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Archive for the ‘Global Health’ Category

vitamin-d

By Dr Amrita Jesurasa

Ever since our most ancient ancestors left Africa to populate the rest of the world the appearance of their descendants has changed.

Height, facial features, hair type, body size and shape, and invisible genes that can protect from or predispose to disease have developed and differentiated racial groups. But the most profound (and superficial) change has to be in the colour of our skin as people migrated and settled around the world.

Skin colour forms a strong part of our physical and social identity, at times unifying people but more distressingly, causing division. The legacy of this evolutionary change has left its scars on human history in the last few hundred years and continues to cause tension in the present. Ethnic inequalities in health are well recognised and yet we perhaps fail to recognise the true message from history: why did skin colour change?

Current theory suggests that this phenomenon arose as a result of our need for vitamin D. As our early ancestors migrated to northern latitudes, they experienced the severe consequences of vitamin D deficiency. These included bone deformities that affected their ability to walk, breathe and – crucially – to give birth (the latter the result of changes to the female pelvis).

In Europe, natural selection began to favour lighter skin that allowed ultraviolet radiation to be more readily absorbed, vitamin D to be synthesised and ultimately our species to survive in Europe and other northern climes.

Fast-forward to the 21st century and rapid technological advances have transformed the way we live. Some of these developments, including air travel, have facilitated evolutionary shortcuts, enabling the humans of today to live in environments that are totally different to that of even the previous generation. But other advances have affected the behaviour of us all by encouraging a more indoor lifestyle than that of our ancestors, creating fear of the adverse effects of the sun and altering our dietary habits.

This perfect storm has allowed vitamin D deficiency to become a population-wide issue, but one which has the greatest impact on those with darker skin. The irony is that this disproportionate effect within the population marginalises the issue of vitamin D deficiency, creating an ethnicity-related health inequality.

To raise the profile of vitamin D deficiency, universal issues need to be addressed and universal solutions provided. While improving access to vitamin D supplements must be part of this strategy, there are worrying common pitfalls associated with an exclusively medical approach.

Instead, a simple message may resonate more with both the public and policy-makers. This could mean promoting a basic principle that “like plants, we need food, water and sunshine to thrive”. With a more holistic approach we can relate prevention of vitamin D deficiency to other important and well-recognised public health concerns, thereby raising the priority of this historically important issue.

  • Dr Jesurasa is a Specialty Registrar in Public Health Medicine/ Honorary Clinical Lecturer in Public Health, University of Sheffield

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  • by Professor Sue Atkinson
  • FPH Health and Sustainability SIG

I am in Paris – for COP 21.

COP 21 (21st Conference of the Parties) of the UN Framework on Climate Change (UNFCCC) are the negotiations between the 195 countries attending, to make a deal to curb emissions and keep global warming below 2°C.

I am not at the main COP negotiations in Le Bourget but at the Global Climate and Health Alliance (GCHA) Health Summit and other parallel health meetings.

Unfortunately the timing of the Summit means I missed the FPH ‘Sustainable development and health’ SIG meeting in Nottingham on 4th December which followed the instigation of the SIG at the Faculty Conference in June.

People are starting to recognise the importance of health, climate change and sustainability and accepting what the Lancet commission identified in 2009, that ‘Climate Change (CC) could be the biggest global threat of the 21st Century’.

The Health Summit was the buzziest conference in ages. Over 500 people and oversubscribed, it was chaired (amusingly and with clear insights) by John Vidal (Environment Editor for the Guardian) and attendees included Health Ministers, the Deputy Mayor of Paris, WHO and GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit, the German equivalent of DFID), who both supported the conference (thank you), representatives of health and climate change groups and alliances from across the globe.

The presentations, parallel sessions and panel discussions were informative, interesting, lively, amusing, challenging and enjoyable with many interesting discussions taking place around the edges with an exchange of shared ideas and experiences to take back home.

