Museologia e Saúde Global

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Ficha Técnica: Heranças Globais – Memórias Locais Revista de práticas de museologia informal Nº 6. Spring 2015 Diretor Pedro Pereira Leite ISSN - 2182-7613 Edição: Marca d’ Água: Publicações e Projetos Redação: Casa Muss-amb-ike Ilha de Moçambique, 3098 Moçambique Lisboa: Passeio dos Fenícios, Lt. 4.33.01.B 5º Esq. 1990-302 Lisboa -Portugal

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Índice Museologia informal e Saúde Global ...................................................................... 8 Global Health .................................................................................................... 17 1.

Introduction to Public Health ....................................................................... 19

1.1 Introduction & History of Public Health ............................................................ 20 1.2 Multiple Determinants of Health ..................................................................... 25 1.3 Evolution of Global Public Health .................................................................... 31 1.4 MEASURING HEALTH STATUS ........................................................................ 38 2: Trends in Public Health ................................................................................... 44 2.1 Demographic and Epidemiological Transitions .................................................. 45 2.2: Economics to Equity in Health ....................................................................... 52 2.3 GLOBALIZATION AND ITS IMPACT ON PUBLIC HEALTH ..................................... 57 3: Infectious Diseases ........................................................................................ 66 3.1: The Changing Patterns of Infectious Diseases in Time and Place ....................... 67 3. 2: Control, Elimination, Eradication, Extinction. .................................................. 72 3. 3: Zoonoses .................................................................................................. 76 3. 4: New and Re-emerging Infectious Diseases .................................................... 80 3. 5: Childhood Diseases with a Focus on Diarrhea and Pneumonia .......................... 86 4: Maternal and Child Health ............................................................................... 91 4 .1: Trends and Progress in Child Health ............................................................. 92 4. 2: Child Health Post- 2015 .............................................................................. 95 4. 3: The Global Maternal Health Scenario .......................................................... 100 4 .4: The Sexual and Reproductive Health Agenda ............................................... 104 4 .5: The Long Shadow of Childhood Undernutrition ............................................. 109 5: Non-Communicable Diseases I....................................................................... 117 5. 1: Introduction to NCDs ................................................................................ 118 5. 2: Impact of Tobacco abuse .......................................................................... 121 5. 3: Diet and Physical Activity-I ........................................................................ 125 5.4 : Diet and Physical Activity-II ....................................................................... 131 5. 5: Overweight, Obesity and Diabetes Mellitus .................................................. 134 6: Non-Communicable Diseases – II................................................................... 140 6. 1: Cardiovascular Disease ............................................................................. 141 6. 2: Cancers .................................................................................................. 147 Revista de Praticas de Museologia Informal nº 6 spring 2015

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6.3: Respiratory Illnesses ................................................................................. 152 6. 4: Mental Health .......................................................................................... 156 6.5: Injuries (Road Traffic Accidents and Alcohol) ................................................ 167 7: Health Systems – I ...................................................................................... 171 7. 1: Introduction to Health Systems .................................................................. 172 7. 2: Delivering Health Services ......................................................................... 175 7.3: Health Systems Financing .......................................................................... 179 7 .4: The Politics of Health Systems and Universal Health Coverage ....................... 184 8: Health Systems – II ..................................................................................... 188 8. 1: Access to Medicines-I ............................................................................... 189 8. 2: Access to Medicines-II .............................................................................. 192 8.3: Health for All - The Moral and Social Case for Universal Health Coverage ......... 197 9: Environment and Health ............................................................................... 211 9. 1: Climate Change and Health ....................................................................... 212 9. 2: Disasters ................................................................................................. 216 10: Public Health in the 21st Century ................................................................. 219 10. 1: The threat of antibiotic resistance ............................................................. 220 10. 2: The challenge of ageing populations ......................................................... 225 10. 3: Health and sustainable development- I ..................................................... 230 10 4. Health and sustainable development- II ..................................................... 235 10 5: The Future of Public Health ....................................................................... 242 Bibliography .................................................................................................... 246

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Revista de Praticas de Museologia Informal nยบ 7 Winter 2014 Pรกgina 6

Apresentação

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Museologia Informal e Saúde Global

A Saúde é unanimemente reconhecida como a pedra de toque do desenvolvimento sustentado. A Declaração do Milénio e os Objetivos de Desenvolvimento do Milénio (ODM) que neste ano terminam assim o indicam.

Tudo indica que nos novos Objetivos de Desenvolvimento Sustentável, que no próximo mês serão discutidos nas Nações Unidas também o continuarão a ser.

Neste número da Revista “Heranças Globais – Memórias Locais” damos início à publicação de quatro números temáticos relacionados com a base do nosso trabalho sobre a globalização. Iniciamos com a Saúde Global, prosseguiremos com as questões das Alterações Climáticas (nº 7), que no final do ano estarão na ordem do dia. Em 2016 será o tempo de abordar a questão do Desenvolvimento Sustentável (nº 8) e finalizaremos com as questões das “Fronteiras do Planeta”. São quatro temos que são trabalhos no âmbito da Rede SDSNedu (ONLINE EDUCATION FOR SUSTAINABLE DEVELOPMENT), uma rede da qual fazemos parte no âmbito do nosso projecto de investigação.

Os indicadores da saúde são diretamente responsáveis por muitos dos ODM, e indiretamente responsáveis por outros tantos. As questões da educação, género, trabalho, criação de riqueza, participação das comunidades, são apenas algumas questões em que uma “Boa Saúde” se pode considerar como condicionante. É certo que nos últimos quinze anos o mundo se transformou profundamente.

Ainda que nem todos os objetivos propostos nos ODM se venham a verificar no final deste ano de 2015, é certo que muitos avanços foram alcançados em muitos dos problemas, ao mesmo tempo que outros persistem e mesmo novas questão emergem. Também não deixa de ser verdade que há várias regiões do mundo que avançam de forma mais significativa, ao mesmo tempo que há outras que se quedam em indicadores mais débeis.

Neste número sobre Museologia Informal e Saúde Global procuramos primeiro conhecer a transição epidemiológica, para depois reflectir sobre de que forma é que os patrimónios das comunidades podem ser mobilizados para a resolução de questões relevantes para a construção de inovação social. Temos defendido que o alargamento do campo patrimonial passas pela procura de questões socialmente relevantes e por uma atuação em domínios que anteriormente

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estavam reservados a outros profissionais. Defendemos que a museologia deve estar preparada para conhecer o mundo e resolver os problemas que são emergentes, ou mesmo antevê-los. Por isso abordamos a questão da Saúde Global com um campo da atuação.

As transformações que ocorrem no mundo de hoje são imensas. A população mundial cresce a um bom ritmo, prevendo-se que em 2030, os atuais 7 biliões de seres humanos passem a ser 9 biliões. Todos terão que comer e ter acesso aos bens essenciais. Comida, Educação Saúde, Habitação, Trabalho e rendimento. Sabemos que a vida será também cada vez mais longa.

Isso leva a relevância da questão da Saúde Global. Está em curso uma transição demográfica e epidemiológica. Enquanto que em muitos lugares do mundo ainda persiste o fardo das doenças infecciosas, em muitos lugares, sobretudo nos espaços onde o desenvolvimento emerge, emerge o pesado fardo das doenças não contagiosas.

Sabemos pela experiencia do mundo do norte, que a extensão do desenvolvimento económico e do chamado “bem-estar” que o mercado dá acesso, é acompanhado pelo fardo das “doenças do desenvolvimento” Doenças do coração e respiratórias, cancro e diabetes crescem exponencialmente nas sociedades “desenvolvidas”. Um espectro que se está a alargar aos países de rendimento médio e economias emergentes. Também o desenvolvimento traz consigo a expansão dos riscos do consumo, com o abuso do tabaco, álcool e outras drogas, mas também de hábitos de vida mais sedentários, uma dieta alimentar desadequada. Há também uma maior exposição a riscos ambientais, como por exemplo a poluição do ar, um acesso desadequado a fontes de água e saneamento, espaços urbanos não amigáveis. Também sabemos que as alterações climáticas potenciam transformações. Transformações nas doenças e riscos nos modos de vida pela ocorrência de eventos climáticos extremos.

A Saúde tem um valor intrínseco, sobretudo compreendida como um Direito Humano básico. Mas este valor ganha importância se for contextualizado no quadro de sociedades inclusivas, economias solidárias e da sustentabilidade ambiental, os três pilares do desenvolvimento sustentável. A Saúde é influenciada pelo ambiente, está relacionada com a segurança alimentar, com o comércio e com as migrações. A Saúde tem um influência positiva em diferentes sectores de atividade e os investimentos em saúde pública têm mostrado que eles resultam em impactos positivos no desenvolvimento económico. A melhoria da saúde pública tem também um impacto positivo em questões como a redução da pobreza, o empoderamento do género, a educação universal, a

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resolução de conflitos. Por isso ela fará certamente parta da nova agenda do desenvolvimento, como uma das suas mais relevantes ferramentas.

A Saúde Global olha para os determinantes de Saúde como uma ferramenta de trabalho com as comunidades no seu conjunto. A Saúde Global procura, enquanto ação, influenciar esses determinantes de forma a aumentar o seu impacto global, através da ação nos indivíduos.

Por isso estas lições constituem uma abordagem compreensiva do campo interdisciplinar da Saúde Global e permitem construir alternativas de trabalho para o alargamento do campo da museologia. Os conceitos que aqui são apresentados, são conceitos de importância vital para a saúde dos indivíduos, das comunidades e permitem entender de que forma a economia e o ambiente se interligam à sociedade, permitindo agir sobre todos eles com uma ferramenta holística. A visão que a Saúde Global fornece permitem criar uma consciência sobre os principais desafios da Saúde Pública, sobre os modos de vida, sobre os problemas da transição socia, económica e ambiental.

A estrutura do curso permite que cada leitor construa uma leitura do quadro de complexidade da Saúde Global. Fornece os conceitos básicos sobre Saúde Pública e Determinantes Sociais, coloca em discussão o problema global das doenças infecciosas, das doenças não infecciosas e permite entender as principais respostas que a Saúde pode fornecer para os problemas emergentes.

Será ainda apresentado a importância dos sistemas de saúde pública, os diferentes métodos desenvolvidos em várias partes do mundo e a relevância da cobertura universal de saúde. Dará ainda conta das questões emergentes mais significativas, tais como as alterações ambientais, as novas tecnologias, a governação global, a partir do campo da Saúde Global.

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Da Saúde Pública à Saúde Global: uma operacionalização do conceito O conceito de saúde global tem vindo a ser cada vez mais usado no campo das políticas de saúde e reflecte a consciência da Saúde como um fenómeno complexo e interrelacionado. Tradicionalmente ligada ao campo da Medicina, a Saúde Global afirma-se no século XIX como um campo de estudo das condições da sanidade e salubridade das populações e aglomerados. Para além da prática da medicina centrada na doença dos indivíduos, na formação do diagnóstico, na proposta terapêutica e no acompanhamento da sua evolução, e da investigação médica específica, a medicina irá um campo de saber específico centrado na dimensão social económica cultural e ambiental.

A Saúde Publica afirma-se como estudo das condições de saúde dum grupo de população ou comunidade, da incidência de determinadas doenças e, como disciplina prática, na formação e imposição de regras de conduta social e, não raro normas jurídicas. As evidências de determinadas doenças, de natureza epidémica, podiam ser evitadas por práticas sociais, produziu ao longo dos últimos duzentos anos um extenso conjunto de ações que influenciaram sociedades, determinaram afectação de recursos, estimularam ou condicionaram processos económicos e conduziram a relevantes formações sociais, de organização sistémica, que absorvem consideráveis recursos financeiros das sociedades e mobilizam não menos importantes atividades de investigação científica. O mais conhecido efeito é a prática da vacinação, que levou à redução da mortalidade infantil. No entanto como veremos a sua influencia é bastante mais alargada do que o campo da doença.

A saúde pública ao longo do século XX determinara e condicionará questões tão relevantes como os processos de alimentação, os sistemas de abastecimento de água e saneamento que estão na base dos processos de urbanização, os sistemas de protecção social, através do acesso ao sistema de serviços de saúde, os processos de investigação científica. Na Europa do Pós-guerra, por exemplo, a construção do Estado Social é baseado na construção de sistemas de saúde pública, que juntamente com os sistemas educativos e de protecção social caracterizam uma forma de organizar e olhar para a dimensão social das comunidades, determinando, por seu lado os modos de olhar para a economia, e sobretudo para a sustentabilidade dos modelos económicos do ocidente.

Emerge aqui uma primeira questão, que mais à frente abordaremos, que constitui a extensão e limites dos modelos de saúde pública: Isto é a discussão sobre a natureza do modelo (universal ou não) e da sua forma de financiamento (pública ou privada).

Como facilmente se deduz desta questão, o campo de estudo sobre a saúde pública assume uma elevada relevância no estudo dos processos de

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desenvolvimento. O simples fato de trabalhar sobre as questões da afectação de recursos, de construção de infra-estruturas, de condicionamento das formas de vida e uso do espaço, da produção de serviços sociais é uma evidência. Um campo já de sim complexo pois trabalha sobre questões de como compatibilizar os fins com os meios.

Mas a questão da Saúde Pública é também relevante pois na formação dos fundamentos da sociedade a da sua forma de organização, o que a colca no âmbito da essência da Política ou se quisermos na essência da ação humana com dimensão social: A questão dos seus fins últimos e da natureza moral das sociedades. Tomemos como exemplo a moderna questão da produtividade do trabalho e a captação de investimento externo. Um problema essencial nas políticas de desenvolvimento. O campo da Saúde Publica está profundamente implicado nesta questão através do seu contributo para a formação de sociedades saudáveis. Se num determinado lugar há um elevada incidência de uma determinada doença, esse não será um espaço que uma empresa escolha para se instalar. Note-se que a questão não se situa apenas ao nível epidemiológico das doenças transmissíveis (por via dum qualquer agente externo). Ela é também relevante ao nível das doenças não transmissíveis, como seja a obesidade, problemas com abuso de álcool ou outro tipo de substância, ou mesmo da questão da deficiência alimentar. Por exemplo uma dieta alimentar pobre em proteínas, tem como resultado deficiências de aprendizagens nas crianças, que gera uma população menos qualificada.

Uma população menos qualificada, com uma alimentação pobre em proteínas tem mais dificuldade em quebrar o ciclo de pobreza e da dependência, não só pelas suas características epidemiológicas, como também tem maior dificuldade em canalizar ajudas externas. Como tem vindo a ser evidenciado Teoria Crítica do Desenvolvimento, a sustentabilidade do desenvolvimento não pode ser assegurada apenas por via da canalização de recursos financeiros, sem uma intervenção mais alargada na dimensão da formação social a quem a ajuda é dirigida.

Regressando agora à questão da evolução da Saúde Pública como conceito operacional, temos vindo a assinalar os diferentes domínios em que ela influi na análise do desenvolvimento. Vimo como ela influi na formação dos diferentes serviços sociais e como é relevante na análise da afectação de recursos financeiros. Vimos também a sua ligação à teoria do desenvolvimento e à formação de sistemas de saúde e à promoção de equidade, justiça social, combate à pobreza e promoção de oportunidades aos grupos sociais. Uma relação que está presente desde 1977 quando declaração de Alma-Ata não só enfatiza a ligação da saúde ao desenvolvimento, como chama a atenção para a necessidade de serem criados serviços primários de saúde para as populações.

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O campo da Saúde Publica evoluirá, no final do século XX para um campo de intervenção que se passará a denominar Saúde Publica Global, ou apenas Saúde Global. A questão começa a colocar-se a partir da Comissão Brundtland, quando em 1987, no Relatório “Nosso Futuro Comum” se questionava sobre se a Saúde beneficiava automaticamente do desenvolvimento económico, ou se, para acelerar e sustentar o desenvolvimento seria necessário aumentar os investimentos na Saúde. A questão não é de imediato respondida, mas ao longo de vários relatórios, que se iniciam em 1990 com os Relatórios do Programa da Nações Unidas sobre o Desenvolvimento PNUD. Por exemplo, logo no primeiro relatório assume-se o objectivo do desenvolvimento está centrado no ser humano. E que para que o desenvolvimento seja um Desenvolvimento Humanos não só é necessário melhorar o financiamento ao desenvolvimento como é essencial alargar os processos de escolha e participação das comunidades na definição desses objetivos. O desenvolvimento é visto como um processo de escolha sobre as formas e oportunidades de trabalho, serviços de educação, saúde e de condições ambientais adequadas . Como sabemos estes relatórios conduzirão à Criação do Índice de Desenvolvimento Humano (HDI ) que procura descentrar a questão do desenvolvimento da exclusividade que até aí predomina na produção de riqueza financeira. O HDI é um indicador composto, onde para além dos indicadores económicos são adicionados indicadores sociais.

Grosso modo estabelece uma relação entre Produto Interno Bruo (GDI) a Esperança Média de Vida e os anos de Escolaridade da População, permitindo alinhar os países entre si como mais ou menos desenvolvidos.

A vinculação da relação entre a saúde e o desenvolvimento ficará de resto vincada na Declaração do Milénio, que em 2000 estabelece os objetivos de Desenvolvimento do Milénio (ODM) onde entre os 8 objetivos, 3 (4,5 e 6) estão directamente relacionados com a Saúde, sendo que indirectamente a Saúde também se relaciona, de forma mais ou menos intensa nos restantes cinco. E tudo leva a querer que os novos ODS assim continuarão a relacionar. É nesta íntima relação entre a Saúde e o Desenvolvimento, incluindo as diferentes determinantes sociais e ambientais que se forma o campo de intervenção da Saúde Global. Já não se trata de trabalhar apenas os determinantes dum determinado grupo num determinado espaço, a Saúde Pública Global procura identificar as formas de viver saudáveis, valorizar processos de alimentação a atividades que favoreçam e previnam os riscos e as pressões sobre os sistemas de saúde. A comparação de práticas entre grupos e entre espaços permitem disseminar importantes conhecimentos que tem efeito ao nível da diminuição de diferentes indicadores ao mesmo tempo que fornece roteiros para a investigação científica em diferentes domínios.

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Também não se trata apenas de olhar para os determinantes patológicos e os sistemas de saúde implementados. Um sistema constituído por recursos humanos, que evolui e necessita de ser continuamente treinada. Da sua distribuição pelas infra-estruturas no espaço. De assegurar a disponibilidade e medicamentos eficazes. Da acessibilidade das comunidades aos serviços. De dispor dum sistema de informação eficiente que forneça a informação adequada em tempo útil. De assegurar que o sistema de saúde é bem governado.

A saúde global alarga o campo de intervenção da Saúde Pública integrando aquilo que era também conhecido como Saúde Internacional por efeito duma consciência de que os problemas são globais. Uma população, um território e um sistema de saúde não está isolado. A Saúde Global incorpora a consciência de que no tempo da globalização não existem fronteiras e os problema de saúde são problemas globais. Por exemplo as patologia infecciosas espalham.se rapidamente pelo mundo, transportadas por um intenso fluxo de pessoas. As alterações climáticas estão a induzir transformações nas patologias, sendo previsível que determinadas incidências se alterem. Os sistemas de abastecimento de água, os regimes de pluviosidade, as disponibilidades alimentares e os sistemas agrícolas estão em constante transformação e interrelacionam-se. A Saúde Global como campo de conhecimento alarga a sua investigação às questões ambientais e olha com mais cuidado as questões da distribuição do rendimento entre a população, para a presença de conflitos na sociedade. Olha e procura contribuir para a sua resolução (Brown, 2006).

De certo modo a Saúde Global herda, no campo da medicina, todo o trabalho que foi feito pelos europeus na formação dos sistemas de saúde colonial. A chamada Medicina Tropical do final do século XIX, instrumento fundamental que acompanhou a colonização do homem branco nas insalubres terras do sertão africano, já se havia transformado em Medicina Internacional na emergência pós-colonial, centrando-se agora na comparação das tendências internacionais.

Um processo que permitiu, por exemplo a criação de vários programas de ajuda ao desenvolvimento, centrado em problemas epidemiológicos específicos, tais como por exemplo os programas de investigação sobre a malária. A questão do HIV/SIDA, que emerge como problema de saúde pública global no final dos anos oitenta do século XX, é um caso paradigmático que ilustra o processo de transformação de Saúde Pública em Saúde Global.

Não cabe aqui detalhar as questões epidemiológicas da doença, mas vale a pena acentuar que numa primeira fase, e dada a extensão que o problema assumiu em diferentes países africanos, a Ajuda ao Desenvolvimento canalizou para os primeiros programas uma forte ajuda. Uma ajuda que no entanto era orientada pelos princípios determinados, quer pelas Instituições de Investigação, quer pelas Agencias de Ajuda ao Desenvolvimento. A Saúde Revista de Praticas de Museologia Informal nº 6 spring 2015

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Global vai produzir uma transformação nesta questão, que até aí surgia como uma questão de cooperação internacional. O desenvolvimento dos programas e a investigação, em Saúde Global são produzidos pelos países destinatários em função das suas necessidades. A Saúde Global aborda a questão a partir da incorporação das lógicas dos destinatários, incluindo, nos casos em que se justifique, uma produção de medicamentos a baixo custo, destinado a mercados locais.

A Saúde Global inverte a lógica da Ajuda ao Desenvolvimento, onde os países ricos de certo modo, prolongam as relações de denominação, colocando-se na posição de doadores que condicionam a ajuda em função de requisitos previamente determinados, para uma lógica de pareceria, onde os atores debatem problemas comuns, alocando para o efeito recursos diferenciados em função dos níveis de riqueza e de incidência dos problemas a resolver. Isto sucede porque há uma consciência global dos problemas. Há uma consciência de que há um futuro comum e um destino comum.

A forma como a Organização Mundial de Saúde tem vindo a trabalhar nos campo dos sistemas de alerta, há alguns anos no caso do surto do H1N1, e mais recentemente no caso do Ébola confirma que a Saúde Global constitui hoje um campo de saber e um campo de prática da medicina na era do desenvolvimento sustentável. . Um campo que se tem vindo a afirmar quando nos novos objetivos do desenvolvimento se fala da “Cobertura Universal dos Serviços Saúde”, (UHC ) que tem como “objectivo assegurar a todos serviços de saúde adequados para promover, prevenir, curar, reabilitar e oferecer cuidados paliativos a quem deles necessite, em quantidade e qualidade suficiente para ser eficaz, bem como assegurar que todos estes serviços não são financeiramente insuperáveis” . Uma definição que reflecte a evolução conceptual da agenda da Organização Mundial de Saúde que temos vindo a trabalhar.

Esta consciência da universalidade dos problemas da saúde e da sua relevância para o desenvolvimento fundamenta não só a relação entre Saúde e Desenvolvimento, como também introduz novos desafios à ação. A Saúde é um relevante instrumento para a redução das desigualdades no mundo, é um processo fundamente de partilha de conhecimentos e ciências. A Saúde Global é indispensável para resolver os problemas da fome e da subnutrição, para alcançar a universalidade da educação.

A Saúde global coloca no entanto vários desafios para as questões do desenvolvimento que importa levar em linha de conta. As relevantes questões do comércio internacional. O mais óbvio é a da questão das patentes. A questão do direito ao retorno dos investimentos em investigação e a questão da

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equidade do acesso aos benefícios do património da humanidade, aqui materializado pela capacidade técnica de produzir saúde para todos. Mas há outras questões que estão na agenda, como por exemplo o uso do tabaco, o consumo de álcool, ou outras substâncias psicotrópicas. A questão da obesidade e da vida sedentária que se tem vindo a tornar um problema de saúde pública em todo o mundo. O problema dos acidentes de viação que se tornam universais. A questão da Agenda Global da Saúde estará é certamente em discussão a propósito dos Objetivos de Desenvolvimento Sustentável. Não será certamente fácil a criação de compromissos, já que a agenda implica, em muitos países importantes alterações de especializações produtivas. O caso de Cuba, a ilha das Antilhas há décadas sujeita a um bloqueio comercial dos Estados Unidos da América é paradigmático, quando olhamos para as sua três principais produções agrícolas (açúcar, rum e tabaco), todas elas na mira das mudanças necessárias proceder na Agenda da Saúde global Não cabe neste trabalho analisar em detalhe todas as questões que emergem na Agenda da Saúde Global. Há contudo uma questão que é relevante para o nosso trabalho que se relaciona com a viabilidade financeira dos sistemas de saúde e que de seguida abordaremos, numa perspectiva duma “Economia Global da Saúde ” que trabalha sobre a viabilidade financeira dos sistemas, sobre os processos de investigação sobre novos procedimentos para averiguar a sua rentabilidade, seja a nível global, seja a nível de disseminação por países parceiros, para verificar a sustentabilidade dos projetos, as suas escalas, a sua optimização. Em suma a aplicação da análise de custo benefício e o estabelecimento de “road maps” para o desenvolvimento de projetos de intervenção. É igualmente relevante o campo da investigação. Se por um lado é relevante a viabilidade económica dos projectos, não menos importante será a negociação dessa viabilidade.

