure for AIDS, and treatments are far too expensive for the budgets of most developing countries. Similarly, both HIV/AIDS and the recognition of the importance of reproductive health and rights has highlighted the extent to which disease and poor health are linked not only with poverty and poor nutrition but also with prejudice, social, political and economic inequality, social dislocation and social or political environments where issues of sex and sexuality are habitually hidden or are difficult to debate in public. Such issues are increasingly acting as a motor for much wider changes in society. Recognition of the scale of suffering caused to women in particular by denial of reproductive health and rights has also raised issues that have cut to the heart of traditional attitudes and practices. The Cairo International Conference on Population and Development in 1994 was a watershed in shifting international policy away from a target-oriented approach towards population to an approach founded on recognising reproductive health and rights (see Section 4, below). But clearly medicine also has a role to play. The reality is that maternal mortality, for example, will not decline until women have access to high quality health care. Many argue that the only real successes in the control and management of HIV infection are drug-related, and that the evidence for the success of health education and behavioural change is limited. Behavioural change depends upon choice to some extent, which is why education alone without an increase in available choices often has little impact on behaviour.
New diseases
HIV/AIDS is only the most widespread of a number of formerly unknown diseases to have emerged in recent years. In summing up the problem the late Dr Jonathan Mann, Director of the International AIDS Center at Harvard AIDS Institute, said: “In one vital area, the emergence and spread of new infectious diseases, we can already predict the future – and it is threatening and dangerous to us all. The history of our time will be marked by recurrent eruptions of newly discovered diseases (most recently, hantavirus in the American West); epidemics of diseases migrating to new areas (for example, cholera in Latin America); diseases which become important through human technologies (as certain menstrual tampons favoured toxic shock syndrome and water cooling towers provided an opportunity for Legionnaires' Disease); and diseases which spring from insects and animals to humans, through man-made disruptions in local habitats… What is new… is the increased potential that at least some of these diseases will generate large-scale, even worldwide epidemics. The global epidemic of human immunodeficiency virus is the most powerful and recent example. Yet AIDS does not stand alone; it may well be just the first of the modern, large-scale epidemics of infectious disease. “The dramatic increase in worldwide movement of people, goods, and ideas is the driving force behind the globalization of disease. For not only do people travel increasingly, but they travel much more rapidly,
10 Panos Briefing: DIAGNOSING CHALLENGES
and go to many more places than ever before. A person harbouring a life-threatening microbe can easily board a jet plane and be on another continent when the symptoms of illness strike. The jet plane itself, and its cargo, can carry insects bringing infectious agents into new ecologic settings… The world needs – now – a global early-warning system capable of detecting and responding to new emerging infectious disease threats to health.” [27]
The drugs war: what price treatment for people with HIV?
In the early years of the new millennium at least 40 million men, women and children will be living with HIV/AIDS in the developing world. The vast majority of them, it seems, will not have access to the antiretroviral drugs which have succeeded in prolonging life for a perhaps a million individuals with the virus in the industrialised world. The primary issue involved is cost. A yearly regimen of three different types of retrovirals – the ‘cocktail’ or combination therapy required to work in unison to prevent HIV from replicating – can cost at least US$10,000. That figure does not include the infrastructure, including doctors’ and other health professional fees and blood and other tests, required to ensure that the combination is effective. Such a sum is way beyond the health budgets of the world’s poorest nations, which are often no more than US$10 per person per year. And it is often the world’s poorest countries that have the highest number of AIDS cases. Look beyond the cost of antiretroviral drugs, however, and a range of other issues appear, centred on the questions of research, profit and patenting. Pharmaceutical companies claim that they have to charge high costs for drugs to recoup their costs of research; HIV/AIDS activists argue that the costs do not justify the research. The argument is that each drug can cost millions of dollars to research and go through various trials, and much money is spent on ‘candidate drugs’ that fail at one stage or another of the development process. Activists argue that the figures are manipulated and the pharmaceutical industry’s research costs are not really so high. They argue that in the face of so much poverty and death pharmaceutical companies have a duty to reduce costs. Pharmaceutical companies have responded, either by lowering costs or by contributing in other ways; for example, Bristol-Myers Squibb and Glaxo Wellcome both have non-profit arms and other means of helping those working in the AIDS sector, such as through support of organisations of people with AIDS. The question of patents also comes into play. Pharmaceutical patents do not apply in every country, and in some, such as India, ‘clones’ of drugs such as zidovudine (also known as AZT) are manufactured and distributed. Activists also claim that pharmaceutical companies are putting pressure on the US government to sign financial aid agreements with African countries that will allow the companies a monopoly on distribution of their drugs, maintaining prices at artificially high – and unacceptably high – levels. Antiretroviral drugs are not unknown in the developing world, as the example of India demonstrates. In many countries a few wealthy patients with HIV can afford treatment very similar to that in the North, while formal and informal networks exist that send (legally or illegally) unused drugs from the North to needy patients in the South. Development agencies have funded the cost of zidovudine in a number of countries in Africa and Asia to prevent the transmission of HIV from a pregnant woman to her unborn child. In some Latin American countries groups of people living with HIV/AIDS have taken their governments or health services to court to force them to provide antiretroviral drugs to those who need them. While this step is obviously welcome for those who are acutely ill, it raises questions as to whether other aspects of the health budget have been cut to provide for these drugs, and whether the infrastructure necessary to provide and monitor the effect of the drugs is in place.