Some of the snippets I picked up included:

  • Wales has a ‘Wellbeing of Future Generations Act’ and a commissioner to make things happen. It is one of only two countries with sustainability in its constitution.
  • California showed the importance of political leadership in Senator Kevin de Leon, who is introducing a variety of relevant bills and noted that air pollution is not just a public health issue but also a political and civil and human rights issue because of its inequities.
  • Air pollution is worst in poor areas and African American children have a 50% higher risk of being hospitalized and Latino children a 40% higher risk of death from asthma.
  • Health care systems are part of the problem. In USA they account for 8% of emissions. Hospitals across the globe are increasingly taking action to reduce energy usage (and costs) but much more needs to be done.
  • Reducing red meat consumption (and its procurement by hospitals and institutions) is good for health and the planet. The Buddhist Dalin Tzu Chi Hospital in Taiwan has moved to a plant based diet to improve health and the environment.
  • Cities are increasingly taking action on reducing emissions where states and countries are unable to reach agreements. In Paris over 100 mayors came together with the Paris Mayor Anne Hidalgo calling for them to unite and work together to mitigate climate change. London has reduced its carbon emissions by 14% since 2008 but I am sure Bristol and elsewhere may be doing better.
  • The Paris Deputy Mayor – Bernard Jornier – clearly understands well the relationships between health, climate change and inequalities.
  • Goldman Sachs decreed in September 2015 that “Coal is in terminal decline”.
  • Using fossil fuels means there are more than seven million extra deaths per year.
  • The co-benefits of addressing health and climate change together are clear – e.g. increasing active travel – walking and cycling – is good for your health and good for the planet.

And much much more …

We have come a long way since COP15 in Copenhagen in 2009, when those of us interested in health and climate change could fit around one small coffee table and it now feels as though the importance of health in the climate change negotiations is starting to make its mark.

CC science is real but it is often difficult to get our heads round and some of the environmental and other impacts seem like a long way off and we know that politicians and all of us (including teenagers) find it hard to recognise and take action on threats that are in the more distant future.

Health brings home the real story of the impact of climate change – imperative, immediate and life changing.

Families displaced because of floods and typhoons, children starving as a result of drought resulting in failing crops, older people dying in heat-waves, even as recently and as nearby as 15,000 deaths in France in 2003.

With 500 people still dying annually of Malaria, the 2.5 million people suffering from the disease could increase again to over four million with the spread of mosquitos due to climate change.People are sick and dying from lack of clean water as a result of either drought or destruction of infrastructure by severe storms and tsunamis.

Closer to home, just this weekend the floods in Cumbria have caused distress and destruction as well as the financial costs of these storms.  And of course the important links between climate change, disasters and water shortages, refugees and terrorism.

IMG_0867

Recent floods in the north of England (like York City Centre, pictured) have brought home the reality of climate change to the UK

The latest Lancet Commission (2015) identified that ‘Tackling CC could be the greatest health opportunity of the 21st century’.

The health summit felt both daunting and optimistic. We must act now.
The spoken word poet – Sophia Walker – captured it in her piece written for the Health Summit as “…we aren’t just talking about the weather” and suggested that nine billion people on the planet could work ‘miracles’ if they all did their bit.

We in public health must do ours, not just individually but in whatever ways we can through our building it into our daily work, e.g. identifying the co-benefits of improving health and the environment. It seems that at last the penny may be dropping that climate change and health are inexplicably linked.  What’s good for health is good for the planet.

References
Lancet Commission. 2009. “Managing the health effects of climate change”. Lancet and UCL Institute for Global Health Commission. April 2009.

Lancet Commission.2015. “Health and Climate Change: policy responses to protect public health” Lancet. June 2015.

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Health protection is a global issue – and there are lessons to learn and share from all incidents, wherever they occur. That was the message from the global health protection workshop at FPH’s annual conference in Cardiff on 19 July.

Delegates heard how the Health Protection Agency (HPA) has built a worldwide reputation for its work, in part because the global nature of health protection means that planning needs to go beyond national borders. The World Health Organisation has 10 collaborating centres in the UK, while the HPA has sent teams on international secondments to South Africa, India and Australia. One of the speakers talked about how the HPA had been involved in giving high-level advice to government agencies after the earthquake and nuclear power failure in Fukushima.

Closer to home, the delegates heard from Dr Sarah Finlay about how she and her colleagues from the charity Festival Medical Services dealt with an outbreak of H1N1 at the Glastonbury festival in 2009. The festival had a population of 135,000 ticket holders, and 35,000 artists and staff, many of whom were the kind of healthy, young people most likely to contract the virus. The infrastructure of the event meant that living conditions were poor. People’s behaviour, as would be expected at a music festival, was not typical. The combined circumstances meant that it was easy for communicable diseases to transfer.