Os sistemas de saúde crescerem em extensão. A sua universalização, um dos objetivos do século XXI enfrentam o desafio da sustentabilidade financeira. Está clara que a universalização do acesso à saúde não passará pela implementação dum modelo em extensão, mas que se torna necessário um modelo compreensivo, com um conjunto de serviços de cuidados primários acompanhado por, por um lado uma intervenção das comunidades na definição de políticas, que assegura a diversidade de necessidades e riscos; e, por outro lado, uma intervenção ao nível da investigação sobre os serviços e sobre a optimização desses serviços. No fundo a Saúde Global acompanha a transição duma medicina centrada nos factores de risco da saúde humana, para um medicina centrada nos Direitos Humanos numa abordagem holística.

Pedro Pereira Leite, junho 2015

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Global Health

Prof. K. Srinath Reddy1

President of Public Health Foundation of India https://www.phfi.org/faculty-a-researchers/491 1

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Health was recognized as a cornerstone of human development in the Millennium Declaration and the Millennium Development Goals (MDGs), with three goals explicitly linked to health indicators, and others in some way linked to health.

However, since the framing of the MDGs, the world has been witness to significant demographic and epidemiological transitions.

While the threat of communicable diseases persists, there is a growing burden of non-communicable diseases such as heart disease, respiratory illnesses, cancers, and diabetes, especially in low and middle income countries. These are attributable to traditional risk factors like alcohol and tobacco use, unhealthy diets and lack of physical activity, and increasing exposure to risk factors like air pollution, inadequate access to clean water and sanitation facilities, climate change, and natural disasters.

Health has intrinsic value, especially when framed as a basic human right, but has added importance when framed in the context of progress on the social, economic and environmental pillars of sustainable development. Health is influenced by environment, food systems, energy security, transport, trade and human migration. Health also has a positive influence on other sectors, with investments in health shown to have a positive impact on economic development.

Improved health is also essential to achieving other development goals such as poverty reduction, gender empowerment, universal education and conflict resolution.

The intersection of health with so many other sectors therefore necessitates an across the board approach to addressing health in any sustainable development agenda post-2015.

Public health looks at the determinants of health which act at the level of populations or people as a whole, and then tries to influence those determinants so that ultimately the impact is on improving the health of individuals.

This course provides a comprehensive understanding of the interdisciplinary field of Public Health from a global perspective.

The concepts outlined in this course will bring to light the vital importance social, economic and environmental factors affecting the health of populations, and of good health for all in achieving sustainable development. These concepts aim at portraying a holistic view of global health and creating awareness about current challenges in global public health, as well as defining the importance of good health in the broader vision of sustainable development.

This course will cover a broad range of topics, starting with an introduction to the basic tenets of public health, and the importance of social determinants. Moving on, we discuss the global burden of communicable and non-communicable diseases, and highlight the appropriate public health responses. We then discuss the importance of health systems in promoting the health of populations, and the different methods employed around the world to achieve universality in access to health services. The course also address new and emerging issues including environment change, technologies, and global governance, emphasizing the links to health in each case. This course is structured 10 chapters and witch one have a series of lectures.

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1. Introduction to Public Health

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1.1 Introduction & History of Public Health Welcome to this course on global public health. Quite often we are asked what is public health? How is it different from clinical medicine? Is it something to do with water and sanitation or is it something more? And for even people who have studied a bit of public health, they say, how is it different from epidemiology, which understands the causes of disease and identifies the means to prevent it. Others wonder what is global public health? How is it different from international health or public health in general? So let us start examining some of these questions. Firstly, public health looks at the determinants of health which act at the level of populations, or people has a whole in a community or a country, and then tries to influence those determinants so that ultimately the impact is on improving the health of individuals who constitute that community or that population.

So it doesn't deal with the individual disease in terms of trying to identify what a person's clinical complaint is or by providing treatment that one individual as clinical medicine does. On the other hand it tries to set right some of these determinants at the societal level so that people don't get ill. It also tries to create robust health systems which will deliver health services in a manner that is effective as well as equitable so that people can get protected against diseases through preventive services as well as get a wider range of diagnostic, curative, palliative and rehabilitative services as needed through a well-functioning health system. And all of these also have to be done cost effectively in a manner that the health system doesn't become bankrupt and individuals have to be protected against health related impoverishment. One of the main driving values of public health is not only to improve the health of people within communities and populations, but also to insure that there is greater degree of equity.

Because even in countries where the health standards are considered to be generally

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very good, we see several population subgroups who do not enjoy the same good health. And we find wide disparities in life expectancy, in maternal mortality or infant mortality or even cardiovascular mortality, between these groups. So public health also aims to reduce those gaps and bridge the inequities. And when we apply the standard of equity across the world, public health then becomes global health and it also starts to examine the determinants which actually act across the global level, across countries in a transnational manner and also tries to provide a concerted multinational or a concerted worldwide response so that these determinants can be further modified to improve global health.

Now if you look at clinical medicine and take the example of somebody who died of a heart attack, well the clinician, and the cardiologist would say that the person died because of blockages in the blood vessels to the heart. Absolutely true. But then the epidemiologist would say, the person developed those blockages because he had consumed tobacco as a cigarette smoker from the age of 16 and therefore he had a premature heart attack at the age of 42 and died suddenly. And therefore the cause of death according to the epidemiologist is smoking tobacco. But then the social scientist would say that in virtually every country of the world, now tobacco consumption is much more among the poor. And this poor person had consumed tobacco because he fell, trapped into the habit, did not have adequate information about it. And after having developed some other cardiac problem, did not have the ability to seek affordable healthcare and therefore died of it.

Therefore the social scientists would write down the cause of death as poverty.

Now every one of them is correct. And therefore public health has to look at not only the immediate cause but the combination of causes and the causes of causes. And that is where public health becomes a very broad, integrative discipline which makes the understanding of health and disease much more holistic than any single branch of medicine.

Now in terms of public health, we also have to look at systems as I said, are doctors and nurses available in adequate numbers? Are for example affordable medicines available, accessible? Let us take for example a person who meets a nurse or a doctor in a clinic.

That is clinical medicine, if the blood pressure is being checked up and some drugs are being prescribed. But what happened to the person before he came to the clinical facility? Could the problem have been prevented by appropriate advice on how to protect health to the community? Could it have been detected early, before it went

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into the stage of established disease or complications? Could the referral system have functioned better by providing a timely referral? All of these issues are part of public health.

When the person leaves the clinic or the healthcare facility, are the drugs that have been prescribed by the doctor, are they available in the market? Are they affordable? Can they be taken on a long-term basis? Are the kind of dietary prescriptions given in terms of fruit and vegetables? Are they affordable again in the market? Or if it's an infectious disease, are there systems for isolation? Are there rehabilitation support systems available for a person with mental illness, or with any other form of physical disability? All of these come under public health. Even what happens in the healthcare facility is also public health because we have to find out firstly, was there a doctor, was there a nurse? Were they adequately trained? Were they following standard management guidelines?

So the whole system organization is also part of public health. So if you want even clinical medicine to function well, you need a very strong public health system.

And when you take it on the global scale and look at the determinants of disease and health on the global scale, and look at systems functioning on the global scale, including the production, export, import, regulation of drugs for example, all of that is part of global public health. So public health really covers health systems, services, policies and other sectors too.

For example, when we look at what happens in terms of agriculture, food systems and the effect on nutrition, that again has to be aligned to the health of the people. Now you may say, why do we actually think that public health links to every single system, whether it's urban design, urban transport, agriculture? Now is there no limiting factor for this? Then we have to really understand that is the primary intent of any measure is to protect health, then that is public health. Like for example, if we say, a seatbelt law, or a motorcycle helmet law, that is public health because the primary objective is toprotect health. If the primary measure is for some other objective, but still we need to align those policies and programs and those sectors to the objectives of health, then that is not strictly in the domain of public health, but public health needs to link up with it. The primary objective of agriculture may be to provide food security, may be to provide cash for the farmers, but even there we have to insure that agriculture and food systems are producing the kind of products that are better suited to human health. So that becomes an extension of public health into another sector. So public health is truly multidisciplinary in very many ways. Now when you look at how

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public health has evolved this is not a new concept. Even in the Roman times there was a diversion of human waste and the Roman civilization knew that if human waste accumulated, that would be a cause of disease. That was a good public health measure.

In the 19th Century Europe we saw the so-called miasma theory coming in where they felt that miasma was bad air caused by rotting organic matter and they attributed all kinds of diseases to miasma. We know that's not entirely true, but we also know that it is important to have clean water and good sanitation and the beginnings of the sanitary movement in Europe actually brought about marked advancement in the health of the population and that was good public health. We also know that public health can use several technologies. For example, vaccination.

Vaccination again is applied at the population level so that individuals do not get the disease. Like for example, Jenner's vaccine in 1796, Edward Jenner brought in the vaccine against small pox. Though it is said that the Chinese used this form of variola inoculation as early as a 1000 b.c., but anyway modern documented history attributes it to Jenner. In 1747, James Lind, an English sailing captain experimented and then proved that serving lime to sailors prevented scurvy, otherwise which was a major problem on long sea voyages. And that is why the English came to be known as limeys in slang.

The history of modern public health in London began with an act of vandalism.

Yes. Somebody actually broke the handle of a water pump and carried it away. And this was John Snow.

In the Broad Street in London, where there was an outbreak of cholera, where cholera was spreading across in concentric circles and affecting a large number of people, John Snow mapped out how the outbreak was spreading. And then found that the center of the circle was a pump which was actually resulting in bad water coming out because of contamination with sewage. So John Snow broke the handle of the pump and the outbreak ceased. So it's an important measure of public health to link sanitation and good water quality to people's health. We have had several public health movements across the world, but at the level of global health, the World Health Organization which was established in 1948 became the principle catalyst and custodian of global health movements across the world, legitimized by the will of all nations.

And one of the success stories led by the World Health Organization in terms of public health has been the eradication of small pox. We know that this very deadly infectious disease have claimed a large number of lives and even in the beginning when

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people started getting inoculated, there were many people who did not believe in its effectiveness, but it was very clearly shown that those who were inoculated had very little mortality whereas those who were un-inoculated had a very high fatality. And the global eradication of small pox is one of the grandest success stories of public health.

But we have also seen public health evolving in terms of the understanding of the links between health and development. In the World Health Assembly of 1977, there was a resolution of health for all which resulted ultimately in the Alma-Ata declaration which also emphasized the importance of primary health services. Then it was decided that in the whole area of environmental sustainability health also needed to be accommodated and that came about in the Brundtland Commission of 1987. But the

question

was

whether

health

would

automatically

benefit

from

economic

development or investments in health also were needed for accelerated economic development. And that conversation began in terms of this bidirectional relationship in the World Development Report of 1993, investing in health. It was advanced then by the Commission of Microeconomics and Health which was formed by the World Health Organization. And recognizing that health and development are integrally related, at least three direct health related goals were accommodated in the Millennium Development Goals of 2000 which were adopted by the United Nations.

And now as we move towards 2015, when the United Nations is looking at adoption of sustainable development goals, the whole relationship of public health and global public health in to sustainable development is so abundantly clear that we see global health as one of the important points around which the SDG's will revolve. We will find they're in one way or the other linked to global public health objectives.

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1.2 Multiple Determinants of Health In this chapter we'll be looking at the determinants of health, especially the social, ecological and political determinants. Of course biology is absolutely critical too, but that is most often dealt by clinical medicine. But we will also look at the interplay of these other determinants with human biology and ultimately how they shape health at the level of populations.

Let me start with the story of Rudolf Virchow, who was an eminent pathologist in 19th Century Germany. He was also the founder of the Anthropological Society of Germany. And he had a place in the Kaiser's court. A highly respected academic. When he was sent off by Kaiser, or the emperor of Germany to investigate an outbreak of typhus in Silesia in Prussia. He came back with a report not looking at the biology of the disease, but on the social circumstances which caused the outbreak. He said the principle cause of that outbreak of typhus in Upper Silesia was poverty and inequity.

And he recommended that there should be measures taken to reduce poverty including

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abolition of feudal privileges and greater levels of democracy. That did not make him popular in the court, but as a philosopher of social medicine Rudolf Virchow has a very prominent place. He said, do we not always find that diseases of the populace traceable to defects in society? If disease is an expression of individual life under unfavorable circumstances, then epidemics must be indicative of mass disturbances.

He went on to say that these mass disturbances are disturbances of culture and therefore great social changes sometimes also bring epidemics in their wake. What was true of typhus in the 19th Century is true of tobacco in the 20th Century and now we are seeing other social movements which are also resulting in the epidemic of overweight and obesity because of unhealthy foods. Even in Victorian London, poor living conditions were recognized to be responsible for ill health. The Black Death of 1655 was again, strongly related to poverty and poor living conditions. And when we had epidemics in London or the United Kingdom, then the rich left the town for their estates while the poor who were to remain, suffered. And we have seen the descriptions of this kind poverty and deprivation affecting health in the books of Charles Dickens. When we look at how sometimes social circumstances can actually change for the better and thereby bring about improvements in public health, we also see the decline of tuberculosis antedated the discovery of drugs against the tubercular bacterium, or the bacillus tuberculosis. And that is where McKeown brought about his famous thesis that it is the social conditions which actually are responsible for decline in infectious diseases in countries which are improving economically.

While it is true that science and technology are also very important allies in bringing about public health improvements, we definitely have to acknowledge the important role of socioeconomic development. But this development also has to be equitable. Now we recognize that if you actually look at populations and compare them.

We also find out that some of the diseases which appear to be very common in some countries are far less common in other countries, even at the same level of economic development. For example, in Finland, in the 1960s and '70s, coronary heart disease was extremely common. Whereas at the same time in Japan, coronary heart disease was very rare. And we find that the way the populations live in terms of their living habits, of diet, physical activity, all of them are responsible considerably for these interpopulation differences.

Geoffrey Rose from the United Kingdom, a famous epidemiologist, while studying cardiovascular diseases across different countries said, sick individuals come from sick populations.

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If your average cholesterol level in the population is high, the number of people who will get heart attacks because of high cholesterol is going to be high. Similarly if your average blood pressure in the population is high, the number of people with hypertension who are going to get a stroke is high. So we have to really alter the population dynamics of risk acquisition and risk reduction if you want to make an impact in public health across the population. Now we also know that migration into urban environments also accounts for a great deal of this change. When you look at Kenyan nomads who live in very rural conditions and London civil servants at the same time, this is one of the earlier studies of Geoffrey Rose, you find a marked change in the distribution of the systolic blood pressure across these two populations. In London, the entire distribution is far to the right. That means even the average blood pressure as well as the proportion of those with hypertension is far higher than those in the Kenyan nomads. And therefore the way in which we lead our lives makes a difference.

This doesn't mean that everybody has to live in relatively primitive conditions and shun modernity, but we are to make sure that as we advance towards modernity we retain some of our healthy living habits. And that is the basis of public health. So when we look at the principles of risk and prevention we understand that since much of this is determined by the population profile of a risk factor, small reductions in risk factor levels when achieved across the whole population. That means when the whole population distribution shifts to the left, shifts to a better level, then that results in a large reduction of adverse events like strokes and heart attacks across the population.

Even though the individual shifts are small, cumulatively the population benefits are large. At the same time you have to also look at people who are at the high risk end of the distribution and who at the individual level have a very high risk and we have to focus public health interventions to get them the appropriate mode of risk reduction therapies. So we need to combine both of these strategies.

These are not mutually exclusive but are synergistically complimentary. But when we look at what makes people healthy, or unhealthy, we realize that there are elements in the health system which are very important. The health workforce, are there enough doctors, nurses, allied health professionals? The infrastructure, are there well equipped health facilities? Do they have enough drugs, vaccines and technologies available and affordable across the population? How is health being financed? And what are the health information systems like? Do we get ready information on what the risk factor levels in the population are? Or what is the spread of disease across the population? How is the whole system being governed? Is it efficient? Is it suffering from

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corruption? Is it accountable to people? All of these matter in the health system. But over and beyond that, we also have to look at the social determinants of health and nutrition. For example, these are factors operating at the societal level. Like the availability of clean water, sanitation, food systems and agricultural systems which provide healthy nutrition across the life course to every individual. A clean environment, having as little air pollution as possible. Social stability, free from conflict and violence and having adequate degree of community participation.

Then all of these matter very much in terms of the societal forces. The level of development and distribution of incomes within society matters. At the personal level, income, education, occupation, social status, gender, participation in social networks, all of these are important social determinants of health. So when we really look at all of these, public health operates at each of these levels. But underlying all of these are political and economic systems which ultimately make choices with respect to many of these determinants. We recognize for example that as per capita income grows across countries, up to a certain level the life expectancy also increases.

Once you reach a certain level of about close to ,or beyond $3000 or $4000 per capita, then the effect starts plateauing off. And this is known as the Millennium Preston Curve. But the fact is, per capita income which means the overall income as assessed as the income per population, per unit, actually matters a lot in terms of life expectancy.

However, how this is distributed within the population also matters a lot. Like for example, in the United Kingdom, there's a huge difference in life expectancy between one county of the United Kingdom and the other county of the United Kingdom. Almost, whereas one county has a life expectancy of 54 years, the other county has a life expectancy of 82 years. Again, even within the U.S. you have differences in life expectancy which is considerable between different counties. Where in Washington you have a predominantly black population, you have 63 years as their life expectancy. On the other hand, in Montgomery County, which has a predominantly white population, you have a life expectancy of 80 years.

Now we also know that because of income differences, but also because of educational differences

and

employment

differences

you

can

have

substantial

differences in mortality rates. For example, if you look at the mortality rates across different classes of occupation, the people who are in higher grades of employment in the Whitehall which is the secretariat in the United Kingdom, they have had much lower levels of mortality as compared to some of those in the lower professional grades who,

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where the stress levels are much higher. And in terms of health inequalities we also recognize that educational levels play a great role.

Even at the same levels of income, differences in education make a lot of difference. Those who have had university education have a much lower mortality as compared to those with only elementary education. So there is a growing recognition that whether, between countries or within countries, we ought to be addressing inequality much more effectively. Michael Marmot who headed the WHO Commission on Social Determinants of Health remarked that the fact that there is a spread of life expectancy of 48 years among countries and a spread of 20 years or more within countries is not inevitable.

This is not something that is a given, irreversible. We can, by addressing through appropriate public health strategies and equitable socioeconomic development and distribution bring about a shrinkage of these huge gaps that lie within life expectancy across and within populations. And we see this can happen in different countries where the differences between the wealth quintiles can be substantial even in terms of the number of births that are attended by skilled birth attendants. And within countries we find that the poorest, again, have unattended births with a likelihood of higher maternal mortality. But as universal health coverage takes place across countries, even in countries with lower incomes, we find that these differences across wealth quintiles are substantially reduced or even obliterated. So we ought to be really looking at universal health coverage to reduce health inequalities brought about by income inequalities.

We also recognize that by making determined efforts to bring about greater equality in society you can overcome many of the existing inequalities. Brazil is a remarkable success story in this direction. After the revolution in Brazil where the military dictatorship was overthrown, and a constitution enshrining the right to health was adopted, Brazil had a number of social initiatives which were directed against reducing income inequality and reducing poverty. And that has had its effect on health.

If you look at the stunting rates across income quintiles, then we find that earlier on we had a huge gap pre-revolution in the stunting rates between the high income groups and the low income groups. But subsequently we find that in the last decade these differences have greatly narrowed and we find the stunting rates in the lower and the high income groups are virtually very similar. So by bringing about a greater degree of equality in distribution and greater access to nutrition, also other social determinants of health as well as health services we can actually reduce some of

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the gaping health inequalities that are a major problem in terms of inequitable development. And that is a very important mandate for global health. How best can we reduce inequalities in health across populations and within populations? We do have the knowledge, we just have to apply it political will and determination supplemented by professional skill brought about by good public health systems.

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1.3 Evolution of Global Public Health DR. REDDY: We have seen that concepts of public health are centuries old.

However the idea of global public health has been evolving over the last few decades.

And this has been brought about by substantial changes in the way people have looked at international health and then, and global health. Peter Piot, who is the director of the London School of Hygiene and Tropical Medicine and previously the director general of the UNAIDS has classified global public health in four stages. The first stage was one of tropical medicine. This was during the colonial period when many of the countries which colonized countries in Africa, Asia or Latin America were concerned about their soldiers and their traders as well as their administrators suffering from the tropical diseases like malaria.

And they invested in programs for prevention and control primarily to protect their own people and their commercial interests and of course the local population benefited incidentally.

But then we moved on to an era of international health in the post-colonial period in which people were interested in finding out what the health trends in different countries were and what the comparative profile of public health challenges and predominant diseases was in the world. Indeed, this is not a curiosity that is very recent. Even in the 19th Century, epidemiology was principally described as geographical epidemiology. And therefore the whole idea of geographical medicine in which they compared people across different countries. But we now see that apart from Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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international health, we have moved on to a third stage where people from rich countries who are leading research programs in poor countries started organizing substantial research programs funded often by the governments or donor agencies from rich countries in order to investigate the causes and course of diseases in the poor countries, more as a matter of international cooperation. But now global public health have entered a fourth stage. Where global health activities, including research are being led by people from poor countries. Indeed, there's a much greater amount of collaboration including leadership of major programs by researchers as well as public health leaders from the low and middle income countries. I would actually put it in a slightly different way. I would say international health was when people went from the high income countries to low income countries and said, what can we do for you? And now global health is where people everywhere in the world are sitting across the table together and saying, what can we do together to identify and solve the leading health problems of the world by working together? I think the recognition that many of the determinants of health today are transnational, whether it is movement of viruses or migration of people or sale of tobacco and essential medicines, all of these have become transnational activities. So global cooperation is absolutely critical now if people have to solve the problems of global health. And it is this working together that really brings life to global health in the 21st Century. The whole idea is that we are really looking at not merely variations in health across the world, but we are looking at common concerns and commitments in global health.

The 20th Century saw global health advancing primarily from a sense of shared vulnerability. There was this threat of bioterrorism. There was the big scare about SARS, H1N1. And many avian influenzas and so on. And people felt that they needed to protect themselves against various diseases that were moving across boundaries. The International Health Regulations came in. And of course we started looking at cooperation merely from the point of view of protecting ourselves against problems that can come in from elsewhere in the world. But in the 21st Century, we are moving beyond shared vulnerability to shared values to provide momentum to global health, because we are looking at issues like universal health coverage. We are looking at trying to reduce inequities across the world. We are looking at sharing knowledge and resources for improving health of people everywhere across the world, whether it is battling under-nutrition or whether it is battling Ebola.

And therefore we ought to be really looking at the fundamental values that guide global health in the 21st Century and that is universality. But universality doesn't

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mean that everything is decided at the global level. We do have decisions to be made at the local level and a lot of action is led at the country level or even at the sub regional level within countries. As the Portuguese writer, Miguel Torga said, universal is local without walls. What we have done is to break down the walls in terms of shared knowledge and built bridges of cooperation across the world to tackle the problems, even as we are acting both at local and the global levels. Now what are we studying in global health nowadays? We are looking at trends in demographic transitions across the world where we're trying to find out how aging populations are now facing different disease burdens. We are looking at the changing nature of disease burdens both in response to demographic as well as economic transitions. And we are looking at how risk factor levels are rising or falling across populations to predict what the disease patterns are going to be. We are also studying the broader social determinants of health, because they are fundamental to determining the health of populations. We are also looking at how the national health systems are responding to the various public health challenges. What are the allocation of financial resources for health within countries?

For example, if you're really looking at universal health coverage, can it be funded at a low level of resources or do the resources need to be augmented? We are looking at health workforce issues. Do we have a multilayered, multi-skilled health workforce, which is capable of delivering a wide range of services which are promised in universal health coverage? We are looking at the access to drugs, vaccines and technologies and trying to find out whether countries need to be supported in promoting greater access and affordability for their populations. We are looking at how health systems are organized. Are there vertical disease programs or is there horizontal integration or what we are now calling a diagonal approach in which there is a certain degree of focus and verticality within a health program but the results are a great amount of sharing and capacity-building for the health system which can be accommodated even within a vertical program which can also support some other objectives of some of the allied programs.