The following are some examples of such new diseases:
Panos Briefing: DIAGNOSING CHALLENGES 11
? Viruses Ebola virus: The fi rst outbreaks occurred in 1976 and the discovery of the virus was reported in 1977. Indigenous cases have been confirmed in four countries in Africa (Côte d'Ivoire, Democratic Republic of Congo, Gabon and Sudan). Up to June 1997 a total of 1,054 cases had been reported to WHO, 754 of which proved fatal. Hepatitis C: Identified in 1989, this virus is now known to be the most common cause of post-transfusion hepatitis worldwide, with approximately 90 per cent of cases in Japan, the USA and Western Europe. However, the post-transfusion situation changed in 1990-91 with the introduction of screening. Up to three per cent (170 million) of the world’s population are now estimated to be infected.
? Bacteria Legionella pneumophilia: The detection of the bacterium in 1977 explained an outbreak of severe pneumonia (Legionnaires’ Disease) in a convention centre in the USA the previous year, and it has since been associated with outbreaks linked to poorly maintained air conditioning systems. Escherichia coli O157:H7: Detected in 1982, this new strain of the bowel bacterium E. coli is typically transmitted through contaminated food and has caused outbreaks of haemolytic uraemic syndrome in North America, Europe and Japan. A widespread outbreak in Japan in 1996 caused over 6,000 cases among school children, of whom two died. During a single outbreak in Scotland in 1996 a total of 496 people fell ill, of whom 16 died. Vibrio cholerae O139: First detected in 1992 in India, this strain of cholera has since been reported in seven countries in Asia. The emergence of a new strain permits the organism to continue to spread and cause disease, even in populations protected by antibodies generated in response to previous exposure to other strains of the same organism. [28] Environmental health problems
Many diseases have been linked to environmental problems such as polluted drinking water and air. Pesticides in the countryside and factory or traffic pollution in the cities all take their toll. But changes in the way people live and work can also cause a sudden increase in old diseases or the emergence of new ones. A poor environment is directly responsible for around 25 per cent of all preventable ill health in the world today, and two thirds of those affected are children. [29] Fears about ‘bad’ food seem to hit the headlines with increasing frequency in the countries of the North. In the South there are fewer such scares – real or otherwise – but as populations have an increased expectation of healthy food and become more aware of hygiene issues, these concerns are likely to come to the top of the agenda along with food poisoning, marketplace and restaurant hygiene and a myriad of other environmental health issues. The fact that many such problems are currently either ignored or covered up is unlikely to hold back public demand for regulations or to check the damage they cause to health. In a few years urban dwellers will for the first time in history outnumber those in the traditionally rural areas. The urban population of the developing world is set to increase by more than double, from 1.5 billion in 1990 to over three billion in 2010. While urban living conditions may bring improvements in terms of access to health care, education, sanitation and clean water, this potential is often not realised, especially for poorer new migrants, who may suffer from overcrowding, pollution and dangerous working conditions. Infectious diseases such as TB spread more easily and more rapidly, while road traffic collisions and other forms of violence are also more frequent in urban settings. Stress and poor living conditions can also cause health problems. Occupational working conditions take a heavy toll in many developing countries: bad working conditions or exposure to toxic chemicals, dust and allergenic or carcinogenic agents affect millions, as does exposure to insecticides and other toxic chemicals on the land. WHO estimates that there are 217 million cases of occupational diseases and 250 million cases of injury at work every year, with about 50 million new cases of occupational respiratory diseases. [30] In 1993 the cost of workers’ compensation in the 12 Panos Briefing: DIAGNOSING CHALLENGES
USA alone amounted to US$57 billion. Data from Latin America and the Caribbean suggest that as many as 95 million workdays are lost in the region each year. Air pollution, both outdoors and indoors (from cooking fires), leads to an estimated three million premature deaths globally. The consequences for health of the recent forest fires in South-East Asia are an example of the serious threats from air pollution on a regional scale. The International Programme on Chemical Safety (IPCS) is a joint programme of WHO, the International Labour Organization (ILO) and the United Nations Environment Programme (UNEP), with WHO as the executing agency. IPCS has provided guidance on safe levels of some 100 chemicals in drinking water, 35 chemicals in air, 655 pesticides, 30 veterinary drug residues in food and 1,205 food additives. The population groups most affected by chemicals are poor, illiterate people with little or no access to appropriate training or basic information on the risks posed by the chemicals to which they are exposed. [31] THE MAIN PLAYERS IN THE GLOBAL HEALTH ARENA World Health Organization (WHO)