Risk was mitigated by following the protocols for managing H1N1, having immediate access to antiviral stocks and good transport to the onsite medical facilities, despite the mud. Good advice was given to festival goers before, during and after the festival, stressing the ‘Catch It. Kill It. Bin It.’ message and the importance of using the hand gels that were available across the site.

Information was circulated via the Glastonbury festival website, music press and general media. Just as the HPA team working on Fukushima had regular updates throughout each day to share information, so the Glastonbury health team relied on situation updates three times each day.

There were six cases of swine ‘flu at Glastonbury in 2009, all of which were confirmed by laboratory test results and each of whom left the site for further treatment. One of these cases was a 16-year old girl who had been sharing a tepee with 12 other people, each of whom had to be tracked down in the chaos of festival life.

In the circumstances, the team felt the outbreak had been well managed, and the lessons learnt from this example of mass gathering medicine were shared with the organisers of the Berlin World Athletics and the Hadj.

Dr Finlay summed up by saying that the success of the festival’s approach to H1N1 was due to having a well thought-through approach, early detection, awareness of the issue and by sharing the lessons learnt.

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Gelada baboons
Move along there: Gelada baboons

By Dr Jackie Spiby

We are still here in Addis Ababa. We have survived the rainy season and the sky is blue again.

Many of you will have seen the news about the famine in the south east of Ethiopia where it borders Sudan and Kenya. Sitting in Addis, it is as difficult to understand the whole story here as it is at home. We pick up the news and some of the debate from the BBC when the internet is working. When we travelled to the south recently, everywhere looked really fertile and verdant as it was just after the rains. But at work I do hear about problems with food-aid delivery and families that can’t feed their children.

As recipients of Global Fund money, my organisation has to have pristine financial arrangements. The management audit letter we received recently could have been one found in any PCT. By the way do PCTs still exist? The only difference was that they were querying why a goat had been bought. I recently found myself on an appointments committee for an internal auditor – something I have managed to avoid in the UK. Amazingly my interviewing instincts rose to the fore. I was delighted that my first choice was the same as the finance director’s. It did help that the interviews were in English. So, another country another culture but actually much is the same.

We took a few days off to travel north to trek in the Simien mountains. Ethiopia lies in the East African Rift Valley so much of the north and central areas are hilly in stark contrast to the desert areas bordering Sudan and Somalia. We were walking at three to four thousand metres and were surprised that it was still scattered with villages, and, wherever we went, small children were keeping an eye on the cattle and sheep. They said they went to school but I wasn’t really convinced.

Walking into a BBC crew filming the gelada baboons was quite surreal. We had just stopped to put on our macks as it was raining when we heard a very posh voice asking if we could move please as they were trying to film the baboons running down that particular hill. If you ever see a documentary on these baboons in the Simiens we were there, and we saw the locals on the other side of the hill ‘encouraging’ the baboons to move.

One of my areas of work is developing a volunteers’ strategy. Not international volunteers but local volunteers. PLHIV associations are similar to charitable organisations in the UK so their boards are all volunteers and most of the programmes workers are also volunteers. However they do get expenses. The latter get 206 birr a month for travel. That is £7.60. In the focus groups they tell me they do it for humanitarian reasons. However when I asked if they also had paid work, they said it was hard to get work as they were HIV+. So what is a volunteer? I really enjoy the focus groups: however formal I try to make them, we have to have a coffee ceremony, and they usually end with music and dancing. The highlight last week was meeting a 22-year-old woman who finished school at grade 6 but was carrying a beautiful, chubby smiling baby who everyone proudly told me was HIV negative.

Am I making any difference? Not an unusual question for anyone in public health. I’ve been asking it my entire career. I’d better get back to work and make sure that I am.

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Monkey drinks Cola in Addis Ababa

A monkey drinks cola in Addis Ababa

By Dr Jackie Spiby

Hello from Addis Ababa.

It is a warm and sunny morning. By lunchtime it will be hot, but not too hot as we are 2,400m high and there is usually a breeze. When I go out it will be dusty, smelly and, if I noticed it anymore, the air will be polluted. This is mainly due to the huge volume of taxis, buses and lorries, most of which are ancient and belch out dark smoke which hangs around the city. I walk everywhere or go on a crowded, filthy line-taxi; so am I green? I came on a plane so blew my green travel limit and I use plastic water bottles – well I have to as I can’t drink the water but I do boil and filter so I reuse the bottles. Plastic bottles are everywhere.

