Global Health Challenges –Course diary
I had a rather unusual holiday this August. I enrolled at the International Health Summer School at Copenhagen University and learned a bit about issues surrounding health. It was an intensive two-week course, and quite a cultural change for me, the cellular biologist whose thoughts tend to revolve around cancer cell lines and proteins, but it was really great fun and definitely worth the effort. I decided to take the course for several reasons. First, I wanted to dip a toe in laboratory-free waters and see whether I would come out alive, or whether I would turn into stone! I also wanted to force my thoughts out of their usual bubble and develop a different perspective on things. Last but not least, I hoped the course would introduce me to debates on health policy and the considerations of policy making. Well, I definitely did not turn into stone...and had a ball! I met some fantastic people and heard some great stories. We learned about various healthrelated topics, were given some basic grounding in economics and were pushed to debate several policies. I kept a diary of my favourite topics, although I did skip a few as it would have taken way too much time. Enjoy!
Course programme Date/Time (facilitator) Theme
16/8 Laura 17/8 Laura (Cecilia) (Olivia) Global Health Poverty and Health
9.00 – 11.45 Intro-lunch from 11-12.15
Intro to Global Child Health Health and (Freddy MDG Karup) (Maximilian de Courten)
12.15 – 15.00
NCD and transition in health (Maximilian de Courten)
Evening
Time Schedule Theme
23/8 Frederikke (Olivia) Emergencies and Health
9.00 – 11.45 Health workers and violent conflicts (Jens Tingleff)
18/8 Frederikke (Laura) The global society and Health Health and Human Rights (Christina Johnsson)
Communicable Global Health: Diseases Partners and (Ib Bygbjerg) Politics (Ruth Bonita and Robert Beaglehole) Opportunity Fair - CSS
24/8 Haifaa (Laura)
25/8 Cecilia (Frederikke)
19/8 Cecilia (Haifaa) Migration and Mental Health
20/8 Johan (Cecilia) Reproductive Health
Migration and health in global context (Thomas G. Hansen – DIIS)
Sexual and reproductive health (Stine Lund)
Migration and Mental Health (Maureen Wilkinson)
Social Capital, Social Justice and Health (Lenore Manderson)
Food for Thoughts
Food for Thoughts
26/8 Olivia (Johan)
Global Health Systems
Globalisation Global and Health Development Strategies Health Systems The state of The global health and Globalization world worker crisis (Stine Lund and development (Mike Rowson) Helene Probst) (Mike Rowson)
27/8 Johan (Sandra) Panel Discussion ‘Humanitarian Aid and the Military’ Speakers: Jesper Jørgensen Birgitte Ebbesen Jens Tingleff Knud Vilby Sebastian Wiberg
12.15 – 15.00
Disasters and complex emergencies (Siri Tellier)
Medicines and globalisation – Ess. Drugs (Hans Hogerzeil)
Globalisation and Health (Mike Rowson)
Development Closure of the Strategies/respon seminar and ses to poverty evaluation (Christian Friis Bach)
Evening
Documentary Afghanistan
Food for Thoughts
Food for Thoughts
Food For Thoughts
1. Introduction 1.1 Globalisation “Globalisation is the progressive integration of economies and societies. It is driven by new technologies, new economic relationships, and a wide range of national and international policies” (modified from ILO, 2004). Globalisation can be viewed as a number of processes that decrease national, cultural and economic borders, so the world progressively becomes one single entity. Such processes include increasingly advances communication and transport technologies, increased movement of people, mass migration, increased economic interactions and international trade and business agreements that allowed economic growth beyond national boundaries. Globalisation has had many positive effects including spread of knowledge, international cooperation , economic growth and improved health in many countries .On the other hand, its negative consequences include increased poverty as a result of job losses in traditional industries or craft, environmental degradation and social inequality. Globalisation is also blamed for the spread of unhealthy consumer products and unhealthy lifestyle, and for loss of cultural diversity. Globalisation and work A global job market allows for increased job opportunities, increased experience through migrant workers, cheaper food and consumer goods through a competitive market…but, Global competition, moving of production to countries with cheaper production costs, pressure for increased productivity and unstable contract conditions negatively affect job security, social security, cause worker stress. Also consider problems of “Brain drain” and poor working conditions and abuse of some migrant workers. Cultural globalisation Positive effects include increased awareness and support for universal values such as human rights and gender equality (at least in some parts of the world!!). Also, improved communication and information technology allowed spread of knowledge and awareness of other cultures. Increased travel is also a consequence of cheaper flights. Unfortunately, these are also accompanied by increased marketing and consumption of tobacco, alcohol and increased traffic and consumption of drugs. Increased availability of fatty sugary foods, computer games and motor cars also contributed to a “sedentary
lifestyle”, obesity and chronic diseases .In some cases, international trade rules have made it difficult for governments to limit the import, sale and advertising for products that are detrimental to health. Globalisation and the environment A “global lifestyle” entails more energy consumption, more pollution from industry and motor vehicles, pollution of air, land and water, depletion of non-renewable resources and disturbance of ecological balance, climate change.