The World Health Organization (WHO) is a UN body concentrating exclusively on health. Compared to the World Bank it is a pauper: WHO has a regular budget of US$842 million for the biennium 1998-99, and estimated voluntary funding from other sources of US$956 million, making a total integrated budget of some US$1.8 billion for the two years. The WHO regular budget has not grown in real terms since the early 1980s, and in size is comparable to the budget of Helsinki University Hospital. [32] WHO was out of favour with many donor governments until recently because of their dissatisfaction with the performance and management of the organisation. But Dr Gro Harlem Brundtland, former Prime Minister of Norway and Chairman of the ‘Brundtland Commission’ (World Commission on Environment and Development) set up in 1983, took over in 1998 as the first woman Director-General, and her arrival was generally welcomed by donors and other agencies. In her address to the WHO Executive Board in January 1999, Dr Brundtland set out the global development agenda and its implications for WHO. “My pledge as Director-General is to put health at the core of the international development agenda,” she stated. “Sound investment in health can be one of the most cost-effective ways of promoting development and progress. Improving health in poor countries leads to increased GDP [gross domestic product] per capita. In richer countries it reduces overall costs to society. In a time of global trade and investment, where nations are searching for ways to make the ends meet, we have been sitting on a secret.” She has also pointed out that real changes in society can be made only when the economic dimension of the issue in question is fully understood. Actions on environmental issues were taken only when the true costs of environmental degradation were analysed and spelt out in numbers. Poverty affects health. However, there is evidence that ill health in its turn perpetuates poverty, and Brundtland's mission now is to highlight the role of health as a strategy for alleviating poverty. “There is solid evidence to prove that investing wisely in health will help the world take a giant leap out of poverty. We can drastically reduce the global burden of disease. If we manage, hundreds of millions of people will be better able to fulfil their potential, enjoy their legitimate human rights and be driving forces in development. People would benefit. The economy would benefit. The environment would benefit. It is a complex process – but it can be done.” [33] As an example, one study from Indonesia shows that workers who are treated for anaemia are 20 per cent more productive than those who are not treated. As for WHO itself, Brundtland has identified four strategic areas: to work closer with countries; to be more focused in obtaining better health outcomes; to be more effective in supporting health sector development; and to be more innovative in creating influential partnerships. The need for new partnerships is significant because WHO has suffered in recent years from isolation and disagreements with the other big player in the international health arena, the World Bank. Brundtland
Panos Briefing: DIAGNOSING CHALLENGES 13
has singled out as priorities closer working relations with the World Bank and the World Trade Organization, as well as a “new dialogue” with the International Monetary Fund (IMF). WHO is upgrading its presence at the Organization of African Unity and also at the European Union. “In addition to governmental and inter-governmental partners, we are making progress in building partnerships with NGOs and the private sector,” Brundtland has said. [34] WHO’s mission statement includes the following objectives:
? to act as the directing and coordinating authority on international health work ? to promote technical cooperation ? to assist governments, upon request, in strengthening health services ? to furnish appropriate technical assistance and, in emergencies, necessary aid, upon the request
? to stimulate and advance work on the prevention and control of epidemic, endemic and other
? to promote, in cooperation with other specialised agencies where necessary, the improvement of
nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene
? to promote and coordinate biomedical and health services research ? to promote improved standards of teaching and training in the health, medical and related
? to establish and stimulate the establishment of international standards for biological,
pharmaceutical and similar products, and to standardise diagnostic procedures
? to foster activities in the field of mental health, especially those activities affecting the harmony of
World Bank
The World Bank is a major voice in national and international health policy debates, and a significant contributor to health policy research. Health sector reforms to produce more effective public health activities and improve regulation of the expanded private sector in health are high on the Bank’s agenda. The World Bank began providing support to the health, nutrition and population (HNP) sector in the early 1970s. It has rapidly expanded its work in this area, offering advice and loans to more than 90 developing countries and countries in transition. The World Bank lends to governments, but it also works closely with people and private enterprises in developing countries. NGOs, for example, collaborate in about half of Bank-supported projects. There are two types of World Bank lending. Firstly, loans from the International Bank for Reconstruction and Development (IBRD) are for countries which are able to pay near-market interest rates. The second type – IDA (International Development Association) credits – go to the poorest countries that are usually not credit-worthy in the international financial markets and are unable to pay near-market interest rates on the money that they borrow. IDA credits are free of interest, carry a low 0.75 per cent annual administrative charge, and are long-term. About half of all World Bank lending in HNP is in the form of IDA credits to the poorest countries of the world.