So we are looking at rapidly evolving models of health systems. We are also looking atpublic health emergencies whether it is Ebola or natural disasters and seeing how health systems in general are capable of responding to it, how they're collaborating with othernational disaster response systems and how international cooperation can help in that. So if somebody is really suffering as a result of Ebola in Africa or somebody is suffering as a result of a post-tsunami effect in Indonesia, it does

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not mean that they're going to be isolated. There's a whole global health community which is going to be responding to that challenge. And that is the essence of global health.

So we are also looking at global health constructs. We are looking at flows of knowledge, technology and services across the world. We are looking at reverse innovation. We have had Lord Nigel Crisp from the United Kingdom who headed the British National Health Service. He was sent by Prime Minister Tony Blair to look at countries in Africa, Asia and Latin America to see what the National Health Service could provide those health systems in terms of support and guidance, in terms of sharing best practices. He came back after a good study and wrote a book called Turning The World Upside Down. He said, there are so many innovations going on in these countries of Africa, Asia, and Latin America, which the British National Health Service could benefit from. So he said, the whole world is now a very different place.

You're seeing a lot of innovation happening in the so-called low and middle income countries which the high income countries should learn about. So there is a greater opportunity for bidirectional, or multidirectional sharing of knowledge. And of course, we require much greater cooperation as well in terms of not only scientific research, but also in the application of research and sharing of resources. We also are looking at governance. Not only of governance in national health systems, but how international health agencies are now trying to look at global health governance with multiple players coming in now, not only the World Health Organization, but also various foundations and a number of governments coming in, how do we coordinate the functioning of all of these agencies at the global level in order to optimize the benefits of their working together and really achieve the maximum impact on global health? So the whole idea of global health governance or governance for global health is becoming a very important area.

So also the whole area of financing of health, particularly in terms of achieving the objectives of the millennium development goals and the sustainable development goals. We are looking at transnational determinants like trade. Trade- whether it's in tobacco, whether it is in fruit and vegetables, or in essential drugs, all of these affect health. We are looking at traffic and migration of people across continents. We are looking at conflicts which are also having refugees moving across different countries, across borders and carrying health problems with them. Or suffering their health consequences of forced migration. So we are looking at communication, how that�s bridging a lot of the knowledge gaps across the world but sometimes also creating

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problems by breeding unhealthy living habits as aspirational goals in changing cultures.

And as we move towards the sustainable development goals from the millennium development goals We still have a problem of tuberculosis, especially multi-drug resistant tuberculosis. We still have HIVAIDS in many parts of the world. And we have now emerging infectious diseases, including zoonotic diseases like Ebola.

We are also looking at the major new challenge of non-communicable diseases.

The idea of controlling cardiovascular diseases, diabetes, cancers and chronic respiratory diseases across the world becomes a major priority for global health. And we say we now move to adding NCD agenda to SDG agenda. At the same time, mental health is a major cause of disability and therefore we are looking at an expanded NCD agenda by incorporating mental health and also adding injuries in what is now being called chronic conditions and injuries agenda.

So we are looking at the prime causes of death and disability across the world and trying to accommodate all of them in the SDG agenda and global health is going to be the principle platform where this action is going to take place.

We are also looking at health equity and particularly universal health coverage.

Provision of multiple services to all the people who require them, but with adequate financial protection. That has become a rallying cry for global health equity over the last 15 years. And we are going to see that resonate in the SDG goals. At the same time we are now bringing back primary healthcare very front and central into the health agenda. Alma-Ata is not dead.

We are now bringing back Alma-Ata's spirit into SDGs by saying that universal health coverage, if it has to be delivered, has to revitalize primary healthcare. So that again is a major global health agenda. But at the same time, we have seen a fundamental shift in the way the world has looked at the health system. Previously health system was being dismissed as a black box. They were looking at vertical programs. Let's go and attack TB. Let's go and attack HIVAIDS. Let's go and attack tobacco separately, and the cancer separately, and so on. Now people have realized that vertical programs, however well designed and well-intended cannot be force-fitted into a weak health system. A weak health system will not be able to deliver them. And also there is an opportunity cost of other programs suffering. So the idea of creating a strong health system which acts as a switchboard to integrate all of these programs and effectively synergize them for better delivery, including health equity that has become a primary goal of universal health coverage and that is the driving spirit again behind global health initiatives.

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So when we're really looking at public health research which has to inform public health action, the objectives for public health research are to provide evidence based, context specific, resource sensitive, culturally compatible and equity promoting recommendations for policy and practice. And these are going to be fundamental for global health.

So when we are really looking at these as the primary objectives for driving policy and practice, we must recognize that policy whether made at national or global level has to be informed by interdisciplinary effort to create the required knowledge base. So public policy sometimes can be an unedifying spectacle when it is based on unenlightened approach. But on the other hand, even an enlightened policy needs scientific credibility. Is there evidence and rationale? For that you require biomedical and epidemiological research.

Financial feasibility. For that you need health economics research to find out whether something is cost effective or affordable for a national health budget. You require operational stability. Is the proposed intervention sustainable and scalable apart from being successful in a pilot? For that you need health systems research. But you also need political viability. Is there a ready and receptive community for accepting whatever is the proposed intervention?

This could be the community of policymakers, this could be the wider community at large. And for this you need social sciences research. So unless you combine all of these fields of knowledge, you not be able to create the impetus for public health action within a country or of the global level. That's why we emphasize bringing together multiple disciplines in order to inform and to actually guide public health action. In terms of public health practice we are really looking at integrating evidence with practices into primary healthcare for preventing and reducing the risk of diseases in a period of health transition. And ultimately when we’re acting at the level of the communities or at the level of populations, we will impact upon people and their health on...and the health of individuals.

But how do we implement all of these interventions? Now global health is beginning to talk about operational research or implementation science as a very critical piece. Previously we were trying to create knowledge about what is wrong and what could be done to set it right. But we still have not understood fully the science of delivery, especially a lot that goes into it in terms of human behavior, in terms of organizational behavior, in terms of management practices, in terms of cost effectiveness of interventions. So for all of these we require operational research or

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implementation science. And one of the prime elements of global health in the 21st Century is going to be implementation science.

So when we're really talking about global health in the 21st Century, the spectrum of research must stretch from molecules to markets. The span of policy must range from persons to people to populations. And the arena of advocacy and action must extend from risk factors to rights, rights of people, human rights.

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1.4 MEASURING HEALTH STATUS When we talk of health we also need to measure it, because as is often being said in management circles, what gets measured gets done. So when we plan health programs, then we need to find out what the impact of those programs is in terms of improving health indicators.

This is important for national systems to look at how they’re functioning and faring in terms of various health priorities. It’s also important to compare across different countries, over time within countries and across geographies in different countries and sometimes over time in terms of the global trends.

Policymakers will also find it very important not only to use it as a measure of progress, but also for priority setting. Clearly when there are a number of priorities which need to be addressed in terms of different health challenges, and they have to allocate resources, they will have to decide which are the ones which are really the most important in terms of tackling early on and those which can be tackled later on or how to allocate resources across different programs.

The WHO defines health as a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.Therefore it s a positive definition, not a negative definition, therefore it goes beyond the absence of disease or infirmity in stating positive attributes of health.

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However, it s a holistic definition which is very pleasing but difficult to measure and pin down. So how do we actually measure health? One of the important measures is longevity because as societies advance one expects life expectancy to improve and life to grow longer and longer. So that depends upon when and why people die. And that captures the life expectancy on an average within a country. But as we know, there are wide disparities in life expectancy across different countries. Japan for example has a life expectancy of 83 years, whereas Mozambique has a life expectancy of 53 years and in between we have Sweden at 82, Bangladesh at 70 and Tanzania at 59.

But the important thing to remember is that while we must try and reduce this huge gap in life expectancy as a measure of health across the world, it is quite clear that all the years of life are not lived in good health. So there are some years which are compromised by ill health. And therefore we are also looking at a modified measure of life expectancy which is healthy life expectancy. That means if you remove the amount of years lost due to ill health, by adjusting in some way for the level of ill health and the years lived with ill health and then subtract that from the total life expectancy, then you come to healthy life expectancy. And Japan in this case has 75, which is very good.

That means the gap between life expectancy and health life expectancy is not very large.

On the other hand, Mozambique which started off with a low life expectancy has a very low healthy life expectancy of only 37. And the gap therefore is quite substantial of 16 years. That means, even in the shortened life expectancy of Mozambique, several years are consumed by ill health. So when we re looking at cause of death for example, one of the very important measures in international comparisons, there is an international classification of diseases which was first proposed by William Farr. And now we are in the tenth revision. So different diseases are provided different criteria of diagnosis and then we attribute the cause of death to the most important cause that contributed to death. And then we compare again, across countries as to which are the dominant contributors to death and within in countries too we compare across social groups and we compare across time periods to see whether there are transitions occurring or whether health policies and health programs have had the desired impact.

And some of these are also linked to individual causes of death or age groups or particular types of programs that we are really trying to assess. Like for example, infant mortality rate, child mortality rate, maternal mortality ratio, or disease specific mortality. What is the mortality contributed by cardiovascular diseases as a whole and

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what is the mortality contributed by coronary heart disease and stroke separately? So we look at all of these in a manner that is disease specific.

And this we gain from different sources of information. Usually countries should have vital registration systems which are quite robust. They should also have very good cause of death certification procedures based on the international classification of diseases. You can t go around classifying death in a very arbitrary manner and then expect good comparison. So you need a standardized method of certifying death and physicians and others who certify death must be trained properly to really adhere to that.

Others

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records,

national

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international

surveys

like

demographic health surveillance systems,sample registration systems and so on. Cause of death information is best generated from systems of civil registration and vital statistics. When these systems are either incomplete or dysfunctional and not really reliable in terms of the validity of the information generated or the completeness of information generated, we can still attempt to gain some useful information on births and deaths from other sources. These include demographic surveillance sites, sample registration systems, population censuses and household sample surveys.

None of them give the full information that we can get from civil registration systems. However by supplementing the limited information that they offer with structured verbal autopsy techniques, we ll be able to get additional information which can inform policy and programs even as civil registration systems are being established or strengthened.

In some countries where the vital registration systems and cause of death certification is not very widespread, well established, or reliable, people also undertake techniques known as verbal autopsy. In order to try and send trained people into the community to try and identify deaths which have taken placeand then through a very well structured interview, try and ascertain what the potential causes of death might have been in those cases. And these are usually verified against available medical records or a physician opinion. So there are different ways of ascertaining mortality data.

But we also need to measure morbidity because death is not the only thing that matters in life. Good health matters and therefore living a life in good health without disability is a very important objective in any society. And therefore we have to measure disability or handicap. And therefore we have to first start defining disability.

So every disease carries a certain degree of disability. In some cases, very short-lived, in some cases chronic or in some cases, permanent. So we have to try and measure

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what the durational disability is and what the degree disability is. So in terms of health expectancy measures, we do look at disability measures and there are multiple disability measures that are there for different categories of diseases. But again, we are faced with a challenge of compressing all of this into one or two indicators which capture all of the information. And there we ideally should look for measures that combine mortality and morbidity, particularly for comparisons across countries and comparisons over time within countries.

So disability adjusted life expectancy has been something that was proposed in the World Health report of year 2000. And now it s called Healthy Life Expectancy. If you assess the nature of disability, attach some weights to it, estimate the number of years lived with that particular disability which could vary actually in terms of its severity across those years, but ultimately calculate the cumulative loss of healthy life years because of the disability and subtract that from the overall life expectancy, then you get healthy life expectancy. So this measures the equivalent number of years expected to be lived in full health.

Now there is another measure that has come in to play, particularly through the global burden of disease project. This was first introduced into global health in the year 1994. This was again to capture the combined burden imposed by premature mortality and prolonged disability as a summative measure. It combines the years of life lost due to premature death and the years lived with disability weighted for the degree of disability. And therefore it subtracts the amount of life lost because of that weighted disability. And this again has become an important measure though it has become a little controversial sometimes by saying that it s a bit of an ageist measure and then it sets too much premium on years of life lost and substantially overweighs certain categories of death and disease over others. But nevertheless it s a useful measure for global comparison.

At the same time, there are other estimates that have come in in terms of measuring health gaps. Years of life lost. This is estimated on a population basis, compared to potential maximum life expectancy, which in this case is Japan. Then we also look at years lived with disability. These are all subcomponent measures of the DALYs. These all go into the calculation of disability adjusted life year lost. So the years lived with disability, they estimated on a population basis the number of cases with that particular condition must be multiplied by the average duration of the disease and a weight factor that reflects the severity of the disease on a scale from zero, which is perfect health to one which is death.

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The global burden of disease studies as I said, first started in 1990. They were published in the first version in 1994 and subsequently they have been revised extensively in 2010 and are going to be also periodically revised. And currently the Institute for Health Metrics and Evaluation in the University of Washington-Seattle is now leading this effort. And they do comparisons of global burden of disease across different countries and groups of countries using the disability adjusted life years. This has had an unprecedented scale and effort going into this, of looking at multiple data sources and compressing that all into a measure that provides for global comparison. It does give a global picture of progress and the status of health which is not available presently through any other source because most of the other measures fall short either in terms of measurement of disability or being very disease specific or particular age specific.

But it also is an important measure for highlighting emerging focus areas and improvements in health. For example, in 1994, when the first global burden of disease study came in, people were surprised to note that many of the low and middle income countries already had very advanced epidemics of non-communicable diseases where there was a lot of premature mortality and a lot of disability. And until the calculations of disability adjusted life year loss was done, mental health did not emerge as a very major factor in global health. So the DALYs calculated for all of these were a great contribution in helping us to re-prioritize some of our public health interventions.

But there are some justifiable criticisms. There are always issues raised on the quality of data available from different countries and ultimately whatever is the summative measure is dependent upon the quality of the data and the extrapolations made. And again, there is a little criticism that this is an ageist measure and this weighting system also is sometimes controversial. The amount of weights attached by patients, by physicians and by people who are healthy tend to vary. And therefore we re not sure which the actual weight to be utilized is. The DALYs and the global burden of disease are supposed to be guides to resource allocation, but they do not always account for differentials in resource availability.

Remember, sometimes you have to take equity also into consideration. You have to take affordability issues into consideration. And there are multiple other factors that go into policymaking. Nevertheless, for prioritizing public health action and to some extent resource allocation, the GBD is useful indeed. We understand that measuring disease burdens is a complex activity but a very important activity. It s an evolving process. We are still gathering knowledge about what are the best methods of

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assessing disease and the disease burdens and measuring health free from disease but global health requires these metrics for decision-making, for comparison and for advancing our progress to adequately prioritized public health programs.

But we also recognize that health now must be positioned fairly effectively in the broader developmental context. It can t be seen in isolation from other developmental activities, including the whole area of sustainable development which is now coming to the fore in the United Nations. So there are some of the indices that are coming up in which health forms a part of a broader development index. Dissatisfied with the gross domestic product as an indicator of economic progress, Stiglitz, Sen and Fitoussi who are very major international economists developed what is known as a well-being index which captures multiple areas including environment, education, poverty reduction, health, among several others. And therefore this is a composite index. There is a multidimensional poverty index developed at Oxford which looks at health, education and living standards and measures poverty in multiple dimensions, including the lack of health. There is a social progress index that s currently under development which looks at basic human needs, foundations of well-being, opportunity and brings in some of the environmental concerns as well.

So as we move towards the sustainable development goals we need to definitely improve our measures of health, but we also need to see how we can coalesce those measures with other developmental indicators to get an idea of what a healthy society should be in all dimensions.

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2: Trends in Public Health

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2.1 Demographic and Epidemiological Transitions As Bob Dylan sang, "The times they are a-changing." As the clichĂŠ goes, change is the only thing that is unchangeable in this world. It is true that even in terms of public health and global health, we see change almost constantly. But there are certain driving forces which are responsible for the direction as well as the dimensions of the change. And it's important that we understand them so that we can not only predict what is likely to happen, but also position our public health interventions so that we anticipate and avert some of the major public health problems as well as advance health equity in the desired direction.

The transitions that shape public health have been described by Rayner and Lang as demographic, epidemiologic, urban, and nutritional. These are traditionally seen by most public health experts as the important drivers of health transition.

However Rayner and Lang also emphasize that there are others that we do not conventionally take into account but nevertheless are very important for understanding changes in public health. The economic transition, energy transition, the biological and ecological transition, cultural transition and democratic transition. Of these, the demographic transition is the most widely studied and most often discussed. This is where there is a transition within a country from high birth and death rates to low birth and death rates, along with the development from a pre-industrial to an industrialized economy. Warren Thompson developed this concept in 1929. And then he basically Revista de Praticas de Museologia Informal nÂş 6 spring 2015

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based it on the historical demographic observations in developed countries and later on this has been adapted to the study of developing countries as they are in developmental transition with accompanying epidemiologic and health transition.

In terms of demographic transition we are looking at five stages where in the earliest stage, which is high stationary, we find a fairly high death rate as well as a high birth rate on the population. And when we look at the population itself, because the deaths and births are canceling themselves out, the population growth is actually high stationary. Then we see a stage where the death rates start falling first and the birth rates continue to be high and therefore the population starts expanding. This is early expanding.

In the later stage we see the birth rate also beginning to fall but the death rate continues to fall fairly sharply and therefore we see a late expanding stage of the population. Then by the time the death rates and the birth rates both fall to low levels, where they reach approximately each other, the population growth becomes stationary and the population level remains stable. But then the birth rate continues to decline as in some advanced countries like Germany and Italy and there, because the death rates have now fallen to a lower level, but the birth rates are fallen even to a further lower level, the population starts declining. And that is where we find the fifth stage in some countries.

So there are several countries which are going through these phases and demographic transition therefore is an important concept in understanding how the age profile of the population, the size of the population, as well as the disease patterns of the population are determined. When we look at China for example, we see a huge shift in the demographic profile from a pyramidal shape in 1990 to a virtually, a cylindrical shape in 2050, where we see that the bulge is mostly in the middle and the top of the age profile, rather than at the bottom of the age profile where the young predominate.

And we see also this happening in terms of life expectancy. As we understood previously from the millennium Preston curve, as per capital income rises, we find life expectancy rising up to a certain level and then gradually plateauing it off. And we found this in the case of China, where up to 1970, life expectancy rose very sharply as the economic development went in and also the social determinants like water, sanitation, nutrition were addressed in a very equitable manner across that society.

But then the population growth started stabilizing a bit and life expectancy also started plateauing off a bit. On the other hand, in India we are seeing a steady rise in life expectancy as we move from 1960 to 2010. And as a result of this, what we see is

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thatthe total fertility rate in China has fallen over a period of time. This of course in China has been accelerated by the one child policy. On the other hand, in India, we do see a falling fertility rate, but far less sharply than in China. As a result we see also a relatively delayed demographic transition in India in comparison with China. In China, the working age population actually peaked close to 2010 and is now on a decline in terms of the ratio of the working to the non-working age population. So China has already had its demographic window of opportunity when there is a large expansion of the working age population, which can give a thrust to economic development through increased productivity. India is still to have that demographic window of opportunity in terms of a rising working age population. This is beginning to happen now and we can anticipate an accelerated economic growth from this demographic dividend.

However, in order to harness this demographic dividend, India will have to invest both in education and skills for the young people, but also in protecting the health of the population. That is where public health becomes a very important element for economic development. Otherwise the demographic dividend can turn into a demographic disaster with a large number of working age people suffering from early death or prolonged disability.

The concept of epidemiological transition based on demographic change was originally propounded by Omran who described three stages. In the first stage where societies still experience a lot of pestilence and famine, the average life expectancy is about 35 years. And infectious diseases and nutritional deficiencies dominated that society. And later on, as people moved from a life expectancy of about 35 years to 50 years, the pandemic started receding and we started seeing the slow advent of noncommunicable diseases like hypertension. But even those were substantially related to hypertension with hemorrhagic bleeding stroke. And we found that later on, in the mid20th Century we saw the age of degenerative disease becoming the dominant epidemiological profile of a demographic transition. And in this, life expectancy rose to about 60 or above, but we found that by now the clotting stroke and ischemic heart disease or coronary heart disease became the dominant killers, infections receded, particularly major infections which killed people all across the world, became, less of a public health challenge. And even nutritional deficiencies were substantially corrected in several parts of the world.

But this was a profile seen mostly in high income countries. Low income countries continued to experience some of the earlier phases of transition. And then we also had other transitions that were added on later in which we had a stage of delayed

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degenerative disease which is proposed by Olshansky and Ault, who said that by the time United States and Europe crossed the 1980s, we started seeing life expectancy cross 70 years, people still died dominantly of non-communicable diseases like ischemic heart disease, stroke and cancers, but many of them died above the age of 70 years.

What we saw in Russia was a reversal after the fall of the Soviet Union where a stage of social upheaval suddenly came in in a period of transition life expectancy among Russian males fell to 58 years the lowest in the century because of the variety of reasons cardiovascular death rates went up, alcoholism became a major problem killing a larger number of people, and that actually can have a reversal of the epidemiological transition. But we can also anticipate that there could be an era of environmental degradation if we do not protect the environment on the planet.

And we do not know exactly what's going to happen in terms of resurgence a of a large number of infectious diseases added on to the already existing problem of noncommunicable diseases and how that is going to play out. We should try and avert that by protecting the environment. So these are the kind of transitions that we really ought to be looking at in terms of various developing countries and seeing the stages in which they're transiting. But one of the important lessons is we don't necessarily have to go through each phase for exactly the same length of time that the high income countries experienced. By utilizing the knowledge that we already have, we should try and telescope the transition by abbreviating the stage 3, where there are large number of mid-life deaths and move quickly onto stage 4, where even if people die of noncommunicable diseases, they'll die mostly after the age of 70 years.

This particular health transition model has been very helpful in providing an model for predicting what's going to happen and understanding some of the dynamics.

However, it's been somewhat limited because it is focusing mainly on proportional mortality. While giving us an evolutionary perspective rather than a limited crosssectional view, it is underestimating the burden of non-communicable diseases in countries of Africa for example where we see in Tanzania already the age standardized mortality rates of stroke in the age group of 15 to 59 far exceed those in England and Wales. But you don't capture that by only looking at proportional mortality, because HIVAIDS, malaria, and others are actually killing a large number, therefore the proportional mortality due to non-communicable diseases appears to be lower. So the model that was proposed by Omran which is mainly based on proportional mortality, looking at the ratio of deaths from a particular cost to total mortality serves a useful purpose, but has some limitations. The other limitation is, health transition is not

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simply a linear model, because all of these are likely to be determined by complex interactions among various determinants. And these complex systems are nonlinear. So while we do depend upon the health transition model, the epidemiological transition model, we will have to look at other elements which determine global health. Some of these transitions can occur very rapidly. For example in Mexico we have seen between 1950 and even by year 2000, a massive increase in the deaths attributable to noncommunicable diseases and a substantial decrease in the deaths attributable to infectious diseases.

So transitions are happening very rapidly because unlike the leisurely pace of transition that took place in Europe and America in the 19th and 20th Century, we are seeing the forces of rapid urbanization and globalization propelling countries in the low and middle income group into a rapid health transition with a very speedy rise of noncommunicable diseases. And sometimes the coexisting burdens of infectious diseases and non-communicable diseases overwhelming the health system simultaneously as in the case of India.

Now in terms of nutritional transition. The traditional diets are now being replaced by western diet patterns. And there is an accelerating rate of change in diet, particularly through transnational trade, aggressive marketing of unhealthy food products. Simultaneously, there is a shift in physical activity patterns with a large number of labor saving devices at home and for transport. We now find that people are far less physically active. In fact this is the paradox of modernity that previously people used to be paid for doing physical work, now people have to pay for doing physical work. They have to actually become members of a gym. So we have seen a fair amount of changes in the nutrition profile across the world. But this pace is not uniform across the world.

For example in Asia, the number of undernourished people are declining as demographic and economic transitions take place. But in sub-Saharan Africa, there still continues to be a huge unresolved public health challenge. In terms of obesity however, we are seeing a rapid rise almost in every region of the world. And we are seeing that overweight and obesity are going to be one of the major public health challenges of the 21st Century, not only because they're a problem by themselves, but they set the stage for a huge rise in non-communicable diseases like cardiovascular diseases and diabetes and cancers.