Globalisation is a complex concept with positive and negative effects. It is important to consider the impact of globalisation when implementing policies to avoid a situation where the rich get richer, and the poor get poorer and sicker. Globalisation based on concern for human well-being has the potential to reduce poverty and improve the life of millions of people. An increasing number of international agreements and discussions have aimed to limit or prevent the adverse effects of globalisation on public health. These include (but are not limited to) the Millennium Development Goals, the WHO commission on Social Determinants of Health, and the WHO Framework Convention on Tobacco control. Other important steps include increasing awareness and consumer pressure to encourage corporate social responsibility, increasing awareness of sustainable development, of the negative effect of agricultural subsidy on low income countries and the abolition of such subsidies, health impact assessment of major investments and continued monitoring and research on the public health effects of globalisation. Scandinavian Journal of Public Health (2007) 35, 3-67.
1.2 Global Health and the Millennium Development Goals Global health refers to health issues that impact on large regions in the world.
Millennium Development Goals (MDGs) The United Nations Millennium Development Goals are eight goals that all 191 UN member states have agreed to try to achieve by the year 2015. The United Nations Millennium Declaration, signed in September 2000 commits world leaders to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women. The eight MDGs are: 1. To eradicate extreme poverty and hunger The aim is to reduce by half the proportion of people suffering from hunger, and those living on less than a dollar a day (i.e.in absolute poverty). 2. To achieve universal primary education This aims to ensure that all boys and girls complete a full course of primary schooling. 3.
To promote gender equality and empower women
To initially eliminate gender disparity in primary and secondary school, then at all levels. 4. To reduce child mortality To reduce by two thirds the mortality rate among children under five (used as a health indicator). 5. To improve maternal health Reduce by 75% the maternal mortality ratio. 6. To combat HIV/AIDS, malaria, and other diseases 7. To ensure environmental sustainability 8. To develop a global partnership for development
Individual countries monitor their own development goals, and the targets are set against base values from 1990. Thus, the MDGs are a set of development goals over a period of 25 years. The MDG approach does not set a fixed goal, but a rate of development. http://unstats.un.org/unsd/mdg/Default.aspx Most regions of the world are making some level of progress towards the millennium goals. Some more than others. However, that is definitely not the case in sub-Saharan Africa, where it is already clear that the MDGs will not be achieved by 2015. For example, as regards the reduction of mortality in children under the age of 5,current progress will reach the set goal 30 years late, i.e. in 2045!
WHO`s comment on the MDGs: “The MDGs are inter-dependent. Three MDGs directly focus on health but all the others influence health too, and are influenced by it. For example, better health enables children to learn and adults to earn. Gender equality is essential to the achievement of better health. Reducing poverty, hunger and environmental degradation positively influences, but also depends on, better health.� WHO.
