Archive for the ‘Global Health’ Category

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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19 June 2010

In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.

Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.

But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.

He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.

Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.

Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.

The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.

But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.

As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.

What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.

Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.

This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.

As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.

As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.

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