There are other transitions also that we must understand. The biological and ecological transitions. When we start deforesting and herding animals close together for

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increasing our meat consumption, we are also creating a conveyor-belt for vectors and viruses to migrate from wildlife and forestry into veterinary population and human habitat. As we alter the environment and create climate change that is also going to affect our health in very many ways. So understanding ecological determinants of health is becoming even more important in the 21st Century than ever before. Even in terms of energy security, this becomes very important. Because the pursuit of cheap energy is also shaped by the desire to replace human and animal labor. But as we move towards increased energy utilization we also have to see what it is doing to the environment, ambient air pollution, indoor air pollution, and also to see whether that is also transforming our life in terms of reduced physical activity.

All of these matter. And even energy security across the world has economic implications which in turn determines how health systems are funded. So all of these are going to be very important, because there are countries which provide huge energy subsidies. Can some of that be withdrawn by reducing the amount of energy dependency we have and the savings be transferred to health for universal health coverage? These are the kind of questions we ought to be discussing in global health in the 21st Century.

Similarly, democratic transitions are also very important. Because how much of decisions are made in a country by the people at various levels? Are communities empowered? Are the provinces and regions empowered? Or is everything so centralized and dictated by a central authority with very little participation of people is going to be important. In the 21st Century democracy is moving from a representational model to a participatory model. Social media are becoming very important. And therefore a lot of public health knowledge is going to be disseminated and a lot of public health action is going to be driven by this kind of participatory democracy. So these are all trends that are going to be determining global health in the 21st Century. So when we look at all the determinants, we look at demographic shifts such as aging, urbanization and industrialization which alter living habits, globalization, which actually through marketing can accelerate a lot of changes in the way we live and education and culture which shape our beliefs, not in one community but across the global community and poverty which limits access to health both in terms of being a barrier for health information as well as health services.

And we are looking at urbanizing environments where the built environment can either be a barrier to physical activity or it can be an enabler or it can create pollution or provide clean air. And underlying all of these, there are also vectors like tobacco,

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unhealthy food and alcohol which are rapidly driving the health transition across the world and towards obesity and non-communicable diseases. Understanding these determinants is absolutely pivotal to global health in terms of its actions in the 21st Century.

So we understand health transition, but we need to respond to it. There are populations because of demographic and social determinants which are being propelled from low risk to high risk. Like rural populations, populations in low and middle income countries which are moving to westernized patterns of living in terms of food consumption, or tobacco consumption.

There are also.people in each country who are actually at low risk. Children, children are not born with a high risk. But the way we actually nurture them in our society can create high risk for them. So we need to provide these low risk populations from moving to high risk through public health interventions which create a healthy society.

At the same time in every population, there are individuals who've already acquired high risk. We need to return them to low risk by clinical and behavioral interventions. So while high risk may be determined by a combination of biology, beliefs and behaviours, there are a number of interventions that we have which can actually reduce the risk. And our public health interventions in the 21st Century must combine all of this knowledge into effective interventions both at the population level and at the individual level through competent health systems which take the lessons of health transition into account while framing global health policies and shaping global health practice.

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2.2: Economics to Equity in Health We have emphasized that equity is absolutely pivotal to public health and global health. We've also recognized that economics are also very critical for development of countries and therefore for health. We now need to look at how economics is related to health and how it reflects on health equity. But what is equity and why are we so much bothered about it? In 2000, when the Millennium Development Goals were framed, they set as targets aggregate national health indicators,whether it is maternal mortality, or infant mortality, or poverty reduction, or reduction in under-nutrition.

However, we recognize that even as countries show improvement in national aggregate indicators, there could continue to be serious gaps in equity across different social groups within the countries.

The richer sections could actually have much better declines and greater improvements in the health status in terms of the various indicators. But the poorer sections could continue to lag behind and the gaps could grow. And that may not always be reflected very well in the national aggregate indicators. So one also has to look at how these gaps can be bridged within countries, even as we move towards a greater national progress in terms of achievement of the MDG goals. The WHO commission on social determinants of health emphasized this aspect by saying that we must put health equity as central to improvement in the health outcomes. We need to look at what health equity actually means. It has been defined as the absence of Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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disparities in health and its key social determinants that are systemically associated with social advantage or disadvantage. So these health disparities when they exist, they contribute to health inequity and reflect health inequity. But they're not merely differences in health indicators, but also in their social determinants. We have seen economic development as a very key lever for improved health in societies. Societies tend to improve upon their life expectancy for the populations as the per capita income of the countries grows. The millennium Preston curve demonstrates that by the time countries reach a per capita GDP, somewhere between $3000 and $5000 per head, the life expectancy actually has reached a very high level and starts, plateauing off. But before that, there is a very sharp rise in life expectancy as the per capita GDP grows.However it's not merely what is happening to the national average in terms of the income. How that income is distributed within countries also matters. At the same level of national GDP or per capita GDP, you could actually have considerable differences between different social classes.

And countries which have a wide gap in the per capita income between the upper income quintile and the lowest income quintile, tend to have poorer health outcomes in comparison to the countries which have the same level of per capita GDP, but have a narrower income gap between the upper and the lower social classes. And this has been seen very clearly in a number of countries. And one of the stark examples taken from Kate Pickett and Richard Wilkinson's book, The Spirit Level, shows how Japan and USA, for a variety of health indicators are poles apart because Japan tends to have the narrowest gap between the income at the highest level and the income at the lowest level. Whereas the USA has seen huge income disparities among, for example its bankers and some of the workers employed in low level employment.

Similarly, life expectancy also is longer in the rich countries which are more equal.

If you take all the high income countries and look at which have done best in terms of life expectancy, again, Japan scores very well and others also tend to show a gradient based upon what the gaps are between the high income and the low income groups in terms of the actual income levels. So as income inequality grows, the benefits of life expectancy that you expect with an overall rise in national income tend to be diminished. Even when you look at something like obesity, this particular income gap seems to have an effect. Japan again, shows very low levels of overweight and obesity, whereas the United States of America shows much higher levels of overweight and obesity. True, you have other factors influencing overweight and obesity such as the nature of traditional diets and so on, but the fact that unequal societies tend to

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have worse health indicators is reinforced, whichever health indicator you take and obesity and overweight is also one more example. Mental illness again is much more highly prevalent in more unequal rich countries as compared to the more equal rich countries. And this again is a salutary lesson to show that social stability, social conflict which reflect ultimately on individual mental health are also substantially determined by the income gaps within countries.

The world development report of 1993 as well as the WHO commission on macroeconomics of health in 2001 demonstrated that good health is not only a product of development, but is indispensable to development. Many economists before that believed that health would inevitably and passively respond to accelerated economic growth. But later on it became very evident that you have to invest in health of societies and populations in order to accelerate the economic growth and to insure that avoidable illness and avertable premature death do not take a toll of economic growth.

We are looking at this very clear bidirectional relationship between health and economic development where health also needs to sustain and nurture economic growth, while benefiting from the products of economic growth. So good health for all and sustainable development of societies can only be addressed by reducing inequities while promoting the overall growth. And this also has an evolution in our philosophical thought of how we understand equality, equity in society. The utilitarian philosophy of Jeremy Bentham basically said whatever is good for society is what we must invest in.

But if you look at it narrowly from a utilitarian point of view, investing in the health of children or investing in the health of elderly and disabled would not be seen as the right thing to do. So we have to go beyond the merely utilitarian point of view.

And John Rawls brought that into the philosophical construct of fairness which he equated with justice. And he said, whatever is fair should be equal in terms of treatment of people in society. And that equality was equated with the equality of opportunity, of fairness across different people and different sections of people. But then Sen advanced it to a further level in terms of the idea of justice being not merely in terms of fairness but of insuring that all sections had the ability to exercise their capability for development, to be healthy and to be productive.

And herein we bring in a rather interesting concept of defining equity, either as vertical equity or as horizontal equity. When we look at horizontal equity, which is what probably John Rawls meant by his concept of fairness, we are really looking at everybody being treated equally in a society, including access to health services.

Universal health coverage for example. But when you look at vertical equity, you're

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also making a deliberate attempt to bridge the existing gaps by affirmative action. And therefore you are sometimes looking at targeting special programs for the poor who have been left behind. Now we do need to integrate both of these concepts, ultimately into the idea of justice even as we try and provide equality across the society, we also need to insure that some of the disadvantages that preexisted and resulted in poor health indicators for some of the population groups must also be bridged by special targeted programs and blending these is ultimately going to be beneficial for all of society by reducing the disparities.

Ultimately when we are looking at this whole idea of capability we also translate it into a right. The right to health. And that is the underlying philosophy that is now driving global health towards universal health coverage and towards a movement for greater health equity. Sridhar Venkatapuram in his book Health Justice, defines this very well. He says, a well ordered society would insure that all individual, all individuals have the capability to be healthy and at a level that is commensurate with human dignity in the modern world, which is their right. So the right to human dignity, the right to development is something that is recognized, but that is dependent on a capability to be healthy. And it is that capability that must be fostered by economic development and equitable distribution of the products of economic development. And then only we can see health equity.

R.H. Tawney who was a clergyman economist in the early 20th Century in England remarked upon this, saying- what is required is not only an open road, but an equal start. When we talk of equal opportunity we forget that we've actually created sufficient disadvantages for some people who cannot make the same use of the opportunity as the person who has had previous advantages. So you can't expect them to run the race at the same speed. So Tawney remarked that with massive health inequalities where many are denied an adequate education, unable to access effective healthcare and housed in slums, equality of opportunity is nothing more than a cruel jest. The impertinent courtesy of an invitation offered to unwelcome guests in the certainty that circumstances will prevent them from accepting it. He called it nothing more than decorous drapery. So that is where we bring in the social determinants of health. Not merely by offering equality of opportunity through a universal health coverage to accessible health services, which is essential, but also to ensure that we address the social determinants of health which define the conditions under which individuals can get an equal start and run the race without handicap. So when we're really talking about social determinants of health and capability for individuals, we are

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also talking about extending that capability beyond individuals. We need equity among communities within a country. We need greater equity in health indicators as well as economic development among countries. And importantly in the 21st Century we also have to think of intergenerational equity. We cannot use all the resources that are currently available or most of the resources that we have to our advantage and deprive the future generations of those resources. We cannot create conditions in which the environment is going to be so degraded that the future generations cannot lead a healthy life. And that is why the concept of equity is no longer confined to countries or communities within countries, are not only across the entire globe, but also generations in time. So we have to look at equity in multiple dimensions across time and space and make sure that sustainable development becomes the framework in which we embed health equity.

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2.3 GLOBALIZATION AND ITS IMPACT ON PUBLIC HEALTH We now live in an increasingly interconnected and interdependent world. If industrialization and urbanization constituted the principle propellants of economic growth as well as health transition in the 19th and 20th Centuries, globalization constituted the tailwind that accelerated health transition towards the end of the 20th Century. This we have seen in the way non-communicable diseases have now become a global phenomenon. We have also seen how knowledge as well as technologies have been used to better control infectious diseases across the world. So globalization offers us advantages as well as disadvantages.

So naturally we find enthusiastic supporters as well as very strong skeptics. We need to critically look at how the advantages of globalization can be amplified while curtailing some of the absolute disadvantages that it has brought to global health.

Globalization has been defined as a process of greater integration within the world economy, through movements of goods and services, capital, technology, labor, all of which lead increasingly to economic decisions being influenced by global conditions. We see that the world economy now is increasingly being dominated by the forces of globalization, whether it is the spread of infectious diseases through rapid movement of people, or even the global contagion of economic crisis which affected the banking system in the first decade of the 21st Century. In such an environment you can have the forces of growth fueling production and employment in other parts of the

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world, but you can also have an increasing vulnerability where financial systems are actually either unstable or inequitable. Globalization affects health in several pathways.

Firstly, in terms of a direct impact on health systems as well as a direct impact on health policies. There is also an increasing exposure to hazards like infections, tobacco and other marketed products. But it also affects indirectly through the impact on national economies. For example, health sector affects the public health expenditure on health in terms of globalization influencing some of the policies related to allocation of resources, both through the health sector overall as well as within health itself, resetting of priorities for expenditure. We also recognize that there can be increasing effects on population risks. For example, on the kind of diets that people now start eating as a result of the global marketing forces and that has an impact on nutrition.

And in turn, on health. Living conditions are also substantially altered by the forces of globalization. And all of this cumulatively can decide on whether the impact of globalization on health is positive or negative. For example, we see in the case of Central America the import of snacks from the United States has markedly increased as a result of trade between 1989 and 2006. And we see overweight and obesity rapidly rising in that region of the world, especially in Mexico. And also in other Central American countries. We recognize that we can also have the market liberalization bringing in healthy foods. Like in the case of Poland, where the opening up of the markets brought in much more vegetable oils which were healthier than the animal fats that were being traditionally consumed. And also a greater amount of fruit and vegetables.

And that resulted in a fairly rapid decline of cardiovascular mortality in the mid1990s in Poland. So globalization in terms of nutrition can be a double-edged sword, depending upon which type of products are being marketed and are being consumed.

At the same time we also recognize that trade impacts access to medicines. While this is going to be elaborated much more in a future lecture, we must recognize that lifesaving medicines can now be exported or imported worldwide. But there are barriers which sometimes prevent access to medicines because trade often prioritizes intellectual property over the social contract of making medicines available to everybody who needs them. And therefore trade is a very important area for us to look at when we see the impact of globalization on health, particularly through access to medicines. The whole area of trade liberalization was also accompanied by prescriptions for structural adjustments in the economy. And that had an impact on the way public funds were being utilized for health. During a transition to a market economy in the

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early 1990s, in Russia, there was a drastic fall in life expectancy, especially of the Russian males, which hit a point which was lower, lowest in a century. About 1.4 to 1.6 million premature deaths occurred during 1990 to 1995. A great proportion of these were among working age men. And there were several factors that were cited as being responsible for this effect.

Firstly the import of a large number of unhealthy foods into the Russian market exacerbated some of the poor diets that they were already having. But one of the most important factors was the deregulation of alcohol consumption which hugely increased alcohol consumption and binge drinking became a norm. And that resulted not only in increased cardiovascular disease, especially sudden cardiac death, but also a huge surge in accidents and injuries. This was also accompanied by reduced public spending on healthcare. And even some of the infectious diseases that were previously very well controlled now started springing up again.

So we saw the destabilization of the Russian health system during this period of economic transition. Again, marketization of health systems became an important feature of the prescription provided by multilateral institutions like the World Bank and the International Monetary Fund, during the late '80s and early '90s. And these traditionally worsened public spending on health by reinforcing the market driven approach to healthcare provision. And we are seeing how their emphasis on user fee became counter-productive. Evidence from Kenya, Burkina Faso, Papua New Guinea, all of them showed a clear decline in the utilization of health services with the introduction of user fee. One of the most dramatic impacts was seen in China, where despite the huge advantage that China had derived earlier from wise investments in nutrition, in public health, for water and sanitation, and in general, spending on provisional basic health services to the Chinese people, the introduction of market reforms saw considerable disinvestment of public finance in the health system. The percentage of women with insurance coverage for prenatal delivery, uh, prenatal and delivery services fell from 58.3% in 1989 to 34.7% in 1997. And the overall access to insurance coverage already available to just one in four Chinese in 1989 continued to decline slowly through the 1990s. This led China to review and revise its policy and introduce substantial reforms with infusion of public finance and an increase in the coverage of the insurance system through three programs to more than 95% of the population The fact that market prescriptions may have been unwise has also been acknowledged by the president of the World Bank, Jim Yong Kim, who referred to some of the prescriptions that the World Bank had made to Thailand against some of the reforms

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that Thailand wanted to undertake in order to launch universal health coverage. He said, "let me acknowledge that Thailand launched its universal coverage program against concerns over fiscal sustainability initially raised by my own institution.

Thailand's health leaders were determined to act boldly and provide access for their whole population. Today the world learns from Thailand's example." This confession that the World Bank prescription of the '90s was incorrect came when Jim Kim addressed the World Health assembly in 2013. But the fact remains that many countries did follow the World Bank in name of prescriptions in the '90s and that may have affected the way health equity grew among those countries. The World Bank has now formally changed its goal to fighting no longer just for the eradication of poverty, but also for shared prosperity, recognizing that mere growth itself is not a guarantor of good health, but you ought to reduce income disparities within countries if you want to gain from growth to the maximum extent. So that again is an important revision of the overall economic philosophy of the World Bank. And that may influence how globalization is perceived in the future.

When we come to the other impacts of globalization and health, we must also consider brain drain of health professionals. More than 20% of physicians working in Australia, Canada and the United States of America come from other countries. WHO estimates that there is a global shortage of about 4.3 million physicians, midwives, nurses and support workers worldwide, and the export of health workers to other countries from countries most in need of them for their own under-resourced health systems adversely affects global health. And this is a problem that we must address.

And the WHO has provided a code on human migration of health workers which can offset some of these problems. But we must recognize again, that if there is a global shortage of health workers, we need a global response which provides those resources to all countries, but does not divert them from the less developed countries to the more developed countries. We also must recognize that global funding is now sometimes skewing the priorities both for health research and health programs within countries.

While the infusion of a lot of private funding from philanthropic foundations and from the private sector is indeed welcome in terms of raising the overall pie of funds that is available for the health sector, if priorities are principally going to be decided by what the donors choose, then you may actually land up with priorities which are misaligned to the needs of countries as well as that of global health. So we need to build in a greater accountability into the whole system of global funding from nongovernmental sources and say that these are the kind of priorities that have to be determined by

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countries and by consensus among countries, and any private funding should not distort those priorities. At the same time we see the increased global movement of humans and goods can increase the risk of infectious disease spread. We have seen that for Ebola. We have seen that for SARS. So we need to be very careful about how we actually ensure the movement of people and goods during a period...during an era of accelerated globalization does not cause more of infectious disease spread, resulting in pandemics.

Globalization has also been recognized as one of the drivers of change in ecosystems. For example, agricultural production itself is greatly skewed to meet international demand created by market pressures rather than by addressing local needs. And not even in terms of looking at global health goals or national health goals, but purely looking at the commercial profit line of the crop production that has often resulted in reduced crop diversity with a much greater emphasis on some of the cash crops than even on staples or protein sources or providing the kind of diversity that's required for healthy diets. For example we see tobacco, meat, soya and palm oil dominating the agricultural system which are not always to the advantage of good health. Global meat production for example is now going up substantially and is likely to rise from about 310 millions of tons in 2013 to about 518 millions of tons in 2050.

While we do require protein sources, this level of meat consumption is not good for health and certainly not good for the environment because of the high level of methane emissions as well as the huge amount of deforestation that is required to produce the grain that goes into feed the animals.

So we must recognize that agricultural systems which are being driven by forces of global commercial compulsions are now sometimes acting to the detriment of good health as well as the environment. And the environmental degradation in turn affects health. We also recognize that shifting of production to low and middle income countries with poor environmental and safety regulations negatively affects the environment in some ways because of increased air pollution levels, because of a number of factories which belch out a lot of carbon dioxide and other greenhouse gases, or contamination of water bodies because of poor environmental regulation.

Drainage of water because of soft drink companies draining away a lot of needed water for production of their beverages in the low and middle income countries.

Or even poor living conditions whether it is the garment factory workers in Bangladesh who suffer because of fires breaking out in very poorly regulated conditions of work, or when you're looking at people working in South African vineyards or people

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working the tobacco factories of India, we find that while the production forces are now investing much more in low and middle income countries,they're not ensuring the health and safety of the low paid employees. And this is again, a distortion of globalization that we ought to correct. It has been said that globalization itself is a wonderful opportunity for equalization of opportunity across the world. And by spurring on economic growth, it'll not only foster better health but also reduce health inequities.

Angus Deaton differs and points out that economic growth by itself will not be enough to improve population health, at least in any acceptable time. Clearly we need growth, but we also need inclusive growth in which health inequities which accompany economic inequities are reduced. And Angus Deaton says that as far as health is concerned the market by itself is not a substitute for collective action. So the imperative of globalization is collective action, not just abandoning everything to the forces of the market. Therefore, we need to recognize that market interventions are required for protecting health. Even in the national context, we have recognized that asymmetry of information and decision-making power doesn't make health a perfect market. In fact, it's a very imperfect market. And the same thing applies even at the global level when trade and other market compulsions often negate the need for policies which are conducive to good health at the global level. Therefore, recognizing that the market is here with us and is something that we have to reckon with, we need to mold the market by adopting a number of other forces which are favorable to public health.

Firstly, we must raise consumer consciousness so that the demand for healthier products steers the industry towards them. We must also offer the industry incentives for producing healthier products by pointing out the health dividend that comes from a health society which is much more productive, which stable labor and consumer markets for a variety of goods. We need to see that public-private partnerships are much more responsible and are responsive to health concerns and produce healthier products for the global market.

At the same time, we ought to adopt national policy frameworks with political, economic, and social motivators that reduce some of the distortions brought about by globalization, whether it is nutrition which has to have incentives for healthy foods in form of subsidies, or disincentives for unhealthy foods in terms of increased import tariffs. We also need global agreements for example by way of the framework convention on tobacco control or agreements to ban advertising of junk foods and soft drinks to children. So there are a large number of global agreements also which can

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bring about some degree of balance in the market forces that dictate global health. As Nancy Birdsall, the director of the Center for Global Development remarked, globalization as we know today is fundamentally asymmetric. In its benefits and its risks, it works less well for the currently poor countries and for poor households within developing countries. In a very famous phrase, Thomas Friedman described the world as being flat; basically pointing out globalization has brought in a number of opportunities across the world reducing the asymmetries that existed prior to that. But even what appears to be superficially a very flat surface sometimes can be very tilted.

And that is the asymmetry of power, even in a globalized world. With multilateral institutions like the World Bank, the IMF, the World Trade Organization, the distribution of power is unequal. The G-8 nations account for nearly half of the global economy and trade. They hold four of the five U.N. Permanent Security Council seats and have a major shareholder control over the International Monetary Fund and the World Bank.

So even in the era of globalization, which offers considerable opportunity for other countries in the world to benefit from an integrated global economy, it is this asymmetry of both economic and political power that brings in distortions. So we need to insure that those are corrected if we are really pursuing the goals of global health and health equity. So for globalization and health what needs to be done is to make more resources available for health systems by expanding and improving the overseas development assistance, improving debt relief. That's very critical because countries which are actually in the poverty trap because of huge, unaffordable debt need to be provided support so that they can escape the poverty trap and invest much more in their own health systems. We need to reform the international trade regime, bringing in health front and center as a consideration. And ensure that the WTO regulations do not undermine what the WHO is trying to do or what countries are trying to do. We need to consider health as a human right because unless we do that, we'll not be able to set right some other distortions that have occurred because of globalization. We need to protect national governments policy space for addressing the social determinants of health in light of the unpredictable nature of financial capital. We can't leave everything to globalization which brings in investment because we know how fickle financial capital is. At the earliest sign of risk, capital flees, leaving the countries high and dry. And that can have a detrimental effect on their own investments in the health sector as well as in the social determinants of health. So we ought to be able to insulate some of the fundamental things like water, sanitation, nutrition, environment and basic health services against some of the imbalances that occur because of the imperfections in the

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financial markets. But having looked at some of the flip side of globalization, we must also recognize that globalization has several advantages to offer. Firstly, there is globalization of knowledge. Globalization of knowledge in terms of science, in terms of technologies, all of these can be highly beneficial to humanity if they're shared. And we recognize whether it is the causation of disease or interventions to prevent disease or reduce the impact of disease, this knowledge has been transformational over the 20th Century, can be even more so in the 21st Century. So we need to build bridges by which knowledge can rapidly diffuse across the world and act in favor of good health.

At the same time, in terms of reverse innovation, there is a lot happening in the low and middle income countries where because of some of the challenges faced by the health systems they're coming up with absolutely brilliant innovations which are problem-solving and low cost. And some of these innovations can now become portable even to the high income countries and they can benefit from some of this new knowledge that's being created. In terms of global financing of health, we now recognize that there can be increased funds flowing into the health sector to a variety of poor resources. Countries need not be all the time essentially living on uncertain charity. Pre-committed funds as the part of global programs for health are going to be very important for supporting some of the health system innovations in low and middle income countries and helping them to overcome their own health inequities. In terms of globalization of health norms we now recognize that communications have now transported role models across the world through the media which is now globally shared. Whereas people were looking at unhealthy foods as one of the norms, now they're looking at healthier foods, physically active living habits as the desirable social norms. Nothing illustrates this more than tobacco-free public spaces. Now in many parts of the world to smoke in public is not only legally taboo, but socially frowned upon. And these are changes in health norms that have actually come from some of the developed countries and are now rapidly moving for adoption in the low and middle income countries.