Since its first HNP loan in 1970, the Bank's HNP lending activities have grown to the point where it is now the single largest external source of HNP financing in low- and middle-income countries. By the end of fiscal year 1998, the Bank had 157 active and 100 completed HNP projects, for a total cumulative value of US$14 billion. Its loans to the HNP sectors that year totalled nearly US$2 billion; this money is lent, not given. In addition to HNP projects that have a direct impact on HNP outcomes, the Bank also lends for education, agriculture, water supply, environment, and rural/urban development, all of which have an indirect impact on HNP outcomes. The stated focus of the World Bank’s work with client countries is to:
? improve the health, nutrition and population outcomes of the poor, and protect the
population from the impoverishing effects of illness, malnutrition and high fertility
14 Panos Briefing: DIAGNOSING CHALLENGES
? enhance the performance of health care systems by promoting equitable access to
preventive and curative health, nutrition and reproductive health services that are affordable, effective, well managed, of good quality and responsive to clients
? secure sustainable health care financing by mobilising adequate levels of resources,
establishing broad-based risk pooling mechanisms and maintaining effective control over public and private expenditure. [35]
The Bank has begun to use a new type of lending operation involving 'sector-wide approaches' (SWAPS). These can help encourage expenditures on areas which will have the highest impact on the greatest number of people but which have traditionally been neglected – such as improving women’s health or slowing the spread of TB – while constraining more expensive tertiary care that reaches fewer, mostly richer people. Bangladesh, Ghana, Pakistan and Zambia already have SWAPS underway. Bangladesh, for instance, spends US$4 per person per year on health. The country has high infant and maternal mortality rates, 80 per cent of children are malnourished and half the population test positive for TB. As a result of developing a SWAP, the government has given top priority to defining and delivering essential basic services aimed at improving maternal and child health and family planning, and addressing the most pressing communicable diseases. [36] UNICEF and child health
About a third of UNICEF’s programme expenditure is spent on child health, and the agency is probably responsible for saving more infant and child lives than any other. In 1997 UNICEF’s total expenditure was US$919 million, of which 89 per cent (US$818 million) was programme expenditure. While 33 per cent (US$272 million) was spent directly on child health, other elements of UNICEF’s programme expenditure – such as water supplies and sanitation (US$90 million) and nutrition (US$49 million) – have a direct bearing on child health and survival. [37] In the area of health policy UNICEF was one of the first international agencies to shift from sectoral health concerns to a comprehensive approach, called ‘planning for the needs of children’. In the early 1980s UNICEF launched the Child Survival and Development Revolution and pioneered the GOBI approach (Growth monitoring, Oral rehydration, Breastfeeding, Immunisation), later enlarged to GOBI- FFF, to include elements of Family spacing, Female education and Food supplementation. Immunisation became UNICEF’s main focus in the WHO/UNICEF Expanded Programme of Immunisation. Immunisation, along with oral rehydration, accounts for about half of UNICEF’s expenditure on child health activities. UNICEF’s partial abandonment of the global primary health care approach in favour of the selective GOBI approach, with a shortlist of priority interventions, was a source of friction between the agency and WHO. UNICEF was also the initiator of the so-called Bamako Initiative, launched in Bamako, Mali in 1987, which proposed that UNICEF, working with WHO, the World Bank and the African Development Bank, would provide funding for primary level health services and basic drugs in the poorest African countries. The provision of drugs would be dependent on the levying of charges and setting up of revolving funds. The success of the initiative has been mixed, and doubts have been expressed concerning equity and access aspects, in addition to fears that it overemphasises the curative aspects of health care at the expense of preventive health care. But it was a significant step towards the establishment of cost recovery systems, which have become more widespread in the 1990s. In 1995 UNICEF launched a new health policy encouraging privatisation of health services if it improves quality, equity and cost-efficiency (conditions difficult to meet); the establishment of community financing mechanisms; measures to ensure that the poorest people benefit from quality care; and the removal of financial, cultural and geographic barriers. These policies, like the original Bamako Initiative, are closer to those of the World Bank than of WHO. [38] Commercial power