I am a VSO volunteer and working in a local NGO (though virtually totally funded by external donors).  After 32 years in the NHS it was time for a change. For me that is, not the NHS because, as we know, that happens all the time. It took some time getting through the VSO process especially as my husband is here as an accompanying partner. Attending the assessment day together was a new experience. Try doing a group activity (you know one of those management games) with your partner. VSO then sends your CV out to local VSO programmes for them to see if they want you. You don’t get a choice; you just get to say yes or no to an offer. The first one was way outside of my experience, the next we had to go in five weeks; the next wasn’t viable for my husband.  Despair; but finally Ethiopia came up, an HIV organisation at national level and a country of spectacular scenery with mountains. It wasn’t the Far East which was my preference but we are here and at some point we will get to the mountains.

I am working in an organisation called the Network of Networks of People Living with HIV (PLHIV) or NEP+ for short. The HIV epidemic in Africa is heterosexual. When it emerged in the early ’90s there were no HIV services.  PLHIV started to form groups to help themselves and a few very brave souls (many of whom are dead now) came out and said that they were positive and demanded acceptance and support. My organisation arose out of the formation of these groups. There are nine regional networks, two city networks and three national ones with some 400 local networks. Civil engagement is one area of activity but primarily they are organisations that help provide prevention, treatment and care as well as projects to increase skills and employability. However, that is changing as the government starts to provide a health service. So, as ever, an organisation in change.  To think I didn’t know about the Global Fund six months ago and now I can quote the rules chapter and verse.

HIV is about poverty here, the treatment may be free but food and shelter are not and many PLHIV can’t afford the basics. Nor is the treatment for opportunistic infections free, so TB and malaria are the main killers.

So here I am. NEP+ is some 30 people – all Ethiopian, except me. It is primarily male, except me. Originally the organisation’s staff were PLHIV. As the donors started to require financial statements, governance and the like, the professionals arrived. Now the balance has changed. Is that right? Should there be positive discrimination toward PLHIVs? Can someone who is sero-negative really know or understand what it is like to be positive or even what it is like to live in a family affected by HIV? All questions that I remember discussing in the ’80s when working at the King’s Fund. All answers gratefully received.

Now more and more HIV infected people are getting treatment and living. But there are still 14,000 HIV-positive babies born a year. In the UK and US the numbers are way below a hundred. Why? Many women don’t use antenatal services or won’t get tested. Why? Lots of reasons but for some their husbands won’t let them, accessing services is too difficult or their families tell them to use traditional services. Even if a woman is diagnosed, follow up is logistically difficult and complying to the full treatment and breast feeding regime complex in a developed country, let alone a rural village with no water or electricity. The net result is a take up of about 12% of prevention-of-mother-to-child-transmission treatment. One of the worst levels in Africa. Tragedy. All those avoidable deaths and HIV+ kids, let alone the number of women who don’t get treatment. The number of orphans is horrendous. The international, political voice on this one just isn’t there.

VSO volunteers work in local organisations and are paid a stipend which is equivalent to local salaries. So I am paid the same as our drivers, but I do get accommodation. That means we live and work in the community much more than the majority of ex-pats (called Farangis here) who work for international NGOS, the private sector or embassies. I think I am going native as I am starting to really empathise with my colleagues as we try to use the EU process for submitting a bid on a slow dial-up computer link or listen to a well-meaning expert from a big international NGO tell us we must do more on civil rights. Of course we should but at the risk of immediate shut down. There is a law forbidding NGOS to speak about civil rights. A classic case of can you do more inside the system or outside.  Only here is it outside the system but in the country or outside internationally? Oh I have a lot of learning to do.

Public health issues are everywhere including my diet. My hips are vanishing as my diet has drastically changed to minimal dairy with fruit, veg and carbs instead. Having had a fractured hip a couple of years ago I am a bit concerned about my calcium intake. I was taking supplements in the UK but stopped when there was a report on increased incidence of heart disease. I am eating injera, the local, unique dough that is eaten with everything. It looks like a chamois leather but isn’t too bad and is suppose to have some calcium in it.  Should I get Steve (my husband) to bring some calcium tablets back when he visits the UK in the summer?

Must go as visiting a local community project for orphans. More to come.