So globalization of health norms can be very effective too. And again, this can be didirectional because some of the traditional cultural norms and traditional health norms of the low and middle income countries can also be adopted by the high income countries. Globally shared goals are important. We've seen the tremendous impact of the millennium development goals and that has been an important area of global cooperation, where a shared vision enabled different countries to work together to reduce maternal mortality, child mortality, under-nutrition and poverty. But for all of

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this to happen, we need globalization

of solidarity. You cannot have narrow, self-

serving sectoral interests driving the forces of globalization.

You need a common commitment to global good as the unifying force of globalization where we are looking at economic inequities being reduced, we are looking at health inequities being reduced and we recognize human welfare as something that we're all concerned about as a common human family. So if we can actually make that as the unifying platform of globalization, then we will be able to eliminate or substantially minimize the distortions of globalization on global health and really build upon that solidarity for advancing global health to levels that we have never seen before and reducing health inequities to the lowest possible. Go back to start of transcript.

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3: Infectious Diseases

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3.1: The Changing Patterns of Infectious Diseases in Time and Place Hello, my name is Richard Cash, I'm a visiting professor at the Public Health Foundation of India and on the faculty of the Harvard School of Public Health in Boston, Massachusetts, USA. In this lecture on infectious diseases, I'll be covering a number of topics in the various chapters. This first one will be on the changing patterns of infectious diseases in time and place, that is looking at infectious diseases in a somewhat historical context.

I'll also be covering the control or eradication and elimination of infectious diseases, zoonoses, emerging and reemerging infections, and lastly diarrhea and respiratory diseases in children as they are a major killer in this group of individuals.

Before we get into this historical look I want to give you some common definitions. What is an infectious disease? It's a disease caused by the entrance into and growth and multiplication in the body of...of an individual of bacteria, Rickettsia, viruses, parasites, protozoans, fungi and prions. All of these are considered infectious agents. Another term which we should become familiar with is incidence. This is the number of new cases that occur per unit time. That time could be a day, a week, a month, a year. But time is very much a factor here. Prevalence on the other hand is the number of cases that occur at any one moment in time, today for example.

I'm going to give you an extremely abbreviated history of epidemics, that is a large number of cases occurring, although that number could be just one. And pandemics which are epidemics that cover the global world. Diseases associated with

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many of these epidemics include plague, smallpox, influenza, cholera, yello fever and measles. Now some of these are more historical because they don't occur today, especially smallpox and plague and yellow fever, but they are important. An example of a devastating pandemic was the black death from plague that peaked in the 1346 to 1350 time period and it was estimated to have killed 30% to 70% of European population. Smallpox and tuberculosis, killed up to 90% of the indigenous population of the New World when they were introduced by the Europeans. Cholera pandemics began in 1816 and now take up, we're in the seventh pandemic worldwide. The largest single pandemic was that of the 1918 influenza pandemic which led to between 75 million plus deaths worldwide. These infectious diseases can be noted in history where they left their mark. For example in this mummy Ramesses V dated about 1157 BC we can see evidence of smallpox lesions. The pandemic epidemic that I want to focus on in the next pictures are those of plague. Plague was so common and was such a killer in Europe that there were dances of death that were developed to deal with the large numbers who were dying in various communities. This is a picture of a bubonic plague from one of the Bibles and we would probably not find these lesions to be consistent with plague today but this is the way people saw them. Doctors would oftentimes have very little to offer and would go around in these long black coats wearing these masks shaped like that of a bird's head which limited the air that they would breathe in since they believed,in some cases correctly, that the miasma- the surrounding air, is what caused these diseases to occur in populations. People were so afraid and felt that the devil had entered their body and that's why they would get these diseases that people would go around the countryside flagellating themselves to try to get rid of these evil forces and to show that they were deeply religious. Unfortunately, one of the things that often occurs in any epidemic or pandemic is we tend to blame the most impoverished, the poorest people who are there as we see them as the ones that have caused this to happen. And of course this is oftentimes very untrue. Jews who were burned alive because they were thought to be the cause of the Black Plague.

Oftentimes people were labeled as witches, as other non-desirables in populations and so that if we got rid of them, the plague would go away. Of course we even do this today and we've done it today with HIV/AIDS and other similar types of pandemics.

This is the organism that causes plague. This is called Yersinia pestis, it's shaped a bit like a safety pin and these are transmitted through these fleas. Obviously not this large but these fleas live on the body of rats, Rattus rattus and so oftentimes when there would be a rat die off these fleas would escape and then bite humans

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causing the plague. Sometimes there were large numbers of rats because the cats had been killed in some communities because they were seen as the animals of the devil. In addition to the tremendous number of deaths that occur, we also have to look at the historical changes brought about by any large pandemic. For example in the Black Death there were huge demographic changes. With 30% to 70% mortality in many areas of Europe, which took at least 150 to 250 years to recover. There were labor shortages, serfdom disappeared, wages became higher, labor saving technologies developed because there was a shortage of labor, land became plentiful, see these were all actually positive outcomes, despite the high numbers of death.

However religious intolerance and the tradition of blaming others also increased and this was a time, oftentimes of religious intolerance that went through the countryside. Let's go back to the terminology that we started talking about. If one is exposed to an agent, an infectious agent, a number of possibilities could occur. That is nothing, there could be clinical infection, the second line, or sub clinical infection or the person could carry the organism but not be sick. For clinical infection, one could see that death might occur, immunity that is what that an individual recovering from the disease might be immune or they might carry it or they might be non-immune and for the sub clinical infection of course there wouldn't be death but immunity, carriage, and not-immunity might also occur. Also there are a number of factors that influence disease transmission and we should be aware of these. One is the agent itself which is the bacteria, viruses and so on. How infectious is it? What kind of illness does it cause?

What leads to its survival or death? Then there's the host which is humans or animals, our age, our sex, our behavior, our nutritional status and so on, our health status, and then there's the environment in which we live. What is the weather like?

The housing? How crowded are people? What is the geography and what occupations do we have at the time that make it more susceptible. What's the quality of the air, the food, our socioeconomic status and even the political nature of the situation. Now again, when something infects an individual there are a number of outcomes. An individual becomes infected and then there's an incubation period which then leads to clinical disease or no disease. When somebody is incubating that infection, that is they're not sick but that it's growing in their body, there is a latent period. A period when they're not infectious at all. They can become infectious, even before they get clinically ill, and it is during that infectious period that they can infect another. So you see in the first patient there's the incubation and clinical disease, a latent period, in infectious period, and during that infectious period they infect the second patient.

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This gives you an example of how infectious diseases have changed historically.

In 1909 the percentages of infections in Chile causing mortality and morbidity was about 50%. Fast forward to 1999, those figures are now down to about 22%...23% so in 99 years, or in 90 years, we have seen a dramatic reduction in the importance of...of infections as causes of mortality and morbidity. We're going to look at what we can do to reduce the importance of infectious diseases. There are a number of basis of infectious disease control. One, what is the quality of water and sanitation? What kind of water are we putting into our body?

And how do we dispose of human waste and other waste? What about improved hygiene, hand washing for example. Housing- By decreasing crowding we can decrease diseases like tuberculosis. Improved nutrition also has a bearing because the host is stronger and able to combat certain infections. In the last 70 years or so we have developed incredible array of vaccines and antibiotics or antimicrobials. And lastly there have been certain behavioral changes. Here's a young girl in a program that is teaching kids the importance of hand washing and how you can use soap and water to reduce risk, particularly after going to the bathroom for example.

Unfortunately in crowded cities in many low income countries waste disposal through these latrines which are over-hanging a body of water in which kids sometimes swim and which are right across from a better off section of a city also leads to environmental contamination and increases the risk of the transmission of infectious agents. Far better that if we could put even this simplified form of a SanPlat latrine which people could use to get rid of waste rather than putting it directly into the water as shown earlier. Going back to vaccine development, the first one was in 1796 where Jenner used cowpox to in fact protect people against smallpox.

We'll see more of this later. In the 1800s we then had the development of rabies, cholera, typhoid and plague vaccine, but the huge increase occurred in the 1900s with diphtheria, pertussis, BCG which is for tuberculosis. In the 1950s we developed poliomyelitis vaccine and then in the 18...1980s, '90s and to the present day there's been a huge development in vaccines such as hepatitis A and B, pneumococcal rotavirus, meningitis, et cetera. The first antibiotics interestingly enough, this was not the first but one of the first, go back really to the late 1930s with sulfonamides but here is streptomycin, 1943 it was developed by Selman Waksman and first given to patients in 1944 for tuberculosis and you can see from this list of tuberculosis drugs that at least seven, and there are many more actually that have been developed since that first...since the first discovery of streptomycin.

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We now have other anti tuberculosis drugs which are used particularly against the drug resistant tuberculosis strains. Now lastly, I want to go back to our examination of the basis of infectious disease control and indicate a few other measures that we can use. One of these is surveillance and reporting, that is who is getting the disease, where are they getting it, and so on. So that we can then institute certain disease control programs, be it against malaria, other vectors, parasites. And we can institute preventive measures such as the promotion of hand washing, screening, education in schools, behavior modification, social marketing and so on and lastly the development of early and effective and affordable therapy to deal with the infections that are...have occurred in the past and will continue to occur into the future. So in this first brief lecture, I've tried to give you a few definitions of infectious diseases and how they might be transmitted. I've tried to look at the history of one of these, that is bubonic plague and pneumonic plague, and lastly to give you a brief outline of some of the basis for infectious disease control.

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3. 2: Control, Elimination, Eradication, Extinction.

In this chapter I'd like to look at the control, elimination, eradication and extinction of infectious diseases. Again, let's look at some definitions here. By control we mean the reduction of the prevalence, that is the number of cases at any one time, incidents, the number of new cases over a period of time, to locally acceptable levels which is usually interpreted to indicate no longer a public health priority. Intervention however is still required. Elimination is the reduction of disease to zero and or infection to zero.

The intervention, however, may still be required. An eradication is the permanent reduction of global, we're now talking about the whole world, incidence of disease to zero with the organism not present in nature. No intervention at this point is required. And now let's take a look at some of these terms as they play themselves out.

The criteria for eradication which is the area I'm going to focus on in a moment is that humans are the only reservoir and there are no non-human vectors. Now we're talking about eradication in people.The absence of a carrier state. That means that people don't carry the organism even though they're not sick. The feasibility of the intervention, is it effective? Is it acceptable? Is it affordable? Do we have ways to monitor whether this infection is present in the community, surveillance?

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Are people concerned and fearful enough that they will buy into these programs and does government have a strong enough commitment to try to eradicate a condition? Now infectious diseases that have been eradicated, there is only one and that is smallpox. And this was done primarily through a vaccine. Other infections that have been pretty much eliminated from many countries are guinea worm, which is only now found in some parts of sub-Saharan Africa, neonatal tetanus or the tetanus of the newborn.

Again, vaccines here. There are still some cases but not very many even though the tetanus bacilli exists in the ground around us. Polio, we're very close to eradicating this through vaccine but there are still cases in some parts of Africa and South Asia.

Diphtheria, these have come way down, as has leprosy. The...but again, smallpox is the only human disease that we have been able to eradicate. There is a disease in cattle called rinderpest that has been eradicated, but this is the only one for humans.

This is what smallpox looked like. It was a terrible disease. This child has lesions all over the body, it sometimes would in addition to causing a lot of deaths, it also caused blindness, and many other complications.

This was a typical picture of a smallpox case. I'm now going to talk about the vaccine that was developed to deal with this. It was noted by Edward Jenner, a practitioner in rural England, that cow...that women who milked cows, cowgirls I guess you'd call them, did not get smallpox and he noted that on their hand was a lesion that was gotten from the cows that they worked with which was cowpox. He reckoned that if it protected these women and he took this from one woman who milked cows, Sarah Nelmes, that maybe this would protect people against smallpox.

And in fact, he tried out the first vaccination was in 1796. Now prior to this, people had taken the serum, the lymph from the smallpox lesion of very mild cases and gave it to people hoping they would also develop mild disease. Sometimes it worked, sometimes it didn't. Now despite the fact that this was shown to be extremely effective, there was a lot of resistance against this.

This is a picture from a British publication, a humor publication called Punch and here is Jenner in the middle and people have cows growing out of their arms, their back sides, their face and so on. People figuring if they got the cowpox they might even turn into cows. Now, smallpox actually had eradication potential. What was that? Well, going back to those earlier criteria, there was universal fear, there was no animal reservoir, people were the only ones who had this disease.

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Nobody was a carrier, there was lifelong immunity after a single episode and a characteristic rash. There was no transmission from subclinical cases, as there were none. And we had a very, very effective heat stable ' (We didn't need a refrigerator) vaccine and we had the development of a needle called the bifurcated needle which allowed us to easily transmit the vaccine to an individual.

We also developed a very effective way of searching and containing this because smallpox moved relatively slowly through populations, once we found a case we could immunize around it so the case would be the orange circle there, we could then immunize around it, that would be the purple, and then we could also immunize the contacts of the contacts by taking these circles and moving out in this ring vaccination area we could reduce and eliminate smallpox from areas without having to immunize absolutely everybody in the population.

We also minimize adverse events and we found that this vaccine was highly efficacious in preventing disease. The last case of...major case of variola minor occurred in Bangladesh in a young girl, Rahima Banu in 1976 and in 1977 the last case of variola minor appeared in Somalia in Ali Maow Maalin who just died recently. He devoted much of his life to also dealing with other disease elimination and eradication programs.

The next disease I'd like to address is polio. Here are some children, we don't see this very much anymore, because polio has almost been eradicated and has been eliminated from almost every country of the world. These children would develop paralysis, primarily in their legs, and in some places they would have to be beggars unless there was some way of looking after these children.

In certain cases the disease affected the bulbar region of the brain and people would have to be on respirators, sometimes for lifetime because they could no longer breathe on their own. But with the polio eradication campaign globally we are down to now hundreds of cases rather than hundreds of thousands of cases. Getting those last few cases of course are extremely difficult so we can not say that this disease has been eradicated but it has been eliminated from probably 98% of the world. This is a very inexpensive, very efficacious vaccine.

This is the oral vaccine. There's also IPV which is an injectable vaccine but it is more expensive. If you look at the polio incidence by month, just in a four year period between 1994-98 in India, you can see that it was very high in 1994, peaked to over 110,000 cases, then came down in 1995 and at the end of '95 and the beginning of '96

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they had national immunization days where they gave the vaccine to every child under a certain year. I think under five years of age.

This was repeated again at the end of '96 and '97 and again at the end of '97 and '98 so that the number of cases came down dramatically. In fact, India has now been declared polio free and it has been eliminated officially from this country, which is a huge undertaking given the population of 1.2 billion There are other infectious diseases that have decreased dramatically in incidence, that is the number of new cases, with a significant reduction in mortality and morbidity. Measles is one of these which is a major killer, was a major killer of children.

Rheumatic fever which affected the heart, hepatitis B which sometimes leads to liver cancer, and also peptic ulcer and helicobacter where treatment of these conditions with blockers of stomach acid and antibiotics has greatly reduced the incidence of these conditions. Here's a child with neonatal tetanus, a condition which we rarely see today and that's because now mothers are immunized against tetanus and they pass this immunity on to their child until that child can be immunized themselves.

And lastly here's a picture of measles which has been up until recently a major killer of children in low and middle income countries. So what I've tried to do in this last chapter is to review for you control, the terms control, elimination and eradication. I haven't dealt with extinction because extinction means that there is no presence of this organism anywhere in the world and most of these organisms exist still in some laboratories.

I've shown you eradication as it occurred with smallpox and the efforts that are going forward with polio. And lastly we've looked at a couple of diseases that have come down dramatically in their incidence and prevalence in the world.

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3. 3: Zoonoses In this next chapter I want to take up the subject of zoonoses. Zoonoses is an infection or an infectious disease that is transmittable under normal and natural conditions from vertebrate animals to humans. It may be enzootic or endemic or epizootic or epidemic.

There's also another term, zooanthroponosis which is a disease transmitted from humans to animals. Now there are different types of transmissions with zoonoses.

There is direct transmission, that is intimate contact with an infected animal, a person such as with a bite, a scratch, a spray by infectious urine, contact with fecal material, inhalation of a discharge, respiratory droplets due to coughing or sneezing, airborne spread, this is direct transmission. Then there is indirect transmission where there is an arthropod vector such as a flea, a mite, a mosquito, a tick and fomites such as cockroaches that are contaminated with the particular product going from an animal to a human.

Another term we should be familiar with is species jumping. This is the transmission from animals to humans followed by human to human spread and this is the group that we are most interested in. That is, we shall see with HIV/AIDS, with SARS, with flu, that the particular agent went from an animal to a human and then began to spread from human to human. So the first one I'd like to take up is SARS or severe acute respiratory syndrome.

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If you'll recall, this completely paralyzed the world a number of years ago because the mortality was quite high from this. Well, it turns out that SARS as we found out much later on was due to a particular virus called the coronavirus which was found in a particular animal called the civet cat which was slaughtered in some of the markets China.

But these civet cats had in fact been infected by bats, so it was bats that had the coronavirus, it infected the civet cat, the civet cat when they were killed, the spray of blood, sometimes people inhaled, they got it and they were then able to transmit it to other humans and it led to a type of pneumonia and if you'll recall there were often pictures such as this from China, which is where the disease particularly had a major impact although it then spread to Honk Kong and Singapore and Canada and to Vietnam and so on. It never became the global pandemic that some of these conditions can become.

This is the latest of pandemics, this is the Ebola virus. Many of you have heard about this. It's been particularly devastating in West Africa in this recent outbreak but it has occurred in central Africa as well, and let's take a look at this particular virus which has been considered very contagious thought not very infectious. That is it can spread from one person to another through contaminated feces and blood and so on but doesn't spread from person to person in a crowded room for example. It doesn't spread through the aerosol route but rather through the blood and feces and so on of individuals who are infected and sick.

They have to be sick with this disease. Here are some of these workers carrying...wearing these gowns to prevent them from having contact with this particular virus. This virus has probably, though we're not sure, been spread by fruit bats, that is the bats again carry this particular virus. The bats may have contaminated food that was then eaten by an individual and that individual developed this disease, Ebola, and then spread it to other people through their bodily secretions. But it was the bat that originally harbored this virus, and then spread it, gave it to people and it was through the person to person spread that it has taken off. Let's take a look at another one of these zoonoses. This is one called Nipah virus. Quite interestingly, again, this giant fruit bat and why they harbor these viruses we're not sure and it's very uncommon actually, would eat some of the fruit of these trees in Malaysia that were planted in areas where pigs were pigs were grown.

The pigs ate the fruit that fell to the ground and because this fruit was contaminated by the virus, the pig in eating the fruit developed an infection. When

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these pigs then were taken for slaughter and killed by, in the Abattoirs, the slaughterhouses, the men who were involved in this in the pig killing got the infection from the pig. So it went from a bat to the fruit to the pig to the people who were killing the pigs and up to 250 people about developed or died from this condition, a mortality of around 40% or 50% and this occurred in 1998 and 1999.

And to get rid of this particular condition, first of all when the pigs became sick the first thing people did is they took them to market, so oftentimes these sick pigs, and they had developed a pneumonia, were taken to market and people would buy it unsuspecting that this might be this particular condition. And the way that Malaysia eventually got rid of this Nipah virus is they took pigs and they killed them and there is no longer a pig industry in Malaysia where at one time it was quite flourishing.

This now takes us up to Bangladesh and in Bangladesh there was also an outbreak of Nipah virus and they couldn't figure out how did this virus get into the human population. Because there were no pigs in that part of Bangladesh. It was a predominantly Muslim society and pork was not eaten, but they pieced together a story that showed that when these bats went to this date palm juice now here's a pot on a palm tree that is collecting date palm juice which is a sort of sweet juice that can also be made into something called gur which is a type of sugar.

And when they would lick this because they're fruit bats and it was very sweet and sometimes they would defecate into the pots. The men who sold this and this date palm juice was considered quite a delicacy would take it from house to house and sometimes this date palm juice was contaminated and individuals who took it would get Nipah infection and the mortality again was around 40% or 50%, sometimes 60%. This was a meningoencephalitis, that is it affected primarily the brain. Here are some bats flying just at dusk and they're quite large, they have a large wingspan but they only drink fruit and sweet things. So the way to get rid of this was to put a skirt of bamboo over where the sap came from the tree into the pot and by doing this you can actually reduce the contamination of the date palm juice because the bat can not have access to that sap that's coming from the tree. So again a bat to the fruit, contaminating that, humans ingest it and it can spread from one person to another only on very, very intimate contact.

And this is only through respiratory droplets, so it's not like someone can walk into a room and cough and others would get it. You have to be extremely close to the individual to get this particular infection. So how do we control the transmission or the introduction of zoonoses?

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Well, this diagram here shows the linkage between wild EID is emerging infectious diseases, domestic animals and humans. And you can see that they interact.

Now I'm not going to go through this entire graph but let's just take a look at a few of the linkages. The linkage, say between wildlife and domestic animals. Here if domestic animals are closely associated with certain wildlife as we saw with the Nipah virus in Malaysia, there's a spillover effect and these domestic animals can pick up the infection. If we look then down to the bottom of domestic animals and look at the food processing technology industry, we see that this virus got into humans through the infection in pigs which was then picked up in the slaughterhouses and then in humans it spread from person to person.

So we have to break a number of these links between wildlife and domestic animals, between domestic animals and humans and even between humans and wildlife and so a lot of the strategies that have been developed to control zoonoses have focused on this type of diagram that we see here.

All or most of the new and reemerging diseases, not all, will in fact be related to zoonoses so zoonoses are clearly very, very important and extremely costly. Bovine spongiform encephalitis or mad cow disease costs the U.K.

over $9 billion in lost

revenue. The Nipah virus which I just talked of cost Malaysia $540 million because of all the slaughter of pigs that had to take place. SARS which we started with cost China upwards of $50 billion because of the lost revenue from trade and tourism and so on and avian flu, H5N1 which we have not covered is going to cost billions and billions of dollars. In fact, another type of flu, H1N1 or what was called unfortunately swine flu, this is just a picture of the economic impact it had in Mexico where this beach would be filled with tourists at a particular time of year and of course it's empty now because people are afraid and go elsewhere.

What I've tried to do in this brief time is to talk about the importance of zoonoses. That is the diseases which linked animals to man and how they can spread, how they develop, SARS, Nipah virus are but two examples and there are many, many others. And then how they might be controlled and the economic impact that they can cause. We must be prepared to put much more attention into zoonoses and there is a global program called One Health which is trying to do just that.

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3. 4: New and Re-emerging Infectious Diseases

Today's chapter, is going to be on new and reemerging infectious diseases.

Let's again try to define these terms. Infectious diseases with an incidence in humans that have increased in the past thirty years or threaten to increase in the near future we tend to term new and reemerging infections.

Now new infectious diseases that have come about in that, roughly in that time period would include HIV/AIDS, SARS, Lyme disease, Nipah virus, influenza H5N1 or H1N1. Infectious diseases are however often times emerge in new places and they are sometimes called reemerging diseases. This would be diseases such as West Nile virus and monkey pox.

Then there are diseases that reemerge in drug resistant forms. A particularly worrisome group which includes malaria, multiple drug resistant tuberculosis, and some bacterial pneumonias and sexually transmitted diseases. Now there are a number of factors that have contributed to the arising of new and reemerging infectious diseases.

These might include increased population density, inadequate infrastructures for water and sanitation, movements of people through travel and social disruption, the centralized production of food and it's distribution, environmental changes, misuse and overuse of antibiotics and other drugs, changes in human behavior and sometimes dysfunctional governments.

Let's look at some of these in greater detail. In terms of the increase in population it was estimated that the population in 2000 was about 6.1 billion people and by 2050 this will come close...become close to doubling to 9.4 or 11.2 billion

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people. We're also seeing a tremendous increase in urbanization going from 47% in 2000 to 60% to 65% increasing urbanization of the global population.

Now as the population of the world increases of course there are going to be greater contacts between humans and wildlife in habitats that normally we don't venture into and because of this interaction with both humans and our animals, we may see the rise of new viruses.

The coverage of water supply, particularly in least developed countries, is also very problematic. Particularly in both urban and rural areas in least developed countries the percentage that have access to potable water is anywhere from 50% to 60% Most of the drawing of water in rural areas and in urban areas is work of women. That is, they are the ones who are doing all the work of getting it from wells, from rivers and so on and taking that water back to their home.