Services and products are increasingly owned and controlled by the commercial sector rather than governments. As well as raising money to finance public-owned health care systems, governments are increasingly working with the private sector to provide health care. Sometimes they give contracts to private companies to build or manage hospitals or clinics. In this situation the government provides all or part of the budget, but must be strong enough to enforce the standards of quality and fairness that
Panos Briefing: DIAGNOSING CHALLENGES 15
companies are contracted to meet, as well as transparent in the process of deciding which companies win contracts. In South Africa the government has found that in some circumstances private companies can run district level hospitals at less cost but with a quality of service similar to the public sector. Many governments want to remain the major provider of health care, while others argue that the private sector has a role, if not the dominant role, in every country. In Ghana the Ministry of Health recognises that the private sector has an important role in the provision of health care and has given contracts to private companies to run some hospitals. It also recognises that market forces will not deliver health care to all and that the private sector is unlikely to want to provide care in rural or urban poor areas with no infrastructure.
The pharmaceuticals industry: promoting health or just their own products?
Drugs are big business. The global pharmaceuticals market is already worth US$300 billion per year, a figure expected to rise to US$400 billion within three years. The 10 largest drugs companies control over a third of this market, several enjoying sales of over US$10 billion a year and profit margins of around 30 per cent. Six are based in the USA, four in Europe. [39] The high profit margins of the pharmaceuticals companies rely on expanding sales worldwide. To this end the companies currently spend a third of all sales revenue on marketing their products – roughly twice what they spend on research and development. Promotional strategies (including gifts or incentives to doctors who prescribe large quantities of particular drugs) can lead in turn to overuse or inappropriate use of medication – sometimes where none was needed at all. In the USA drugs companies are allowed to promote prescription drugs direct to consumers too. As a result of this pressure to maintain sales, there is now in WHO’s words “an inherent conflict of interest between the legitimate business goals of manufacturers and the social, medical and economic needs of providers and the public to select and use drugs in the most rational way”. This is particularly true where drugs companies are the main source of information as to which products are most effective. Even in the United Kingdom, where the medical profession receives more independent, publicly funded information than in many other countries, promotional spending by pharmaceuticals companies is 50 times greater than spending on public information. In order to tackle this problem, the World Health Assembly adopted in 1988 the WHO Ethical Criteria for Medicinal Drug Promotion, dedicated to “the rational use of drugs”. However, many observers complain that these guidelines have been largely disregarded – as has the voluntary Code of Pharmaceutical Practices developed by the industry’s own International Federation of Pharmaceutical Manufacturers’ Associations (IFPMA). While industry spokespersons angrily dismiss charges that they are putting their own profits before people’s genuine health needs, others believe that regulations have made little difference. “The same companies repeat their transgressions again and again,” according to Andrew Herxheimer, coordinator of the International Society of Drug Bulletins. [40] A similar conflict of interests exists in the area of drug research and development. The private sector dominates this field too, spending millions of dollars each year developing new drugs for the mass market. Many feel that the profit imperative of big business ensures that the drugs chosen for development are those most likely to provide a high return on the company’s investment. Drugs for use in the industrialised world – such as Pfizer’s impotence pill Viagra – are therefore favoured over ones for use in the South, where many patients would be unable to pay for them. It is predicted that North and South America, Europe and Japan will continue to account for a full 85 per cent of the global pharmaceuticals market well into the 21st century.