1.3 Non communicable diseases Although the MDGs focus on several aspects of health, they completely neglect an important category of diseases: the non communicable or chronic diseases. These are diseases that cannot be transmitted from one person to another via infectious agents, and include cardiovascular disease, cancer and diabetes. When MDGs were discussed in 1999, chronic diseases were not on the agenda. They also suffered from the myths that they are solely lifestyle-related, and more predominant in rich countries. In fact, chronic diseases are the most important cause of death in the world, mostly in poor and middle income countries. Only in sub-Saharan Africa do infectious and parasitic diseases cause more deaths than chronic disease.
1. Deaths resulting from non‐communicable diseases in 2002 accounted for 59% of total deaths. Territories are sized in proportion to the absolute number of deaths caused by non communicable diseases. From www.worldmapper.org
2. Deaths resulting from infectious diseases in 2002 accounted for 19% of total deaths. Territories are sized in proportion to the absolute number of deaths caused by infectious disease From www.worldmapper.org
Non communicable diseases are getting more attention from WHO now and next year, the first UN conference on chronic disease will take place. The top risk factors for these diseases are totally preventable and so policies that will focus on addressing these factors will be needed and will have the potential to dramatically reduce the global disease burden.
Cardiovascular Cancer Tobacco disease Unhealthy diet
Lack of physical activity
Diabetes
45% global mortality!
2. Poverty and Health Child Health If you are poor, you cannot eat properly and you do not have access to proper healthcare so you become sick. If you are sick, you cannot work to improve your situation. Not exactly rocket science. Some countries have too much, while others have nothing! We spent the whole morning looking at pictures of very sick and undernourished African kids. That was more than enough!
3. Picture from http://cozay1.blogspot.com/2008/04/poverty‐in‐africa.html
3. Health and human rights 3.1 The Universal Declaration on Human Rights The Universal Declaration of Human Rights dates from 1948. It was based on the notion that respect of the dignity and equality of human beings is essential to freedom and peace in the world. Disregard for such basic human rights underlies rebellious acts against oppression, violence and miserable living conditions. Basically, the main purpose of the Declaration of Human Rights was to preserve peace and freedom for all human beings. It states that all people are born free and equal in dignity and rights. The declaration as such is not a legally binding document. It is a mere declaration by politicians. It only become legally binding when a convention is signed about how the aims of the declaration will be integrated into the individual countries` laws and constitution. Agreement on the declaration is only the first step. After adopting the declaration on human rights in 1948 it was agreed that a legally binding document on human rights should be developed. Cold war pressures led to the development of two separate conventions: 1-The International Convention on Political and Civil Rights (ICPCR) Followed by the West, this focused on what is also referred to as freedom rights and its basis is that governments cannot interfere with citizens` choices provided they are within the law. Examples are the freedom of speech, of opinion, religion, the right to vote, etc. 2- The International Convention on Social Economic and Cultural Rights (ICSER) Eastern countries focused more on the rights to education, social security and healthcare. These are also referred to as positive rights since, in contrast to freedom rights, they are about what governments SHOULD do for their citizens. Nordic countries also adopted this convention. Of course there was a lot of disagreement and conflict between the two sides on what was the fairest and best convention. This lasted until the end of the cold war, and the two conventions were put together in the early nineties. Today, there are seven international UN conventions that regulate the Human Rights (HR) system. These relate to:
Civil and political rights (It took 17 years to reach a consensus on the text for the convention, and a further 10 before it as ratified by enough countries to become a universal convention!) Social and economic rights Elimination of all forms of discrimination against women (1979) Rights of the child (1989) Torture Racial discrimination Disability (The most recent one. Note that the right to equal treatment does not protect people with disabilities, since they require special treatment to be able to function properly and equally to non-disabled people)
Implementation and monitoring of human rights
UN general assembly * Average values from 8 companiesEconomic
UN general secretary
and social commission
Political representatives
Human Right Council
High Commission for HR
Make the rules. Diplomats, politicians
Monitoring committees Experts in different branches of human rights. Gather and evaluate reports from individual countries and from NGOs/special rapporteurs/ special representatives
UN committees linked to the core human rights conventions develop interpretations, set standards and guidelines, monitor implementation and investigate violations of human rights. They are appointed by and report to the UN General Assembly. They consist of independent experts representing different regions and professional backgrounds. All countries that have ratified the conventions report directly (every 5 years) to the monitoring committees. The monitoring committees can also solicit reports from non governmental players, or special rapporteurs such as NGOs. The committees review the reports and invite representatives of the countries to an open “constructive dialogue” where they present their observations and suggest how human rights can be enhanced in the particular country. Reports and concluding remarks can be found here: www.ohchr.org There are also human rights institutions at the national level. Governments have the obligation to educate citizens about their HRs. Not all of them do it as they should.