This is assuming that there is not an indoor water tap. And in this, the bringing of water into urban areas through trucks and so on where people are then forced to come to this area, collect the water, take it back to their home, is another way of distributing but it's also very problematic as that source could be contaminated as well as the buckets and vessels which carry the water back to the home could also be contaminated. It also limits the amount of water that's oftentimes available. The disposal of human waste is an increasing problem.

The privies are directly linked to a body of water which connects to other parts of the city and that...that fecal disposal is of course quite unsatisfactory. We are increasingly discovering that open defecation may well be linked to under nutrition in children where this is a broad problem. The increase in travel both internationally and locally also provides opportunities for diseases to move about.

We can move Ebola from one country into another in a matter of a few hours by air and we have seen this...this happen. No place in the world is unconnected to any other. We are really truly a global village. The production of food on an industrial basis has allowed for increasing availability of food, both grains and meat, but has also intensified the use of antibiotics and the raising of animals and where a central food supply is contaminated that contaminated food then travels far and wide.

It's not the same as getting milk from your local farmer or buying vegetables at the local farmers market. When we buy vegetables and fruits in many of our large cities of the world we have no idea where this comes from.

Here's the production of chickens in an industrialized production where thousands upon thousands of chickens are grown together in oftentimes extremely

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inhumane circumstances where they have no movement and so on and one can see that where a disease would enter this population it would destroy many, many chickens in a short period of time.

This is of course quite different than what takes place oftentimes in local areas where there may be one purveyor of chickens from a few individuals in the community.

Where ecology is involved is of course in climate changes, where temperatures have increased in certain areas which have allowed for the introduction of mosquitoes for example that had not been there in the past. The tires are often traded internationally but when one trades in tires, there's oftentimes water that is in the bottom of the tire and those...that water will you don't need much to set up a breeding ground for mosquitoes.

Those mosquitoes can then carry the viruses from where they came from to where they are going. And then the misuse of and overuse of antibiotics has led to the development of antibiotic resistance. We have only had antibiotics really for about 70 years. A blink in the eye in terms of evolution and yet we have managed to create a number of organisms that are extremely difficult to treat and far more expensive to treat.

For example, multiple drug resistant tuberculosis is much more expensive to treat than is regular tuberculosis. Artemisinin which is the last, the latest drug we have to treat malaria, the last in the line, resistance is developing to that even though we treat these...malaria now with three drugs to try to avoid resistance to artemisinin.

Tetracycline for cholera, multiple drug resistant gonorrhea which is a problem and in our hospitals, multiple drug resistant staphylococci which can infect wounds and cause devastating diseases. I would now like to focus on one particular new disease that has taken the world by storm over the last 30 plus years and that's HIV which leads to AIDS. One might ask, where did HIV come from?

Now is it a..... It's defined as a new disease. It most likely came from somewhere in sub-Saharan Africa. There is a, an infection in some of the great apes, simian immune deficiency virus. It might well have been that someone in the forest or in a market was skinning a, a chimpanzee or a related species and cut themselves with a knife that carried the blood of this animal and therefore infected themselves. And unfortunately this virus adapted itself to humans.

It then spread from that person through sex most likely, but it could have been through other means to another person and so on, until there was a critical mass of individuals who were infected and then the epidemic gradually increased. And then of

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course spread globally over time. We don't know the initial events but it would seem to be that this was a zoonosis where the organism adapted itself very effectively to human beings.

The distribution of HIV even though it came upon the world within probably five or six years it had been introduced everywhere, you can see that the distribution is of quite variable with most cases occurring in sub-Saharan Africa and if one looks at the population to case ratio, it's even higher in that part of the world. Which raises an interesting question: why though HIV appeared in the world in many parts of the world around the same time, why has the spread been heterogeneous, not only globally, but even with the epidemic in sub-Saharan Africa?

And I'd like to explore those ideas for just a moment to look at why this might happen and what does it tell us about prevention of these conditions? Now the spread of HIV in sub-Saharan Africa between 1984 and 1999 was quite interesting because it in 1984 it was fairly evenly distributed. By 1999 this had become a disease much more in the very southern parts of Africa and eastern Africa and West Africa in some parts have remained somewhat unchanged, Senegal, Mauritania, Niger, and so on.

The dark red represents the highest prevalence of HIV. Now there are certain risk factors, I'll call these proximal determinants that are associated with HIV/AIDS, the getting of the obtaining of this infection.

Clearly transfusion with contaminated bloods or contaminated needles and syringes which is like a mini-transfusion. Unprotected sex with a single or particularly multiple partners can increase your risk substantially. Mother to child transmission through delivery and breast feeding and interestingly the non-circumcision of men in certain parts of the world. Let me look at that last issue. Male circumcision interestingly enough is probably one of the oldest forms of surgery going back to at least 2200, 2300 years before the common era, as seen in this hieroglyphic from ancient Egypt.

The circumcision rates in different countries in sub-Saharan Africa you can see are quite different with the highest level of...of AIDS in those countries which have the lowest level of male circumcision.

Now why should male circumcision protect one? Well, it turns out that the inner lining of the foreskin contains cells which have a particular avidity for the HIV virus as well as the human papillomavirus which is associated with cervical cancer. Also when one removes the foreskin, the skin underneath hardens a bit and is more impenetrable probably to the virus itself.

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So there are biological reasons for why this particular simple operation reduces risks. We should remember that the initiation or the institution of...of male circumcision which by the way has nothing to do with female circumcision, was related to tribal or religious identity. It was not initiated initially to as any type of health measure.

Certainly we didn't know about these issues hundreds of years ago when these practices were introduced. Now distal determinants, that is those factors that affect the proximal determinants would be socioeconomic conditions, domestic violence, the status of women, the degree and type of migrant labor, sexual practices and values as defined by culture, and we have to be very careful that we don't associate practices and values with any kind of ethical or moral character of the individuals involved. They have their antecedents in other...in other issues.

And then concurrent partnerships. This is having many partners over a week as they have...having those many partners serially over the course of a year. Now what strategies then can we use based on these risk factors to reduce the possible risk for HIV? Well, if we delay the age of sexual debut that is when adolescents begin to have sex, we clearly reduce the time when they're going to be exposed as we would be reducing the number and the exposure to high risk partners. If we reduce the degree of concurrency that would also reduce risk.

If we limit alcohol and drug use prior to sex we make sure that the inhibitions to using condoms for example are not taken away. We can increase the level of male circumcision where the rates of HIV are very high and this would be again very much in southern Africa but not in East Africa but not in many other parts of the world. We could presumptively treat some sexually transmitted diseases to reduce transmission and certainly test the blood supply and needle exchange and syringes for I.V. drug users.

One could also treat individuals who are HIV positive and thereby limit the transmission of this to their partners. This is problematic however and is not as easy to implement. If one looks at this schema of the HIV infection, one will notice that the first few weeks, months is when we have the highest level of viral particles in our blood, viremia. It is during that period of time when one is most likely to transmit the infection.

So if one has a number of partners during that time, has sex shortly after one is infected, you are more likely to transmit the infection than when you enter the asymptomatic period which can go on for a number of years. Now we can measure the viral load in the blood and we can also look at other associated factors such as the CD4

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count but it's those first few weeks, months maybe, that we are most likely to transmit the infection because we don't know we're infected. There is no way of telling other than to do frequent HIV tests which is somewhat impractical. We can also reduce the risk of infection post exposure.

That is, if someone is exposed, we can give nevirapine for the transmission, to reduce the transmission of mother to child. We can treat with ARVs as I noted post exposure or even give it prophylactically especially to high risk groups, people who have multiple partners for example.

The use of vaginal microbicides has also been recommended but these are the factors that you can do post exposure. Clearly it's far more practical if we can prevent the infection to begin with. Well, what I've tried to do in the...in this brief chapter is to look at new and reemerging infectious diseases. Why they occur, what are the risk factors in the modern day world. I then focused on HIV/AIDS as an example of a new and reemerging disease.

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3. 5: Childhood Diseases with a Focus on Diarrhea and Pneumonia In this next chapter I'd like to look at some childhood diseases that are particularly common in low-income countries and focus particularly on diarrhea and pneumonia, as they provide some very interesting examples of both how to prevent as well as how to treat these conditions so that the mortality and morbidity continues to go downward.

The pie chart indicates the prevalence of each of these conditions in today's world. You can see both diarrhea and respiratory diseases make up a large segment.

And in some parts of the world, malaria is a major contributor as well. This is mostly in sub-Saharan Africa. Now here's a child with a severe dehydration caused by diarrhea.

Dehydration is the loss of fluid from the body. It'd be like if you took a grape and made it into a raisin or a plum into a prune. And you can see the child's eyes are sunk back.His breathing would be deep and rapid. His pulse would be rapid. He'd have very little urine output.

All signs of the loss of fluid and electrolytes. And here is a, a much younger child. And here you see the top of the head is depressed. This is called a fontanel, soft spot to many of us, before it closes. And here the dehydration has led to this sort of depression of the fontanel. Sometimes mothers would actually put mud or other substances there to try to draw this out, not recognizing that it might be due to dehydration.

For a long time, in the summer months particularly through out the world, America, Europe and in lower-income countries you would see this scene in hospitals.

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Bed after bed after crib with children with diarrhea. And you could see here the dehydration, the loss of food and electrolytes are being replaced by I.V- intravenous solution.

That's fine if you have that solution, but in some parts of the world, this was very hard to come by. The IV solution wasn't available or if it was available, it was expensive. You needed the tubing and the needle to insert and someone to do it. So there was a search for many years to find something that could be given orally, as this would eliminate the need or greatly obviate the need for interven...intravenous fluids.

Now I show you this picture of a cholera cot, which is a wonderful piece of appropriate technology designed to be used with someone who significant diarrhea.

And it's simply a, a jute cot with a plastic sleeve that fits over it with a hole right where the buttocks would be. And that plastic sleeve goes into a bucket. So the liquid stool goes through the hole, through the sleeve, into the bucket. And one can then measure how much fluid has been lost. And the simple way of treating diarrhea is the patient gets exactly in what they have lost.

And a way of measuring the level of hydration of course is whether they're putting out urine and the concentration of that urine. Here's a little girl who's severely dehydrated. You can see again, that face that she looks. Again her pulse would be rapid. Urine output very low, rapid deep breathing. Now the mother is giving her an oral solution with the proper amount of electrolytes and glucose, that's the magic ingredient.

And to hydrate her. She's alert enough to take it by mouth. And just a few hours later, here's that little girl again and you can see a tremendous difference in the way she looks. The basic principle is simply this, a plant without water and you restore that plant by giving water and in the, in the case of diarrhea, electrolytes. Now what is the oral rehydration solution? It's simply sodium chloride- table salt; sodium bicarbonate or Trisodium citrate; potassium chloride, and potassium is found in bananas and various fruits, citrus fruits; and glucose. Glucose is the key. And you can see on the other side that the sodium chloride, potassium bicarbonate and glucose are the millimoles per liter.

In today's solution, the sodium would be down to about 75 millimoles and the bicarbonate would be somewhat lower. And.... But that would be the major changes.

Lower sodium chloride, slightly lower glucose and so on. But the basic principle and the basic composition remains the same. The message of course is to hydrate, hydrate, hydrate, because without the hydration other things can occur that will be a detriment

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to the individual, including circulatory collapse. To remind you, the...another side effect of continuous episodes of diarrhea is under-nutrition. Oftentimes because the mother will not necessarily feed the child, sometimes doctors recommend against it, unfortunately, and also the child may lose their appetite. Here's a child who's got severe marasmus. You can see the thin extremities. The child seems to be sensitive to light. The hair is thinning.

And this is obviously a very poor family. Also the giving of a bottle of milk through the bottle can also be problematic if the water is not clean and if it sits out in the sun and bacteria are allowed to grow. Here's a child who's had multiple episodes of diarrhea and formula feeding. And you can see he has severe marasmus. So breastfeeding should always continue. And mothers should continue to feed their children if they have any appetite whatsoever, with whatever food is presently given to the child.

So if the child wants to eat and the child is hungry, the child should be encouraged to eat. The teaching of this is best done of course in the community itself with three or four women who are taught now to prepare, shown how to prepare it and actually prepare it, which is what is being conducted here. You also notice lots of children around and these kids are picking up the message, just like their mothers are.

And since children learn quicker than adults do, they're going to carry the message into the community as well.

One of the early tests of the oral rehydration therapy was in a refugee camp in 1971, refugee camps, where people from, refugees from what was then East Pakistan fled into West Bengal. And here they took up residence essentially in the pipes that were going to be placed in the ground to take away sewage. And when one lives in these kind of circumstances, you can guarantee that diarrhea is going to be a major problem unless there is strict attention paid to water and sanitation. And if that occurs then the treatment of this both in adults and children is essential. Another example of that is this is from a flood that occurred in Bangladesh. These occur periodically. This was 2007.

And you can see individuals in an urban setting are trying to get clean water, even through a, a tube well pump which is almost totally submerged. This led to a major outbreak of diarrhea where up to 44,000 patients were seen at a treatment center within a nine-week period. What is interesting about this picture is that the family members are very much engaged in the treating of their loved ones. This is very critical because in these huge outbreaks it's very difficult if not impossible for the

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medical staff to treat everyone. So one can engage family members who can be taught rather quickly how to deliver oral therapy and how to feed the patients and so on. And in that 44,000 cases, there was no one death from diarrhea and dehydration. This is a, an example of a packet that was found.

This is for 500 cc's which is now the standard in many countries. One liter is the standard in many other countries. So this, these salts can be given through a distribution scheme of these packets, as long as the packets are designed for whatever standard container people have. The next area I'd like to address is pneumonia, especially bacterial pneumonia, because this is what kills children.

A number of years ago WHO developed what's called an algorithm, a way of looking at pneumonia and deciding how to treat it given the severity. So in this particular algorithm you'll notice on top that very severe pneumonia is defined as when the patient is confuse...cyanosis has set in. That is the child looks a bit blue, their lips look blue. They're unable to drink. They're unconsciousness, state of consciousness may be reduced.

They're clearly very, very sick. Severe pneumonia is when the lower chest indrawing occurs and these children also need antibiotics. Where the respiratory rate is accelerated in the next box, going down, either above 50 is the child is two to eleven months or above 40 is one to four months, pneumonia is also the diagnosis. But if none of these occur, the child need not be treated for pneumonia. Now fortunately there are a number of vaccines that can prevent acute respiratory infection, many of which lead to pneumonia.

Pertussis vaccine, diphtheria. Measles is a very important component, a very important vaccine. As is HiB conjugate vaccine, and the pneumococcal conjugate vaccine, two vaccines that have appeared on the scene in the last number of years that can make a significant impact on the incidence of disease. I put in meningitis because although it doesn't cause pneumonia, it is a respiratory infection. Lastly I have this last picture in to remind us that malaria in some parts of the world can be a devastating disease to young children.

This is simply an Aedes aegypti female, cause it's only the female that takes a blood meal to help to grow her eggs. And you can tell the kind of mosquito by the white banding on the legs. So malaria can be a devastating disease to children, especially in low-income areas of sub-Saharan Africa.

So what I've tried to do in the, in this chapter to point out that infectious diseases are certainly still with us and a major cause of morbidity and mortality,

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especially from diarrhea and pneumonia. But both of these conditions can be treated with oral solutions or I.V if necessary for diarrhea and antibiotics or other supportive measures for pneumonia. And both of them can be prevented through clean water and sanitation or vaccines, depending on the type of illness we're talking about. The same by the way is true for malaria where the use of bed nets and early diagnosis can dramatically reduce the incidence of malaria, particularly in high incident countries.

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4: Maternal and Child Health

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4 .1: Trends and Progress in Child Health In this lecture we shall examine the trends in child survival and look at the priorities beyond 2015. The Millennium Development Goal IV relates to reducing child mortality. And the indicator for child mortality is the under-five mortality rate which is the number of deaths under the age of five per 1000 live births. So the target for MDG IV is to reduce by two-thirds the level of under-five mortality rate between the year 1990 as the base and 2015 as the timeline.

This is MDG IV which has triggered a great deal of action in saving children. And we made remarkable progress in reducing child deaths in recent times. Although the challenge continues to be huge, but there are successes that we can celebrate. Underfive deaths worldwide have declined by 50%.They have been halved between the year 1990 and the year 2013. In the year 1990 there were 12.7 million under-five child deaths. And this number now stands at 6.3 million in the year 2013. And we must be proud to, to appreciate the fact that despite population growth, there are 17,000 fewer children dying every day in today's time.

But the other side of the challenge is that another 17,000 children under the age of five continue to die every day till this date. When we examine the progress in the context of MDG IV we also note that there are huge inequalities. Most child deaths occur in sub-Saharan Africa and South Asia. Children from poor families are twice as likely to die as those from rich families. And social determinants such as mothers' education influence child mortality in a very, very big way. And diarrhea and

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pneumonia, two causes of child death which are eminently amenable to prevention and treatment continue to kill as many as two million under-five children in the world today.

Let's examine the effect of the Millennium Development Goals on child mortality, which is truly phenomenal because global under-five mortality rate is falling faster than at any other time in the history of humankind during the last two decades.

Since the year 1990, the under-five mortality rate worldwide has dropped by 49%.

There were 90 deaths per 1000 live births in 1990 which is down to 46 per 1000 live births in the year 2013. And all regions except sub-Saharan Africa and Oceania have reduced the under-five mortality rate by 52% or more.

That's very remarkable. And if you examine the global annual rate of decline in under-five mortality rate it is notable that there has been more than tripling in the annual rate of reduction in the under-five mortality rate. It was 1.2% annual decline between 1990 and '95. It has now risen to 4% decline in the time segment of 2005 to 2013. And this has happened because the Millennium Development Goals triggered political commitment, greater resources for child health enabling research and evidence and above all a monitoring framework which drove action.

We can see in this graph that there has been progress post-MDG in reduction in child mortality in all the regions of the world. But overall, despite these gains we as a global community shall not be able to reach the intended MDG IV goal. Only eight of the 60 burden countries would achieve the MDG IV goal in 2015 and that's the unfinished agenda which will be now carried over to post-2015 scenario. This picture shows the distribution of under-five mortality rate worldwide. The blues are the regions with low under-five mortality rate, typically below 20. And the orange and red indicate areas where under-five mortality rate is very high. The red indeed is an under-five mortality rate of 100 per 1000 live births which is extremely high. You would see that globally areas with high under-five mortality rate are located in sub-Saharan Africa.

And then there are intermediate areas in South Asia, the India subcontinent and parts of Africa. And the developed nations have much lower under-five mortality rate as you would expect. It's also important to know that about half of under-five deaths occur in just five countries: India, Nigeria, Pakistan, DR Congo and China. And India and Nigeria put together account for one-third of the entire global burden. Clearly in order to address the unfinished agenda of child mortality there has to be a focus in five nations and in particular, India and Nigeria.

It must be stated that immunization has had a vital role in bringing down child mortality in recent times. It's estimated that since 2000 measles vaccine alone has

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averted as many as 14 million under-five child deaths. There is an important issue within the child health survival paradigm and that relates to the complexity of tackling neonatal mortality. Neonatal period is the period of infancy less than 28 days of life.

The first four weeks of life are the newborn period or neonatal period. Neonatal mortality is the number of deaths per 1000 live births in the first four weeks of life. And this as you would note is a part of the overall under-five mortality as a sub-segment of that.

Now neonatal mortality is tougher to tackle because it is influenced a great deal by maternal health and the care that the mother and the baby receive at childbirth,which is quite different from the care that is required for a child with diarrhea or pneumonia. Neonatal mortality has also declined in all parts of the world, as is obvious on this graph. The neonatal mortality rate in the year 1990 was 33 per 1000 live births, which is down to 20 in the year 2013. The absolute number of newborn deaths in the year 1990 was 4.7 million. It's down to 2.8 million. That's remarkable. So we have made progress in this regard. However when we see the progress in neonatal period vis-a-vis progress in reducing mortality after the neonatal period, the postneonatal period something very significant stands out.

That the progress in post-neonatal mortality reduction has been more remarkable, faster than that in the neonatal period. So it's notable that the decline in neonatal mortality is lower than that in post-natal period. That means we have made less progress in reducing deaths occurring in the first four weeks of life. And that is therefore important for us to focus on as we move beyond 2015 agenda. We also note an epidemiological phenomenon that neonatal mortality component of under-five mortality has risen with time. Therefore future progress in child survival is linked to our progress in saving lives of infants in the earliest period of life, which is the riskiest period in humankind.

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4. 2: Child Health Post- 2015 Why do children die? First and foremost, about 50% of children's deaths are related to complications that occur in newborn period. And these are preterm birth complications. Complication during the intra-partum period.

We also call them as birth asphyxia, as a composite cause of death. That infections of newborn babies such as sepsis, meningitis and pneumonia and malformations, birth defects. In post-neonatal period the predominant causes are three: pneumonia, diarrhea and malaria. And they account for about a third of global child mortality burden. It's also important to know that nutrition plays a very important part in determining the child survival. Under-nutritional state, whether in the form of wasting, stunting or low birth weight has a bearing on at least half of under-five child mortality.

And we need to correct under-nutrition in a significant way to make an overall progress towards better child survival. We have well established evidence based affordable effective interventions to save lives of children. Neonatal life can be saved with good care of the mother in ante-natal period. Skilled care at birth. Skilled care in labor and at and soon after birth will save many child lives. Resuscitation of the baby who doesn't breathe at birth. Kangaroo mother care for a small baby who needs warmth and access to breastfeeding. Antibiotics. Supportive care.

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which avoid pneumonia and diarrhea. And if diarrhea does occur, effective treatment is possible through the use of oral rehydration solution and the zinc.

And for pneumonia, if it does indeed occur, antibiotic therapy will save most children. In the recent times we have been able to package these interventions into programs. So integrated management of childhood illness combines these interventions into a package which is delivered by the health workers after training and insuring that there is a supply chain of treatments out there in the field where the babies and children are.

Home based newborn care. Facility based care of sick newborns and children.

These packages of services will save most lives. It must also be stated that safe water, sanitation and hygiene are also crucial in improving the health outcomes of children, particularly in preventing illnesses. And nutrition is fundamental to child survival.

Exclusive breastfeeding in the first six months of life. Timely and appropriate introduction

of

complimentary

food.

Addressing

moderate

under-nutrition

and

addressing severe, acute malnutrition aggressively are the building blocks of a good nutrition program in a nation.

If we have interventions they must reach children, women and households. If they do not reach, these interventions cannot save children. So when we examine the coverage of various interventions we find that there are gaps. For instance, breastfeeding which does so much good to children is, covered to only about 40% of the global population. Exclusive breastfeeding rates in the first six months of life at just about 40% globally.

This should be 90%-plus. Oral rehydration solution should be accessible to every child with diarrhea,100% coverage. But what we have is 30%. And antibiotics for pneumonia which should be accessible to any child with pneumonia, is at the present rate is only 50% coverage.

The gap amounts to deaths. And this gap has to be bridged therefore. The interventions must be taken to scale and every child should receive the intervention that he or she deserves. It's not just about access to interventions alone. Interventions to be delivered through an efficient, and a quality mechanism. So quality of services is also extremely important.

For instance if you just close the quality gap and newborn care, we can save additional two million newborn lives. So it's not only about reaching, but reaching effectively, reaching with quality, that will lead to optimum survival of children. Access to intervention is also linked to mechanisms that connected the babies, that target

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children, target mothers, target infants to the intervention. In Rwanda performance based payment to community workers led to a better connect of this nature, that children accessed care and services.

In Bangladesh engagement with NGOs and commercial partners led to disconnectivity of increasing access by the, the children, by the families to the livesaving interventions. And in India, conditional cash transfers to families and to health workers led to a phenomenal increase in facility births from 40% to 80% in a span of five to seven years.

There are drivers of change that lead increased uptick of interventions on scale that we should learn from, adapt them, and implement them if appropriate contextually. What is the agenda of child health beyond 2015? First and foremost we still have to end all preventable child deaths. There are still too many child deaths happening, particularly among newborn babies as we stated.

For this, the global community has now set 2035 as the horizon, by which time we all as a global community end all preventable child deaths. And this translates to bringing down under-five mortality rate to 20 per 1000 or less by this timeline. Just to remind you, the current rate is 46 per 1000 live births.

So our endeavor is to reduce it by more than half beyond 2015 and up to 2035, a span of about two decades. Likewise, global newborn mortality rate is now targeted to be brought down to single digit by 2035. Current rate being 20 per 1000 live births.