In many developing countries, especially in Africa, private not-for-profit (NFP) health care providers constitute an important part of the health care sector, owning up to half of a country’s hospitals. However, where the right market conditions do exist, private profit-making companies can offer competitive prices to the public. In Jamaica, for example, a private company has been contracted to run a programme selling essential drugs to elderly people at a reduced cost, not only in privately owned pharmacies and hospitals but also at public health care centres. The programme is a success because elderly people often cannot afford the cost of insurance schemes.
16 Panos Briefing: DIAGNOSING CHALLENGES
Other issues that relate to the commercial sector:
? As health becomes a marketplace, suppliers of everything from aspirin and cough medicine to
insurance and doctors begin to compete with each other and use advertising to convince ‘consumers’ to use their product or service. The commercial sector has a major impact on expectations as well as being a prime source of information relating to health.
? The potential spread of water privatisation also means an increased likelihood that the local
supply of clean water is handled by a company rather than a government. This can bring both positive and negative results. [41]
? Big pharmaceutical companies are also criticised for using their power to gain long-term
footholds in developing markets, suppressing cheaper new treatments and creating demand where there is no necessity. This active and lively debate often turns into campaigns for companies and governments to adhere to essential drugs policies and rational prescription. [42]
? The new free health care: in a number of cases international corporations and foundations have
contributed drugs or products free of charge to help in disease eradication. Merck & Co Inc have contributed, via the Jimmy Carter Center, free supplies in perpetuity of ivermectin, one tablet of which taken yearly prevents onchocerciasis (river blindness). SmithKline Beecham has made a US$500 million commitment to WHO of its drug albendazole, used to treat lymphatic filariasis (elephantiasis). American Home Products has provided a non-toxic larvicide, and the DuPont Company has contributed free cloth water filters for the eradication of guinea-worm disease (dracunculiasis). The Japanese Nippon Foundation has enabled WHO to supply blister packs containing the drugs needed for multi-drug therapy (MDT) of TB in sufficient quantities to treat about 800,000 patients per year in some 35 countries. The patients receive them free of charge.
STRATEGIES FOR HEALTH: PAYING THE COSTS OF HEALTH CARE – AND TREATING THE POOR FAIRLY
Most observers agree that the widening gap between rich and poor is the single most important issue affecting health today. And for the world’s poorest communities, the situation continues to deteriorate. Save the Children UK describes investment in health systems, especially in the recurrent costs needed for the maintenance and support of staff, as “inadequate, inefficient and largely ineffective”. It is interesting to note that less than 10 per cent of the US$55 billion spent globally each year on medical research is aimed at health problems affecting 90 per cent of the world’s population. [43]
WHO’s call of ‘Health for All’ has never meant ‘Free Health for All’. The debt crisis, structural adjustment and economic recovery programmes, together with reduction in aid flows, are all associated with a decline in funding for health services. Increasingly, government -financed health services in most developing countries have come to depend on payments by patients. This is especially the case in low- income countries, which devote a smaller proportion of public spending to health than do high-income countries. In low-income countries (excluding China and India) private health expenditure (including direct household expenditure, private insurance, charitable donations and direct service payments by private corporations) is nearly double public health expenditure. [44] In many countries the quality of health care has also declined: outreach services no longer function, drugs are often unavailable and health staff are often unsupervised and sometimes unpaid for long periods of time. Rural populations have faced higher costs for transport to get to hospitals, or in payments to private providers. [45]
It is argued that economic instability, globalisation and the triumph of the free market have meant more pressure to produce profits and a greater move to private health systems, while transnational media and marketing have also increased their influence on the way people conduct their lives. These trends, it is argued, have either resulted in increased inequities and/or increased freedom of choice and availability of services. In most countries of South-East Asia, for instance, 60-75 per cent of total health expenditure occurs in the private sector, and the same is true in many Arab countries. This means that households bear a
Panos Briefing: DIAGNOSING CHALLENGES 17
substantial proportion of health care costs while having little or no protection in the event of major illness or injury. [46] Health in Russia: new system, old challenge