3.2 Human rights and health Human rights and health are linked in multiple ways:
Sida.Health and Human Rights. Health division document2002:2A
The universal declaration of human rights states that “everyone has the right to a standard of living adequate for the health of himself and his family, including food, clothing, housing, and medical care and necessary social services” and recognises the right of everyone to “ the highest attainable standard of physical and mental health”. This means that governments must take adequate measures to ensure:
Maternal and child health Environmental and industrial hygiene Prevention , treatment and control of epidemic, endemic, occupational and other diseases Medical services and medical attention to all in the event of sickness
The Siracusa principles It is up to each government to decide on how to achieve the rights to health. Governments also have the power to derogate certain human rights under exceptional consequences, if that is necessary to protect the general wellbeing and welfare of the population. Examples include restriction of movement, or compulsory immunisation during outbreaks of epidemics.
The Siracusa principles regulate such cases to ensure that government intervention is absolutely necessary and non-discriminatory.
General comment 14 General comments are documents that give more detail about the application of human rights, and bring them up to date. General comment 14 was developed together with WHO. It is based on, and further develops the Alma ata declaration of 1978, which was concerned with primary healthcare. General comment 14 contains comprehensive guidelines for the interpretation of the “rights to health”. It discusses how “health” should be understood, what the obligations of the state are, and what the responsibilities of the individuals should be. The main point of general comment 14 is that health services should fulfil four criteria, or AAAQ:
Available to everyone Accessible to all citizens, regardless of where they live in the country Acceptable to those who receive them, i.e. ethically and culturally acceptable Of good scientific and medical Quality
HR for health Everybody should have access to affordable and adequate health services, and to living conditions and information adequate for protecting health and preventing disease.
HR in health systems Everybody should be treated with dignity, without discrimination. Confidentiality and physical integrity should be respected.
HR through health Adequate health systems promote human rights by promoting and protecting health and by restoring dignity and well being.
From Birgitta Rubensen. August 2010.
Other Human Rights for health documents The code on marketing of breast milk substitutes (1981) Originated from research in the 60s and 70s showing the immune boosting and protective superiority of breast milk relative to powdered milk. It caused a lot of controversy because of the consequences on industry but it gained universal support and caused a shift into the recommendations for feeding infants. The Cairo conference on population and development (1994) This states that each person or couple has the right to choose the size of their family, and the spacing of children, and that governments should provide them with the care, information, education and means to do so. The participating countries could not agree on a convention but agreed on a plan of action including the prohibition of forcible sterilisation.
4. Global Health partners and politics Big lecture on WHO, tobacco control, development aid in poor countries. It would take a month to summarise everything we talked about. Stucker and McKee (2008) Lancet 372, 95-7.
5. Migration and Global Health We talked about the increase in worker mobility as a result of globalisation. Increased access to information and the reduced price of travel have led to a dramatic increase in migration. Conflicts, natural disasters and famine are also causing displacement of populations. We discussed illegal immigrants and refugees, and the health problems they face-both physically and mentally. We had a lot of debate on ethical issues related to migration, from exploitation of illegal immigrants and their contribution to the economy of the country they migrate to, to how health systems should accommodate illegal immigrants and refugees. A lot of food for thought.