So this is the new set of goals and targets that the global community has set for itself and that's the direction that 2015 onwards we will take as a global community. There are other priorities beyond survival for children.

Over-nutrition is looming large. Too many children are becoming obese because of changes in lifestyle. In some ways the ill effects of so-called development. Diabetes, childhood cancer, childhood kidney diseases, birth defects that requires surgical corrections. And very importantly, psycho-social issues, autism, abuse and disabilities are increasingly important to be tackled even in the lesser resource settings and nations.

There is also an area of insuring intact survival that is the expectation of the society of today. There's another important area which is calling for attention, now and beyond 2015. And this is the domain of developmental origins of health and disease.

We now know very well that the physiology prevailing in fetal life, distresses and the well-being as fetus has a profound implication in regard to growth, development, health, ill health, abnormal physiology in adolescence and adulthood.

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The nine months within the womb of the mother have profound programming that determines how the life goals of individual is as an adult. We now know very clearly that if the fetus is constrained, restricted in growth and in terms of well-being in utero, that this baby is predisposed to obesity, hypertension, heart disease, diabetes and so on. So we have an interesting situation here that we have a baby who was deprived in utero.

If he survives, comes out as a small baby. And then if he does well and moves into adulthood, he has a second jeopardy and that is the risk of diseases such as the heart disease, hypertension, dyslipidemia, stroke and so on. Can this be modified? Can this be changed? Can this be averted? That babies not only are healthy in utero, not only they are healthy as fetuses, but also as children, also as adult.

This is a Holy Grail in child health and adult health in...and in the context of non-communicable disease today. And post-2015, as it is now, this will be a major area of attention for all of us by way of research, by way of intervention design and by way of scaling up these interventions to, to avert this catastrophic pathway that you...that we now know operates in a very significant way in our lives. Health we believe is a driver of development.

And that's at the heart of the global and the national agendas beyond 2015. But healthy children of today are healthy adults of tomorrow. So if adults will drive development, then they have to be healthy. And healthy adults, the beginning is made by being healthy children. So beyond 2015, we have one part of the agenda of ending preventable deaths.

And in this context we have summarized the, the...the trend and the situation by making a statement that child mortality has been halved since 1990. Further progress is linked to acceleration in newborn survival in particular and we offered reasons for it. Universal coverage of interventions with quality is the key to end preventable child mortality that stands today. Birth defects will need attention. Their prevention and correction should be a priority.

As we move beyond survival, in post-MDG IV scenario we have to ensure that babies not only survive, but they're intact in terms of their potential for growth and in terms of their neuro-development abilities. Childhood disability, autism, neurodevelopmental problems will be an important priority in this period. Under-nutrition will continue to plague us for quite some time, but we now have an epidemic of overnutrition in children looming large. And we need to apply our attention to both these areas of nutrition.

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Chronic pediatric diseases such as cancer and systemic iseases will require attention. And a huge effort will be required to find ways of insuring that fetal origins of adult disease could be averted or could be modified. So that children who survive the fetal life and early neonatal life eventually do not pick up non-communicable diseases such as heart disease, hypertension and diabetes.

And this would be a very major challenge that we will have to put our heads together to energize the science and epidemiology and operations research to, to tackle this emerging area of a huge problem which will be a very important focus post-2015.

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4. 3: The Global Maternal Health Scenario We now turn our attention to global maternal health. We will examine the progress made in reducing maternal mortality and also look at the issues which will be the focus beyond 2015. Let me first define two terms. Maternal death and maternal mortality ratio because these two terms would be used repeatedly in this particular lecture. Maternal death is defined as the death of a woman while pregnant or within 40 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management.

Thus, maternal death is a death of a woman related to pregnancy and its complications. Maternal mortality ratio is defined as number of maternal deaths per 100,000 live births. Please note that this is a ratio where maternal deaths are the numerator and live births, babies born live after pregnancy are in the denominator.

Where do we stand in regard to the status of maternal mortality? Maternal mortality has been the focus of our endeavors, worldwide.

It used to be extremely high and it continues to be high, at an unacceptable level. Although we have made progress and we'll come to that in a moment. Even today however, approximately 800 women die from preventable causes related to pregnancy and childbirth.

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In 2013, 289,000 women died during and following pregnancy and childbirth.

More remarkably almost all of these deaths, 99% of them occurred in developing countries.

There are hardly any maternal deaths in the developed world. This is the quantum of preventable mortality among women who go through pregnancy in the natural course of their lifetime. This map shows the distribution of maternal mortality ratio in various parts of the world in the year 2013.

The reds and the oranges are high MMR where are the blues and the light blues are the lower maternal mortality rates. The deepest blue is just a rate of less than 10 per 100,000 maternal mortality ratio and you can see that that color is present only in the best of the, of the developed world.

The deep red is a maternal mortality ratio of 500 per 100,000 live births.

Extremely high. Fifty times that in the blue zones that you notice. It's also obvious from this map that the highest rates of MMR prevail in sub-Saharan Africa. Indian subcontinent and other parts of Africa are somewhere in the middle where the rates are between 200 to 300 per 100,000 live births.

So the agenda of maternal mortality reduction is the agenda of poor nations of sub-Saharan Africa and relatively poor nations of Asian subcontinent. The Millennium Development Goal number V relates to improving maternal health. And its specific focus is reduction in maternal mortality. And the target of MDG V is reduction in MMR or maternal mortality ratio by three-quarters, 75% from the 1990 baseline, to 2015 as the timeline. So MDG V is about reducing maternal mortality ratio by 75%, between 1990 and 2015. Let's see what progress has been made in the context of MDG V since 1990. Between 1990 and 2013, and 2013 is a year for which we have the most updated data, maternal mortality worldwide has dropped by 50%. So if you notice, the number of maternal deaths on the right side, 1990, 523,000 and in 2013 maternal deaths are down to 289,000.

It's about 50% reduction. If you look at the ratio, the maternal mortality ratio, it declined from 380 per 100,000 live births as we defined shortly ago, from 210 globally in the year 2013. It's again, an outstanding reduction, close to about 50%.

More importantly the MDG initiatives have been a trigger for faster reduction in maternal mortality ratio. Between the year 1990 and 2005, the average annual percent change in MMR was the reduction of 2.2% each year.

And this accelerated to 1.5 times in the time period of 2005 to 2013 to 3.3%.

There is no doubt that the political commitment, increased resources, better monitoring

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and better and higher scale up of effective interventions triggered by the Millennium Development Goals, has resulted in saving additional lives of mothers. However, only 10 high burden countries of the 75 will achieve the MDG V. The rest of the world and the world as a whole would unfortunately still fail to achieve MDG V. And that's the unfinished agenda that we carry beyond 2015. But let's look at the regional progress and inequities in maternal mortality ratio. As you would see from this graph, the global community as a whole reduced MMR from 380 to 210 between 1990 and 2013.

A decline of 45%. This decline was greater in South Asia, the middle two bars, from 530 to 190. The sub-Saharan Africa, where we see the highest rates also made a significant reduction, the blue is much bigger than the red. And this decline was 48%.

So there has been progress all across the world, including the tough places like the African continent and the Indian subcontinent. The progress has been uneven and this needs to be corrected.

So there are inequities where we need to invest in order to make sure that there is more even progress and faster progress in time to come. When we look at the causes of maternal deaths and try to derive lessons for averting maternal deaths, something very clear emerges. Thirty-five percent, more than one-third of maternal deaths occur because of hemorrhage or bleeding, triggered by childbirth. High blood pressure, eclampsia accounts for 18% of maternal mortality. Infections, 8%. Unsafe abortion, unsafe abortions account for 9% of maternal deaths.

This is the global scenario. How do the mothers survive the period of pregnancy and childbirth? One of the key things that we know that works is conducting delivery in safe hands. Providing care during labor and childbirth by a skilled health professional, a doctor or a nurse or a midwife. Therefore for MDG V, a key indicator is births attended by skilled health personnel. And if you look at the coverage of this, you will note that in high income countries, and even in upper middle income countries, the two bars on the right side, almost every birth is being attended by skilled personnel or skilled professionals. Every mother.

On the other hand, on the extreme left, in low income countries, this proportion is less than 50%. And low and middle income countries are somewhere in the middle.

You can see that further reduction in maternal mortality is related to how best we ensure that the labor and delivery is in the hands of skilled people. And, this inequity between the low income countries and the better off countries has to be bridged. This is the centerpiece of our strategies to improve maternal mortality.

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Skill care at delivery coupled with the emergency obstetric care which would involve emergency caesarian section and blood transfusion and manual evacuation of placenta. These interventions are at the heart of our efforts to reduce maternal mortality. Then unsafe abortion need to be addressed through legalization of abortion services and abortion as a, as a, as a domain and its acceptability in the society coupled with expertise to undertake safe abortion.

These are the key approaches to addressing maternal deaths. In the context of maternal health MDG, namely the MDG V. This MDG is linked to very interestingly many other MDGs. It's related to eradication of poverty, access to basic services. It is linked to improving the status of gender and empowering women and empowering communities. It's linked to its impact on child mortality and child survival.

The MDG IV, it is linked to universal education because educated women are less likely to, to have adverse pregnancy outcomes and maternal deaths. It's also linked to the HIV related MDG because a part of mortality of mothers is linked to HIV. In some ways, it is at the heart of the entire MDG effort and we also view MDG V as a final common pathway and an indicator of overall development. And of course global partnerships, environmental sustainability are linked in ensuring empowerment of women, good health of mothers, and above all very, very low levels of maternal mortality.

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4 .4: The Sexual and Reproductive Health Agenda Maternal health shall be always a core health priority in any nation. It shall always be part and parcel of the universal health coverage, whatever the model.

Indeed, MDG V also had a sub-target which espoused ensuring universal access to reproductive health as its horizon.

And we still have to achieve this. Maternal mortality is an indicator of how well health systems are functioning. In well-functioning health systems, maternal mortality is extremely low, as low as less 20. Negligible. And in ensuring universal coverage for mothers and women would require access to quality reproductive health services, but not just that, it would also require financial protection without which this access is not possible without impoverishment.

When we move toward examining challenges post-2015, then one of the bottlenecks is the problem of poor quality and poor access to data, in the context of maternal health. Only 11 of the 75 countries have information, good enough information on maternal health indicators. And 85% of the global population lives in areas where cause of death data, as basic as the cause of death data are of poor quality and therefore one of the endeavors as we move towards post-2015 framework says, to set up maternal morbidity indicator frameworks and capacity worldwide. And such an initiative has been launched by the World Health Organization.

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We must remember that maternal mortality, the death of a woman related, occurring as a result of, or a complication of pregnancy is just the tip of the iceberg.

For every maternal death, there are 20 to 30 other women, other pregnant women who experience acute or chronic morbidity. And this emanates from a near death that they just managed to avert.

Or, non-severe obstetric complication, but can be very devastating, such as uterine prolapse or a fistulae. So we move from reduction in mortality, that's one aspect, but we also have to take care of this part of obstetric morbidity and the near misses that continue to occur in a very large number of women, even now. sexual and reproductive health continues to need greater attention in the development agenda. It's a fundamental pillar of core development of a nation and a society. Unsafe sex is among the top ten causes of disability and death globally. It's a key toward bad outcomes. And addressing this is the pathway to overall better health, overall sustainable health and sustainable communities.

More than 120 million couples continue to have unmet need for contraception.

More than 120 million couples. And even today 80 million pregnancies are unintended each year on the globe. This has to be addressed. We're still far away from an optimum reproductive health scenario in the world today. Our efforts to intensify this and in particular to address the younger women, the adolescent girls and women and mothers in marginalized societies.

Poor households, poor communities, rural or urban, has to be an important endeavor even in the post-2015 scenario. Family planning promotion has the potential to reduce poverty and hunger and avert almost a third of all maternal deaths, because the number of pregnancies comes down, the mother is able to cope with pregnancies much better. And also family planning can reduce childhood deaths by 10%. Women's health cannot be optimally addressed without addressing the social determinants such as the status of women in the society and the level of their empowerment, education, and connectivity with the environmental sustainability. In the post-2015 frameworks an important priority for women's health shall be addressing the problem of unsafe abortions.

Each year there are 19 to 20 million unsafe abortions in the world. Almost all of them take place in countries that are low or middle income. And they are particularly so in countries with restrictive, conservative abortion laws. Very disturbingly each year there are 40,000 deaths of adolescent girls and women each year in the world who do unsafe abortions.

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We have the overarching picture of the abortion laws. The green color depicts liberal abortion laws where the choice is offered to the woman, to undertake an abortion. The red colors indicate those countries where the abortion laws are restricted and there are conditionalities to undergo abortion.

In the second map that how appears on the screen, you would see that areas where there are restrictive abortion laws the burden of unsafe abortions is high. Thus, in Latin America and in sub-Saharan Africa, where the laws related to abortion are restrictive, conservative, the prevalence of unsafe abortions is very high. The take is that if you wish to curb unsafe abortions, the abortion laws should be liberal and prochoice as far the women and the girls are concerned. I'd like to move toward the unfinished agenda of sexually transmitted illnesses in the context of post-2015 priorities.

The STI, the sexually transmitted illnesses are the second most common cause of healthy lives lost in women after the pregnancy resolves. Our focus has been on gonorrhea, chlamydia, syphilis and trichomonas and it remains a challenge. HIV is also a sexually transmitted illness and it could be put here as a part of STIs. But we also have human papillomavirus infection, herpes simplex virus infection, hepatitis B infections.

And somewhat less troublesome, problems such as scabies and pubic lice that need to be addressed. You will see that the Americas in the developed parts of the world have a huge challenge of sexually transmitted illnesses. So that's one major area is the Americas, then Asian countries are the other major hub of STIs. And this needs to be put on the high priority agenda in the post-2015 scenario. STIs have a huge impact on not only women, but also on the fetus and the child. ~ STIs cause premature delivery, newborn deaths, birth defects, infections in children. They are contributing toward infertility in women. And they also of course are associated very importantly with rejection of the women by the families and disempowerment. STIs must be addressed optimally and among all women in the world as we move on.

Then we look at other challenges in women's health post-2015. One problem stands out very clearly and that is the issue of violence against women. Not fully understood, often hidden, but we now know from large studies and one particular one done by WHO that the prevalence of violence against women, often by the intimate partner, the husband or the partner is extremely high. Non-sexual as well as sexual violence.

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Sexual abuse before the age of 15 is quite significantly prevalent across nations. Across societies. At times, transactional sex is common in some regions. And pays for education among the girls. Women who experience violence lose their sexual and reproductive choices because they are forced. They lose their rights. Intimate partner violence is common cause of unintended pregnancies. And this happens in the confines of the home.

Thus there are multifarious impacts of problem, affecting a large number of women in the world today. And this must be addressed as a health problem, this must be addressed as a social problem. One form of violence against women is the practice of female genital mutilation, which occurs as a traditional practice in some parts of the world, particularly Africa and some Asian countries. Female mutilation, female circumcision has no medical benefit or value.

This is an unacceptable practice. There are problems related to psychological trauma and the impact it has in future reproductive live. But there are also acute problems such as infections and hemorrhage, which can potentially kill the woman. And there is also likelihood of chronic morbidity, obstetric problems, fistulae, which can ruin the life of, of the girl, of the woman.

Female genital mutilation has to be curbed in the post-2015 frameworks. If required there has to be laws against this depraving practice and if required, there has to be a major social movement to, to address this menace. We must also remember that women's health is not just about reproductive health or pregnancy or maternal health, there is also a huge importance of mental health in the context of healthy women, healthy mothers.

Suicides are among top causes of deaths in peri-natal period in the developed world. And this would happen increasingly so in developing countries as we move toward better, so-called better care. Often the conversation around the mental health is focused on post-natal depression and that's fortunately getting new attention. But other psychiatric illnesses in peri-natal period also need to be paid attention to.

So peri-natal mental health is an important emerging agenda for the global community to address. Other priorities that await focus, are the breast cancer and cervical cancer. And infertility in its own right, not only are we concerned about excess fertility, but we are also concerned about women's choice and the families or the couple's choice to have children. And infertility is equally devastating to individuals and families. So this is waiting attention and this should be a priority in the post-2015 agenda. My key messages in this lecture are the following.

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First, we have made progress in regard to reduction in maternal mortality. And we are proud of it, even though we would miss the MDG V but the, the progress made is remarkable. Maternal mortality has declined by 50% since 1990 and this is the effect of the MDG initiative.

Although the current burden, as we have stated earlier is unacceptable and we need to take care of this unfinished agenda, we must always remember that 99% of all maternal deaths are really in the developing countries. It's the agenda of the poor. It's the agenda of the developing nations and emerging economies.

Maternal health is at the heart of development agenda and it's at the heart of our quest toward universal health coverage. As we move beyond 2015, we have to take care of the unfinished task of averting all preventable maternal deaths. But we also need to focus clearly on the near misses and the obstetric morbidity that may not result in mortality. We have a huge unfinished reproductive health agenda, huge unmet family planning and need has to be addressed.

Unsafe abortions have to be tackled. These are needless deaths and needless morbidity and needless risk to the women. Sexually transmitted illnesses have to be a focus for us to eliminate them, bring them down to a negligible level in years to come.

The new agendas on the table are violence against women, peri-natal mental health, and other conditions such as cancer and infertility that affect women and mothers of the world.

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4 .5: The Long Shadow of Childhood Undernutrition In some of the previous chapters of this lecture, we've spoken of how maternal mortality and child mortality are influence also by the state of nutrition during pregnancy, prior to pregnancy and what happens to children in terms of their own nutritional status and probability of their succumbing to illness before the age of five.

So we now recognize that childhood under-nutrition is a very critical element in global health. Not surprisingly it was positioned as one of the millennium development goals to be targeted for a substantial reduction in the prevalence of childhood undernutrition across the world. Even a report as recent as the global nutrition report of 2014 lists that about two billion people are estimated to be deficient in one or more macronutrients, when we are really talking about macronutrient deficiency, we are really talking about ultimately being under-nourished due to deprivation of calories or energy.

But we also now recognize that it's not just calories or energy, it's the quality of diet that matters in multiple ways. So we are looking at nutritionally balanced diets as well. And that is where we find the problems are probably even more than this particular estimate. We also know that about more than three billion people are afflicted globally with micronutrient deficiencies, whether it's iron deficiency, vitamin A deficiency, or iodine deficiency, or a combination of all of these. When we look at the global profile of low birth weight and under-five malnutrition and look at what the

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magnitude is in different parts of the world in comparison to the standard, conventional, geographical atlas, the picture is really very different.

Countries of south Asia, particularly India and its neighboring south Asian countries like Bangladesh and Nepal have a huge burden of under-nutrition, as do some of the countries in sub-Saharan Africa. Whereas in many other parts of the world, childhood under-nutrition is no longer a challenge and indeed, does not figure as a part of their own agenda for implementation of the millennium development goals. Despite all the progress that has been attained because of the millennium development goals and even to some extent the period preceding that, we have seen that there are huge disparities, even among the low and middle income countries in terms of the prevalence of underweight in childhood.

While Brazil, China and Thailand have been models of great success with prevalence less than 10%. Indeed in Brazil, about 2%. In the countries of south Asia we find the picture very different. India, even in 2011 in a global nutrition report of the World Health Organization was reported to have 43% underweight below the age of five years. Bangladesh, 41% prevalence. And Nepal, 39% prevalence. Even in subSaharan Africa, which is better off than south Asia, there was a 28% prevalence of underweight children under the age of five. And these have profound effects. There is impaired physical growth, particularly linear growth among these children who are underweight and under-nourished.

There's a much greater susceptibility to infections, whether it is measles or respiratory infections or diarrheal diseases. Most of the infections can take a toll and even chronic infections like tuberculosis are far more often in the setting of undernutrition. At the same time, it has an impact on cognitive and intellectual functions. The brain power of these children is substantially reduced as compared to what their potential would have been if they were well-nourished. And while it is certainly a tragedy for the child, in terms of not being able to obtain their full developmental potential, it's also a huge problem for the countries in terms of the cumulative loss of brain power which they could have otherwise utilized for productive growth.

At the same time, because education is also affected of these children because under-nourished children are sickly. They don't learn very well. And they do not advance well to higher education; therefore their employment opportunities are also substantially decreased. They have reduced ability to participate in sports and other recreational activities and therefore their ability to really be important members of a large peer group, whether in schools or in society is also decreased over a period of

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time. But even more importantly this link carries on to pregnancy also. Imagine a girl child who's under-nourished and anemic, growing on to become an anemic and rather underweight adolescent with a limited pelvic size. And when that adolescent girl then becomes pregnant soon thereafter we find that the small pelvic size also results in a small placental size that creates a problem in terms of the pregnancy outcome for the mother, but in the same time the reduced blood flow also results in under-nourished children, particularly when the baby in the womb is not able to get enough blood flow from the small placenta.

So it has an impact on the mother, it has an impact on the child. And you may have maternal mortality or child mortality, particularly neonatal mortality, or you may even have a child who has been born successfully but is small size and then there is a further penalty to be paid thereafter. There are also a fair amount of negative effects on the risk of adult chronic disease like cardiovascular disease, diabetes, and even to some extent, some cancers. There are intergenerational effects not only between the child

who

becomes

the

mother

and

her

own

child,

but

sometimes

these

intergenerational effects can spill over to subsequent generations as well. So there is this intergenerational disadvantage of childhood under-nutrition that can carry on to subsequent generations.

And we see this long shadow of childhood under-nutrition being cast into adult life when we look at the impact of rebound adiposity in a child who has been born small in size and low in birth weight, but gains in weight between the ages of two and twelve years. That doesn't actually translate to an increased muscle mass. It translates much more into body fat, especially fat deposited in the abdomen and around the vital organs in the abdomen. And this sets the stage through metabolic programming for onset of high blood pressure, early onset of diabetes, and heart disease in, in these children as they grow into adulthood.

And even in fairly early adulthood, you can find diabetes and heart attacks claiming a huge toll of health on these children. And we have evidence of this from multiple countries, but here is an example from India, from what's called the New Delhi Birth Cohort. And this cohort that's been followed up from birth to adult life what was determined was that while in the first two years of life the children in the lowest birth rate range were reasonably well protected against acquiring a lot of body fat, by the time they cross two years of age and started having a compensatory nutritional intake, their percentage of body fat markedly increased. And it is these children who had low birth weight under the age of two, but who had rebound adiposity or relative obesity. It

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was not actually obesity or overweight, it was relative obesity compared to their low birth weight in the beginning who turned out to have much higher incidence of diabetes by the time they became adults. So it was this problem that set the stage for adult diabetes.

And it's not surprising therefore to see that India, which had such a huge burden of childhood under-nutrition in the earlier pictogram, now in this pictogram also it has one of the highest burdens of diabetes in the world. So these are fairly interlinked, at least in the south Asian subcontinent. But these effects are not only limited to the life of one child or even the offspring of that child. When we look at a woman who is now pregnant and who is carrying the consequences of her own impaired nutrition from childhood, we must recognize that the female fetus that is in the womb also is having eggs which will result in her own children when she becomes a mother later on in life.

And those are also affected in terms of their gene expression by the childhood under-nutrition that the mother suffered. So at least three generations are linked by this intergenerational transmission of nutritional disadvantage. And perhaps even more as we understand epigenetics, we recognize that some of these disadvantages can be carried into multiple generations.

So we need insure that childhood under-nutrition is corrected, not only because we want to protect the present generation or the immediate next generation, but truly in the spirit of sustainable development we want to prevent some of these disadvantages accruing to as yet unborn generations. There are interventions that we need to adopt in order to insure that childhood under-nutrition can be successfully tackled by countries.

And some of these are nutrition-sensitive interventions. They do not lie in the form of nutritional supplementations or specific nutrition related or diet related interventions, but they have a profound effect on nutrition because they impact the level of nutrition both in terms of intake as well as in terms of absorption and utilization. Water for example is absolutely important. Unless you have clean drinking water, you can get diarrheal disease and that can wash out a good part of the nutrition that has been taken in.

For the same reason, sanitation and hygiene are absolutely important, because infectious diseases, because of poor sanitation and hygiene, again, can drain away much of the limited nutrition that children in low and middle income countries get. And at least 50% of under-nutrition in India has now been ascribed to lack of sanitation. In

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terms of agriculture and food security, that becomes absolutely important, because we do need to produce enough dietary diversity through crop diversity as well as healthy food products to ensure that every citizen has calorically adequate but also nutritionally appropriate diet at each stage of life.