Some while ago, in order to gain popularity, Boris Yeltsin publicly moved from the elite ‘Kremlin’ medical centre to the ordinary city district polyclinic. He was applauded but ran no risk: at that time the health care system guaranteed medical treatment for all people. Since then, many argue, reforms have practically ruined the health care system in Russia. Now Yeltsin is treated in the specially equipped elite Central Clinical Hospital, with the assistance of foreign physicians. 1992 saw the start of economic ‘shock therapy’ and liberal reforms in Russia. The health care system was among the first areas to undergo financial cuts. At the same time a restructuring of the whole health protection system was initiated. The target was to create a compulsory health insurance system. It seems now that the old system has gone but the new system still does not work. Vladimir Usanov, press secretary of the Health Committee of the Russian parliament, announced that it plans to spend less than US$5 billion for medical purposes in 1999. This is about US$32.5 per head. To compare, the USA spends up to US$4,000 per head annually, and Western European countries between US$1,500 and US$2,000. According to WHO estimates, a country needs to spend five per cent of its internal domestic product in order to sustain its health care system. Russia planned to spend a maximum two per cent of its internal domestic product. The share of the 1999 federal budget allocated for medical purposes is four per cent higher than for 1998 in absolute figures, but taking inflation into account it is 2.5 times lower than last year. The introduction of compulsory health insurance systems has changed the way people can receive medical treatment. Gennady Roshchupkin, the representative of the AIDS Info Connection, an organisation disseminating information about AIDS, says: "Compulsory health insurance medicine makes work with infected people more difficult. Insurance companies divided up the Russian territory and if you have insurance from one company, it is possible to receive emergency help while being on another company's territory. However, it is much more difficult to receive regular medical assistance." The insurance system was also seriously jeopardised during the August 1998 financial crisis. According to the rules, insurance companies had to keep the lion’s share of their funds in state short-term bonds. On 17 August these bonds were depreciated and operations with them stopped for an unknown period. In an instant insurance companies, the basis of the new medical system, had lost their capital. To cushion the impact of the arrival of paid medicine, several categories of citizens (pensioners, disabled people and others) were given the right to some free medicines in pharmacies. Originally the list included 385 medicines; recently the list was reduced by 25. To support socially unprotected citizens, the Moscow government increased financing for free medicine by 33 per cent. At the same time, as a result of the crisis the real prices for medicines (especially imported medicines) increased between 100 and 150 per cent. Sergey Podobed, Panos Features, April 1999
The World Bank believes that governments should finance public goods and essential health services and that most low- and middle-income governments are insufficiently involved in these areas. In the Bank’s words, “As in 19th century Europe, when health care was still in a primitive stage of development, direct out-of-pocket health expenditure continues to be a distinctive feature of many low- and middle- income countries. Household payments can account for as much as 80 per cent of total health expenditures because of: nontrivial user fees charged in public facilities (official and unofficial); high copayments required in health insurance schemes; and use of private health services (hospitals, clinics, diagnostics, medicines, and health care providers). This undermines the social protection that could be provided by the HNP sector even in low-income settings.” [47] Primary health care
18 Panos Briefing: DIAGNOSING CHALLENGES
The key to attaining health for all was identified in the Declaration of Alma Ata6 (1978) as the effective delivery of primary health care (PHC). PHC was in turn defined as “essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost the community and country can afford”. The Declaration goes on: “PHC addresses the main health problems in the community, providing promotive [actively promoted], preventive, curative and rehabilitative services. Since these services reflect and evolve from the economic conditions and social values of the country and its communities, they will vary by country and community.” And “since PHC is an integral part both of the country's health system and of overall economic and social development, without which it is bound to fail, it has to be coordinated on a national basis with the other levels of the health system as well as with the other sectors that contribute to a country's total development strategy.” [48] PHC includes: adequate nutrition safe water basic sanitation maternal and child care, including family planning immunisation against the major infectious diseases prevention and control of locally endemic diseases education concerning prevailing health problems and the methods of preventing and controlling them appropriate treatment for common diseases and injuries, including the provision of essential drugs. How countries finance health care
In the last two decades public spending on health has been cut so drastically that many governments have had to introduce new policies to raise more money for public health care. In countries where there has never been an effective free public health care system, people are used to buying drugs and treatment from unregulated private doctors and chemists. The difference today is that more public health care systems are introducing formal charges. There are a number of ways that governments can raise money to pay for public health care systems including the introduction of user fees and insurance schemes.
Aid
Official development assistance (ODA) from the rich countries has fallen overall in the last 10 years. ODA per head of donor country has fallen overall from US$77 in 1985/86 to US$71 10 years later, with the sharpest falls in USA and Canada (US$56 to US$34), and only the Nordic countries showing an increase (from US$202 to US$218). [49] The proportion of bilateral (as opposed to multilateral) aid that goes to the health and population sector varies from year to year and between donors – on average, between three per cent and nearly 20 per cent. Total bilateral aid spent on the health and population sector in 1996 was over US$3 billion, but aid levels have since dropped off. [50] As well as coping with their own economic problems, poor countries have had to become more self-sufficient in the provision of health care and other social services.