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By Dr Mahmood Adil, a member of International and Policy committees of the FPH and Co-chair of North to North Health Partnership, a charity to build public health leadership capacity in developing countries

Pakistan is facing the worst floods in 80 years. The natural disaster, brought on by unusually strong monsoon rains, has killed over 1600 people and left two million homeless so far. Floodwaters have roared down from the northwest to the agricultural heartland of Punjab and on to southern Sindh along a trail more than 600 miles long, equating almost to the size of Britain and afflicting 14 million people on its way – the toll is still rising every minute because monsoon weather is not over yet. The UN has described it as the biggest natural disaster with health and economic ramifications surpassing the South east Tsunami, Haiti earthquake and other recent catastrophes faced by any country in the world.

Drowning, accidents secondary to evacuation, water-borne illness, loss of health and non-health infrastructures leading to inadequate basic health care and increased risk of food shortages are some of the immediate challenges faced by those 14 million people all across the country. Therefore, the immediate objectives are to evacuate the trapped and vulnerable (while communication and transport infrastructure is almost totally washed away by the flood), provide shelter, food and essential medical care for the displaced before thinking of any long term solutions. The government, in particular its armed forces, international agencies and communities themselves are trying to achieve those objectives with remarkable courage – but the challenge to save lives and to mitigate wider public health impact, is a mammoth task for any country in this overwhelming situation. It is a huge undertaking for the Pakistani government with help from the global community. The British public has reacted to the humanitarian crisis call and donated generously to the DEC (Disasters Emergency Committee) and other charities working on the ground.

Recently, we have seen the heartbreaking scenes and post-disaster public health challenges in Haiti, Italy and China and not too long ago South East Tsunami and Pakistan Earthquake. These international emergencies have immediate as well as long-term consequences on those unfortunate communities. In this case, once the monsoon weather is calmed down and disaster relief operation is over, the recovery phase will start to deal with long-term challenges. This may include building the infrastructure and settling those 14 million back to their own lands while meeting their physical, social and mental health needs on a continuous basis. Therefore, such national disasters pose challenges to public health community across the globe to find ways to deal with not only the immediate but most importantly long term consequences effectively.

Have we learnt any lessons from such situations in the UK and applied them to help nations around the globe so far?

We, in the north west of UK, last year saw the Cumbria floods and put efforts in place to deal with it effectively.  It was not on the scale of Pakistan’s current floods but some key lessons have been learned on three fronts to mitigate the public health impact in such situations. First, a strong public health system is pivotal and you need to develop your emergency preparedness system on solid grounds much before the floods hit you. Second, a well trained public health workforce (with a skills mix) is fundamental to support your system and put your plan into action at the time of need. Third, at times, things do not go according to the plan or they achieve much more than what you expected – but in either case, the knowledge must be captured and shared in a systematic manner, rather than becoming tacit. There might be similar lessons learned from other recent floods in the UK e.g. Gloucestershire.

FPH and other relevant organisations can pave the way on all those three fronts, nationally and internationally. These lessons should be incorporated in our efforts to support Pakistan in dealing with its emergency, in particular during the recovery phase. Traditionally, Pakistan has a good secondary care system but its public health capacity on the ground may not be adequate, to help the communities to deal with long term health consequences in a holistic manner. In addition, health emergency preparedness skills are highly needed if future catastrophes are to be mitigated efficiently.

No doubt, the immediate help through donations is required and a number of doctors from the UK have also gone to Pakistan to help with immediate healthcare needs – but these floods will leave a long lasting impact on health, social and economic infrastructure of the country. We need to generate new innovative programmes and to strengthen any existing public health projects that were already taking place to build the relevant public health capacity in Pakistan.

Therefore, the question is – are we ready to save lives with conviction, in natural disasters hitting Pakistan or any other part of the world, by dealing with long term health consequences? If so, then UK public health community must harness its prowess and act accordingly. As a first step, we all should share any innovative ideas and examples of existing public health projects happening in Pakistan to develop an insight before the recovery phase starts. Let us hear about them.

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Afternoon parallel session at the Faculty of Public Health annual conference, on Wednesday 7 July.

Chaired by Susan Elden (Public Health Advisor at the Department of International Development) and panel members Clive Needle (Director and EU Policy Advisor at EuroHealthnet) and Helmut Brand (Professor of European Public Health at Maastricht University).

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