6. Health systems and Globalisation The policy and organisational nature of WHO was originally disease-oriented (based on vertical approaches to disease control). WHO comprised separate departments, each of which was dedicated to a specific disease, e.g. smallpox, tuberculosis and malaria. Each group of disease specialists at WHO guided national disease experts at the level of health ministries in each country. These in turn organised separate, disease-specific control or eradication programmes. This strategy proved successful in the control of many viral diseases thanks to the development of efficient vaccines and efficient immunisation programmes. However, this was not the case for other diseases that required a multipronged approach to disease control. Poorer Moreover, new disease burdens emerged in developed countries, including chronic diseases such as diabetes and cancer. Diseaseoriented curative care was not available or adequate for such diseases, and it became apparent that curative methods would not be sufficient without health education and behavioural changes. In 1978 an international consensus was reached that a change in health policy was necessary. This led to the Primary healthcare strategy and the Alma Ata conference. The primary healthcare strategy was based on the principles that healthcare should be made accessible to all, that it should encourage communities to be active in the promotion of health as opposed to being passive receivers, and that it should involve other sectors of society such as education and agriculture.
The eight elements of primary care are E-Education L-Local disease control E-Expanded programmes of immunisation against childhood diseases M-Maternal and child healthcare, including family planning E-Essential drugs N-Nutrition and food supply T-Treatment of common diseases and injuries S-Sanitation and safe water supply
Financial aid and health systems The Paris declaration on donor coordination stipulates the harmonisation and alignment of donor and NGO services with the host country. We discussed what that means in terms of the primary healthcare strategy. 1-Education- to allow people to take responsibility for their own health and the health of their family. Interestingly, the literacy of the mother is the most important factor in child health and mortality. Traditional medicine plays a big role in many poor and rural areas. It is therefore important for aid efforts to encourage good practises and to integrate them with the local health system. It is equally important to halt and discourage detrimental practises e.g. use of cow dung to heal the freshly cut umbilical cord. 2-Vaccination- Points to consider are:
The ability to reach the whole population especially when are scattered over a large area. To develop the trust of the population. Outreach vaccination programmes and national immunisation days can be expensive or challenging.
3- Mother and child healthcare- The most important factors are
Regular antenatal check-ups. Presence of skilled workers during labour. Access to emergency care in the event of complications.
4-Water and sanitation 5-Nutrition- Growth charts for babies, promotion of breastfeeding, and special dietary supplements for the most vulnerable.
6-Treatment of common diseases and injury 7-Prevention and control of local diseases such as AIDS and malaria 8-Essential drugs- Each country has an essential drugs list to treat the most relevant diseases to that country. Aid efforts need to establish essential drugs lists for the health facilities they work in, and to monitor drug availability, storage conditions and accessibility.
Health reforms and health economics. Increasing healthcare costs and inefficiency resulted in health reforms in most countries. These aimed to decrease bureaucratic planning, reduce public spending and increase the efficiency of health systems. The major changes involved: Decentralisation of management and financing of public health systems from a national to a local, district level. Introduction of fees in the public level. Increased privatisation of the public sector. Increased cost awareness, cost-benefit analysis applied.
We also discussed how the efficiency of health systems is determined, and how increased spending on health services does not always lead to better health indicators. China was given as an example of how a massively increased income was achieved at the expense of health (in this case child mortality). The opposite example was Egypt with a substantial improvement in child health and hardly any economic growth. We discussed how it is difficult to set criteria for a globally efficient health system. The outcome depends on the context in each country. We also debated whether striving to achieve MDGs can have detrimental effects on health systems by encouraging short term, fast solutions in order to meat the MDGs. In the end, we agreed that a combination of short-term and long-term measures were essential, albeit not always possible especially in low income countries.
7. Essential drugs and pharmaceutical companies
Should pharmaceutical companies be involved in basic research?
Can academic institutions benefit from collaborations with the pharmaceutical industry? Could that affect scientific integrity?
Pharmaceutical companies in third world countries.
Should governments have more or less power on pharmaceutical industry?
Clinical trials in developing countries?
28% Production* 32% marketing and administration* 13% Research and Development* 16% profit*