? User fees Patients using public facilities may be asked to pay for part or all of their treatment and medicine, either when they need it or at a later date. These charges are called ‘user fees’ and have been introduced to a greater or lesser extent in many countries, rich and poor. They were popular in the 1980s because governments thought they would be simple to administer and that the money generated would raise standards and increase health care facilities. However, user fees have proved problematic, mainly because poor people cannot afford to pay them. In Nigeria, Kenya and Ghana, for example, within one or two weeks of introducing charges hospitals and
6 Alma Ata has changed its name to Almaty since the end of the Soviet Union.
Panos Briefing: DIAGNOSING CHALLENGES 19
clinics reported a dramatic 50 per cent decline in use. Indeed, in Nigeria the rise in the maternal death rate is partly blamed on the systematic introduction of user fees for emergency admissions. In Zimbabwe it was found that because charges were introduced at every stage of the health system except for emergency care, people waited until they were very ill and then went to hospital. Instead of being simple, then, user fees need complicated exemption mechanisms so that vulnerable sections of society such as the poor, those with long-term or infectious diseases, children and pregnant mothers do not stay away from public health care. User fees may be successful in places where a local hospital or community decides who and what should be charged, and is allowed to decide locally how to spend it. As Andrew Creese, a leading researcher at WHO, says, “User fees are here to stay but their role needs to be strictly controlled in order to make sure that the health objectives of government and of people aren’t contradicted by the financial barrier.” The main aim of user fees is to raise money. However, if large sections of society are exempt from paying and others stay away because they do not qualify for exemption but cannot afford to pay, the revenue will not cover costs and health care will remain underfunded.
Essential drugs In 1975 WHO recognised the urgent problem of a lack of essential drugs in many countries, and provided the impetus for the first WHO Model List of Essential Drugs, published in 1977. Since that time the concept of essential drugs has been widely applied. It has provided a basis not only for drug procurement at national level but also for establishing drug requirements at various levels within the health care system. Essential drugs are those that satisfy the health care needs of the majority of the population and should therefore be available at all times in adequate amounts and in the appropriate dosage forms. This definition remains as valid today as it was 20 years ago. Over those 20 years 166 new drugs have been added to the list while 68 drugs have been deleted, resulting in an overall increase from the original 208 to 306 drugs. [51] There has been great progress, but serious problems remain due to overprescription, inappropriate prescription and the quality of some of these essential drugs manufactured under less than optimal conditions.
? Insurance schemes There are many different types of insurance schemes, but the general principle is that people contribute a small amount of money regularly when they are well, and when they are ill or need treatment or drugs they do not have to pay a large bill. Sometimes governments run compulsory schemes, and sometimes communities organise voluntary schemes. Studies have shown that the population is more satisfied in countries with government-run insurance schemes than in countries with user fees. People prefer insurance schemes because they spread the cost of health care over a period of time and spread the risks associated with unexpected ill health.
Governments like insurance schemes because they get a regular income and can plan health care spending. They also get credit for improved health care quality, without spending more money. In Thailand, paying into the National Social Security Scheme is compulsory for companies employing more than 10 people. It is estimated that, as a result of the revenue, the government will be able to provide a package of health care to 100 per cent of the population within 10 years. However there are problems. First of all, to make compulsory insurance schemes work, countries need a reasonably large part of the population in formal employment, because it is more efficient to collect money from large employers or formal employers than it is from individuals. So governments in countries where there are large rural poor populations will not be able to collect enough money.
MUELLER HINTON AGAR (7101) Intended Use Mueller Hinton Agar is used in antimicrobial susceptibility testing by the disk diffusion method. This formula conforms to National Committee for Clinical Laboratory Standards (NCCLS).1 Product Summary and Explanation Mueller Hinton Agar is based on the formula recommended by Mueller and Hinton2 for the primary isolation of Neisseria species . Muelle
Date: 26/9/2012 Imtiaz Cajee - Biography: I was born in August 1966 at my maternal grand-parents’ residence. As per Indian tradition, a first time mother is expected to return to her parents’ home for maternity, thus I was born in Roodepoort on the West Rand. However, forty days after my birth my mother returned to her matrimonial home in Standerton, the Eastern Transvaal (now Mpumalan