And therefore these systems are to become better aligned to the need of nutrition of all society but particularly from the point of view of preventing child undernutrition which is such a crying shame. Now we need social safety nets because if there are huge income disparities and also in terms of access to diets because of poor living conditions in low income communities, then we are going to see under-nutrition being perpetuated.

So we do need some social safety nets as well. We need a greater focus on early development of children. We need focus on better schooling. Again, education fosters better nutrition. At the same time, midday meal schemes in different countries are also helping to improve some of the nutritional problems, especially micronutrient deficiencies among children. And we need child protection.

We need maternal and mental health to be looked at, because if the mother is mentally stressed, she cannot feel a young infant or even the growing child properly.

We need women's empowerment. Having more income and more social status and political power for women insures that children grow up much better. At the same time we need access to health and family planning services because if you have an early pregnancy in an under-nourished adolescent girl being pushed into early marriage. And of the subsequent spacing of pregnancies also is very small, you are bound to get children who are under-nourished.

And that is going to have an adverse influence later on as well. So we do require a large number of nutrition sensitive interventions. But we also need to incorporate nutrition specific interventions such as insuring adequate food and nutrient intake at each stage of life as appropriate to that age. And the specific requirements which may vary based on the level of physical activity, based on whether the person is at that point in time undergoing an illness or not and so on. Now we also particularly need to focus on promotion of exclusive breastfeeding at least for the first six months of life.

That is absolutely mandatory for good nutrition as well as building of the immunity of the child. And this is very critical but unfortunately not widely practiced even in low and middle income country settings where one would have considered it to be a traditional cultural norm. But it is not. And we also need to promote the right

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complimentary feeding practices and responsive feeding practices when the children require food.

So all of these actually are built in in earlier infancy and childhood. In fact while exclusive breastfeeding is required up to six months, continual breastfeeding should be carried on as long as possible even up to two years, if it's possible. At the same time, good feeding practices are very important in the growing child. When we talk about the catch up growth happening because of compensatory nutritional feeding, getting ultimately converted not into real good, linear growth with muscle mass, but into a lot of body fat, we must recognize that high carbohydrate diets with low physical activity may be responsible for that.

So we need better diets which also are combined with rigorous physical activity in the children, which can ensure that the catch up linear growth is translating into actually a better physical stature in terms of linear growth, but also more muscle mass rather than just body fat.

So we need to pay attention to what kind of food we are giving. At the same time, caregiving and parenting practices are important in the entire area of child nutrition, control of infectious diseases is critical because we said; diarrheal diseases can drain away nutrition.

Other infections can also reduce the appetite, reduce the absorptive capacity.

So control of those infectious diseases, even treating intestinal worms which actually make the child malnourished, that's also very important. Now we need to look at multiple micronutrient supplementation as a possible additional element, though that cannot be the sole pathway for good nutrition. We have to depend upon natural foods for good nutrition. The use of ready-to-use therapeutic foods has been recommended, particularly in treatment of severe forms of childhood under-nutrition.

This is a little controversial because it appears to be pushed sometimes by the industry. But they may have a limited space in the treatment of the severe forms of malnutrition. In terms of the impact of various programs, we have also seen success stories which we can learn from and other countries can emulate. Thailand has been a poster child for such a success.

If you see what has happened in the three Southeast Asian countries of Thailand, Philippines and Indonesia, between 1980 and 1990, Thailand had a marked decrease in the prevalence of underweight children. There was a bit of a spike thereafter when all of these countries were facing economic challenges because of some of the financial crises that their country's faced but nevertheless we noticed that

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Thailand's success continues to be commendable. And this has been a feature ever since thereafter. Indonesia has shown a slower growth, but even there we are finding a considerable amount of success. Philippines on the other hand till recently hasn't had much success, but now it's beginning to record some gains. What succeeded in Thailand and what is it that we can learn from there?

That Thailand adopted the basic minimum needs approach, which looked at some of the social determinants like housing and environment. They brought in family planning and reproductive health services. They encouraged community participation.

They also utilized spiritual and ethical development as a platform for promoting healthy nutrition and good eating habits.

So they combined all of this and the effective linkages between services in various sectors with community level action mediated by community mobilizers who were interfacing with families, brought nutrition from the abstract policy level into very much of the home habit. Now when you look at how the Thailand model worked, they looked at services and brought in government, NGO action into health, education, agriculture and other sectors. But they also brought in facilitators who worked with community mobilizers, provided supervision, training, information and support. And these

mobilizers acted with the families and that interface involved counseling,

organizations, supplies, referral for prenatal care, child care practices, growth monitoring, supplementation of micronutrients when needed.

All of this happened at the community level. And the communities also became active participants in planning, implementation and monitoring. So this has been Thailand's prescription for a successful program which reduced childhood undernutrition in a very short space of time.

And that is where other countries can actually learn from. What we recognize now is that childhood under-nutrition is not an aberration that comes in because of poor feeding in the limited space between birth and five years of age. It is sometimes a carryover effect of poor nutrition during pregnancy. It sometimes is a carryover effect of the poor nutrition that the mother herself had as a child and as an adolescent. But we also recognize that there are factors in infancy and early childhood which again need better attention, particularly to reduce the risk of various ill health conditions which can affect the child but also trying to prevent some of the later problems of adult chronic disease.

And the stage there is set between birth and two years and between two years and twelve years. We also need to look at adolescence as a very important period of

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life. We don't want anemic mothers resulting from anemic adolescent girls. We want to make sure that they also have good nutrition so that they can grow up well and bear healthy children later on.

Even male adolescents too require healthy nutrition rather than becoming obese or having poor nutrition otherwise. This again needs to be carried over into adult life because again, if nutrition suffers in pregnancy, the child is bound to suffer again.

So the idea of building nutrition into a life course model is absolutely critical.

Even if we target childhood under-nutrition and monitor specific metrics related to childhood under-nutrition, when we plan programs and frame policies, we have to have the life course model. And we have to look up, look upon it as a multi-sectorial societal responsibility. And that is where it fits into sustainable development.

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5: Non-Communicable Diseases I

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5. 1: Introduction to NCDs In this lecture we will be discussing the most important public health challenge of the 21st Century in terms of the global burden of death and disability, that is, noncommunicable diseases. In September 2011, the United Nations convened a high level meeting of heads of state to discuss the response to this growing global threat. The second time ever that heads of state met to discuss a health issue under the United Nations. The first one being a meeting on HIVAIDS in 2001. This is because the four major

non-communicable

diseases,

cardiovascular

diseases,

cancer,

respiratory

diseases and diabetes together account for the largest number of deaths as well as the highest burden of disability in the world. Of course there are other non-communicable diseases that are chronic diseases like for example cirrhosis of the liver or kidney diseases and of course mental health which is a very major chronic disease. And we also have other problems like oral health, or eye health, which also qualify for noncommunicable diseases. But if you take these four major disorders, that is heart diseases and blood vessel diseases, cancers, respiratory diseases and diabetes, they're linked by four common risk factors. That is, unhealthy dietary patterns, physical inactivity, tobacco and alcohol consumption. And that's why these were clumped together in that high level meeting which the United Nations and the WHO convened. If Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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we look at how this has become a major global threat from 57% of all deaths occurring in the world in 1990, it has grown to contribute to over 65% of deaths in the world by 2010. But that's not the only problem. The problem is that a large majority of these deaths are occurring in the developing countries and are occurring in very young people. If you look at the deaths that occurred in 2008, about 60% of all deaths in the world were because of non-communicable diseases. But 80% of them occurred in the developing countries. A quarter of all NCD related deaths occurred below the age of 60 years. And 90% of them occurred in the developing countries, the low and middle income countries. So it is the question of prematurity of these deaths in the productive prime of midlife which is a major threat to development and sustainable development.

And the pattern of these diseases also has been changing. In the developed countries heart attacks or ischemic heart disease and stroke or brain attacks due to blood vessel disease of the brain have been the dominant killers over the last 20-25 years and have remained so. However, in the developing countries, infections, particularly among children used to be the major cause of death in 1990, but now both stroke or brain attacks and ischemic heart disease or heart attacks have risen to the top, even among the developing countries. And this is a major threat to development. And we find that because people are dying young in the developing countries, what we call the age standardized mortality rates are much higher in the low and middle income countries.

Even though, at the proportion of deaths occurring in the population, the high income countries still have NCDs as the major killer. But even the proportional mortality is rising in the developing countries and the problem of premature death continues to haunt them. And this is a major consequence for development, because we do recognize that as health transition occur, the poor among countries and the poor within countries are increasingly becoming vulnerable. This has been so in the high income countries for the last 30 years. But even in the developing countries, we are now finding that the poorer socioeconomic groups are much more affected by chronic diseases because of the risk factors are becoming much more common among them.

And even deaths due to non-communicable diseases are occurring much more frequently among the poor than among the rich who now know how to protect themselves. So this is a huge directed development and sustainable development. And the economic impact of this is tremendous. NCDs by themselves have been estimated by a study of the Harvard School of Public Health to lead to a cumulative loss of $30 trillion dollars globally between 2011 and 2030. And if you add the loss due to mental illness, this loss rises to $47 trillion dollars. And many of the developing countries are

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going to be experiencing a serious threat to their economic and social development if we do not stem this epidemic with concerted global response. And we recognize also that this is a threat to health equity because the poor are suffering much more, because of lack of knowledge, lack of access to health services, and inability to obtain timely and efficient care. But it's also a threat to the sustainable development because many of the determinants of NCDs are also linked to the determinants of environmental degradation. And we need to look at this as a common problem in the context of what we are attempting for sustainable development over the next 15 years. As NCDs rise year by year, between 2010 and '25, we will see a rise of NCD related deaths by 10.5 million per year. And 9.5 million of these additional 10.5 million deaths in 2025 will be in the low and middle income countries. But fortunately we have the knowledge to act and save many of these. It has been estimated that about 37 million lives can be saved in these 15 years if we act on six risk factors of non-communicable diseases, which have been identified as targets for action by the United Nations and the World Health Organization. And if we act even more effectively on tobacco we will be able to reduce it even further in terms of the total number of deaths that can be prevented. And if we add effective treatments which are available but become, need to become more accessible, then we are likely to save even more lives. So we do have the knowledge and tools to bring about a substantial reduction in the total burden of noncommunicable diseases if we act effectively. And in order to help us do that, the United Nations has now set up a goal globally for 25 by '25, which means that we need to try and reduce the number of premature deaths in the age group of 30 to 70 years which are occurring because of non-communicable diseases, by 25% by the year 2025 compare to the baseline year of 2010. So 25 by 25 means we are preventing premature deaths by utilizing effective interventions against risk factors as well as effective treatments. So now we recognize that non-communicable diseases are the major public health challenge of this century affecting not only the developed countries, but sweeping across the low and middle income countries, where it is particularly a threat because of the age at which these diseases kill. Cardiovascular diseases or heart and blood vessel diseases, cancers, diabetes and chronic respiratory diseases are now accounting for the largest number of deaths in the world, but are also killing a large fraction of them in the developing countries below the age of 60 years. And this is a major threat to economic development, particularly in these countries and is a threat to sustainable development globally. But fortunately we also recognize that these risk factors are modifiable and many of these diseases are treatable. And in that, we can

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save many valuable lives through effective interventions. We know that by acting on the important modifiable risk factors like tobacco, healthy dietary patterns and alcohol consumption, we can substantially modify the projected disease burden of noncommunicable diseases and by coupling it with effective treatments we can save many lives across the world. And that is why the goal of 25 by 25 which asks us to reduce premature mortality due to NCDs by 25% by the year 2025 is not unrealistic. We can do it.

5. 2: Impact of Tobacco abuse Now I want to introduce you to the number one mass killer in the world, tobacco. In the 20th Century tobacco killed 100 million people. And this was more than all the wars of that very violent century put together. But in the 21st Century, it is estimated by the World Health Organization that tobacco could kill one billion people if we do not take measures to stop it. The problem about tobacco is that it is killing people all over the world, especially poor people. Even as of now, about six million people die each year because of tobacco and about 70% of them are in the developing countries. By year 2030, tobacco will be killing at least eight million people each year and about 80% of them will be in the developing countries. It is the largest preventable cause of death in the world today. Tobacco is consumed in many forms across the world, mostly in the form of cigarettes in the western world and in many of the Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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developing countries. But there are other forms of tobacco consumption, whether it is the hand-rolled beedi in India or the shisha in the Middle East, or even oral tobacco, because tobacco is chewed in many forms in South Asia and now increasingly in Africa and the Middle East. Indeed, you would find that deaths due to oral cancer are much higher in the South Asian countries because of the habit of chewing tobacco which is now the leading form of tobacco consumption in India. Tobacco steals away about eight years of a person's life on an average. And the British Physicians Study which first brought this to light showed that people who smoke even small numbers of cigarettes stand to lose some part of their life expectancy compared to those who do not smoke at all. And those who smoke in large quantities are likely to die much younger because of the effects of tobacco which are far reaching in terms of more than 25 diseases. You have cardiovascular diseases which are the number one killer because of tobacco, followed closely by cancers and then by respiratory diseases. And all of these serve to take people away prematurely into death or disability. But the good news is that if people stop consuming tobacco, especially before the age of 35 years, then much of this risk can be reversed. Most of the risk of cardiovascular disease can be reversed within three years. Some of the risk of cancer can continue up to 20 years. But if you want to ensure that your life expectancy is almost similar to that of a nonsmoker, better give up tobacco consumption early on, especially before 35 years where there's a huge gain because of cessation. Tobacco steals not only health, but also steals income and an opportunity for development. For example in most households where tobacco is consumed in poor families you find that education as well as children's nutrition suffer. In the Philippines, the poorest households were spending more on tobacco than on education, health and clothing combined. In fact about 20% of the household income in a smoker's family was going to tobacco. And similarly in China, India and Thailand, everywhere we find that there is a developmental cost to tobacco in terms of lost educational opportunities for children, for nutrition, and many other ways in which tobacco affects household welfare. And we recognize that as tobacco is increasingly becoming a global threat, there are very many ways we can prevent the harm from tobacco and reduce the consumption of tobacco, especially among the poor and the young and the women who are being targeted by the tobacco industry. There is evidence available from a number of countries, particularly from the high income countries, but also from the low income countries that measures such as taxation, advertising bans, smoke-free policies which ensure smoke-free public places and indoor work places as well as effective health warnings, especially pictorial health warnings are

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very effective in reducing tobacco consumption. Indeed, in the United Kingdom in the 20-year period between 1981 and 2000, 48.1% off all deaths averted, the entire mortality reduction in the U.K., 48% of that was because of reduced smoking. You can't have a more effective public health intervention than that. And much of this has now been codified into what's called the MPOWER Package developed together by the World Health Organization as well as the CDC in the United States. In year 2003, about 178 countries subscribed to the Framework Convention on Tobacco Control which was developed by the WHO as the first public health treaty in the world. And the measures that are advocated for implementation of that treaty and which are captured in the MPOWER package are effective surveillance and monitoring, protection against secondhand smoke, that is, ban on public and indoor smoking in workplaces and cessation support, that is offer of help to quit, effective health warnings on tobacco product packaging, enforcement of comprehensive advertising bans and raising tobacco taxes. Of these, tobacco taxes have been identified both by the World Health Organization and the World Bank to be the most effective way of reducing tobacco consumption because raising taxes raises prices and those with low disposable incomes like the poor, the young, and others who have low incomes like women in many developing countries are less likely to consume tobacco or are more likely to give up tobacco if that happens And this has been shown to be quite effective in many countries. For example, in France as well as in South Africa it has been shown that if you raise tobacco prices threefold, then you halve the consumption and double the income that the government earns from tax revenue. And in the Philippines now, they have not only raised the taxes but are using 70% of that to finance universal health coverage. So much good can come not only by lowering consumption, but by also using the revenue for improving public health. Also we recognize that banning of smoking in public places and indoor work places can have tremendous health benefits. For example, it has been shown in a number of countries that if you ban smoking in public places, hospital admissions due to heart attacks come down within six months. In fact, it has been shown by combining all the data from many studies in many countries that at least 17% reduction in hospitalization due to acute heart attacks can happen. Within months, if you ban smoking in public places. So there can be tremendous benefit from some of these policies. But we also know that effective pictorial health warnings, especially showing the harm in terms of cancer, heart attacks and effects on children, small babies who are born to smoking mothers, all of these can motivate smokers to give up smoking and these health warnings are now being implemented across the

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world. Started in Canada, went onto Brazil, Thailand, now the European Union, United Kingdom and even in developing countries like Thailand and India, you see these pictorial warnings. But we cannot merely content ourselves by warning people against tobacco and expecting them that they would give up gradually. We have to accelerate the movement towards a tobacco-free century. And for this, we have been looking at what goals the WHO has set. And the WHO say it's between 2010 and 2025 there should be a 30% reduction in tobacco consumption the world over. But some of the countries have been more ambitious. They've been looking at a 40% reduction and a 50% reduction. Some countries like Norway, New Zealand and others have said, between 2025 and 2040, they will bring down the consumption to less than 5%. They call it, the endgame for tobacco. So really we are looking at trying to accelerate the decline in tobacco consumption to levels lower than 5% when it ceases to be a norm and it is possible to regulate it away from society. So we can actually achieve a tobacco-free society by an endgame for tobacco, we just need to be more ambitious in our goals as well as more effective in our tobacco control measures. But we ought to not, not, not only look at tobacco as a threat to health; we now recognize tobacco is a threat to sustainable development. We have talked about one billion deaths like to happen in the 21st Century, but tobacco kills trees too. In order to cure tobacco leaf you have to burn wood. And for 300 cigarettes smoked anywhere someone, somewhere has killed a tree, because you have to burn wood. Also a modern cigarette manufacturing machine consumes about four miles of paper per hour because of the wrapping of cigarettes. So trees are harmed. We have air pollution because of secondhand smoke. Tobacco is a water intensive crop and can accentuate water insecurity. Four million hectares of arable land which could and should have been used for growing nutritious crops are now being wasted on a killer crop. So it's a threat to food insecurity. Tobacco lands families in poverty because they're consuming the resources that should have been used for economic welfare of their family on tobacco and they're actually pushed into poverty each year because of that. So in a number of ways, tobacco is a threat to both health and sustainable development and that is why the United Nations is identifying it as an important component for action under the health goal, but also is looking at it under the sustainable development goals framework. So we recognize that tobacco is the number one public health threat as well as a major threat to economic and sustainable development in the 21st Century. If we do nothing, about one billion lives will be lost in the century because of tobacco. But if we act effectively, especially through tobacco taxes, through ban on smoking in public

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places and indoor work places, effective health warnings and then promote cessation among people who are already addicted to the habit, we can substantially bring down the number of deaths. And the world is now responding by not only setting goals of 30% reduction in tobacco consumption by 2030, or 2025, but is looking to a tobaccofree century by asking for an endgame for tobacco. And indeed, sustainable development in the 21st Century cannot become a reality unless we eliminate tobacco from the world within this century.

5. 3: Diet and Physical Activity-I Two of the most important risk factors that have been identified for noncommunicable disease are diet and physical activity. Indeed, they feature very prominently among the goals set by the World Health Organization and the United Nations for reducing NCD related premature mortality. We recognize of course that the world

today

sees

two

faces

of

malnutrition.

First

is

the

huge

problem

of

undernourishment where we find a large number of children and young women in the developing countries having low body weight or anemia or even both. At the same time we are also see a rising burden of overweight and obesity across the world. Not just in the developed countries, but also in the developing countries. Interestingly, both of these problems while perceived as quite different from each other, have a profound impact on the risk of non-communicable diseases which can arise even from underweight or overweight. The whole idea that children are born small for size and underweight are much more susceptible to adult cardiovascular disease, diabetes, and Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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some cancers was first proposed by Forstal and David Barker then in U.K. And this hypothesis known as the Barker hypothesis as acquireda great deal of evidence over the last 30 years. We know that children who are born with low birth weight, if they acquire what's called rebound adiposity, that if they start gaining weight, even within the normal range, between the age of 2 to 12 years, especially between 2 to 6 years, they are much more likely to put on fat rather than muscle. And this is likely to result in early onset of adult diabetes, heart disease and even some cancers and reduce lung function. So we now recognize that there is a link even between under-nutrition and non-communicable disease. But when we look at the larger picture of what are the risk factors for disease and disability across the world according to the global burden of disease study and we take all diseases and all causes of death and all causes of disability into account we find that there are ten leading causes, almost all of them are related to non-communicable diseases, but the vast majority of them are related to diet and physical inactivity. Indeed, when you cluster all the risk factors responsible for death and disease which is avoidable across the world, then the diet and physical inactivity cluster is the largest cluster. So the good news is that we can actually modify much of this by altering the dietary patterns of people across the world and making them more physically active. Now when we look particularly at non-communicable diseases we recognize that apart from smoking and certain other risk factors like high blood pressure and cholesterol which of course are also related to diet and physical activity we find low intake of fruit and vegetables, high intake of unhealthy fats, low intake of nuts, low intake of fish, all of these have been recognized to be important risk factors for non-communicable diseases. And when we look at how diet can best prevent non-communicable diseases we can think of it in terms of what's called primordial prevention. Preventing the acquisition of risk factors whether it is diabetes, high blood pressure, high cholesterol, or overweight. So if you prevent it in the first place by having a healthy diet across the life course, there can be nothing better. But even when risk factors have been acquired, a person has developed high blood pressure or diabetes or overweight or high cholesterol for that matter, we can actually reduce those risk factors substantially by what's called primary prevention, effectively using diet and physical activity. But even people who have had a heart attack or a stroke can actually get much benefit from diet and physical activity and prevent a recurrence of heart attack or early death. So whether it is primordial prevention of risk factors or primary prevention by reducing risk factors before they get into disease, or secondary prevention of preventing recurrence of events, diet and physical activity have a potent

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influence in protecting us against non-communicable diseases. Now clearly we are looking at various elements of nutrition. Diet is what we eat, but nutrition is what we get out of it. Unfortunately most of nutrition science so far has focused on individual nutrients and occasionally on food items. So we have been talking about either saturated fat or monounsaturated fat or trans-fat or refined carbohydrate or we have been talking about other elements like antioxidants. All of them as though they were isolated in terms of their action on health. All of these need to be taken together, not merely as nutrients or food items, but as composite dietary patterns. But even for that, let's look at the science behind it. Among the various types of fats we have the good fats, what have been called the good fats, the omega 3 fatty acids and the unsaturated fatty acids called monounsaturated and polyunsaturated fatty acids. Then there are the fats which have been considered bad, the saturated fatty acids as well as dietary cholesterol. Though the current evidence suggests that this may not be entirely true.

Taken in moderation, these are actually helpful for building some of the essential body structures like cell membranes and hormones and so on. But taken in excess, they can also contribute excess calories. But the real ugly fats are the trans fats, or the partially hydrogenated fats which are not naturally produced, but are usually industrially hydrogenated fatty acids. Now the industrial hydrogenation is done in order to prolong the shelf life of these fats. But anything that lengthens shelf life unfortunately shortens human life. And this is very true of Trans fatty acids where a 2% increase in energy intake from trans fatty acids is associated with a 23% increase in the incidence of coronary heart disease or heart attacks. You can't have a worse fat than that. Now there's been a huge amount of debate about which type of fat and how much of fat and so on. But I think there is a reasonable consensus that has been built up now which says, it is not so much the quantity of fat that matters, it is the quality of fat that matters. Quantity does matter to the extent that you don't want to take too many calories. But within that caloric limit it is the quality of fat that is much more important.

You need more of monounsaturated and polyunsaturated fatty acids, less of saturated fats and certainly very little or none at

all of Trans fats. And there is that kind of

consensus that's been built up. One of the problems of course has been in trying to reduce the total amount of fat in the diet. Many people have advocated the introduction of high carbohydrates as a substitute for fat. That's been a big mistake because introduction of carbohydrates to substitute fat actually increases certain types of abnormal fat patterns in the blood and also increases the risk of diabetes. So we can actually take fat, but prefer to take healthy fats rather than unhealthy fats. We

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recognize of course that omega 3 fatty acids are principally derived from fish, though they can also be produced from certain other fats that we can take in from some of the vegetables as well, particularly certain types of nuts and so on. And of course flax seed and others are sources. But mainly they're derived from fish oils. Even as we are trying to increase the amount of healthy fats, we ought to pay attention to the carbohydrates, which have assumed a lot of importance recently, not only in the causation of diabetes, or

increase

in

overweight

but

also

in

coronary

heart

disease.

That

refined

carbohydrates are particularly dangerous and we need to take a lot more fiber through unrefined carbohydrates in our diet. Indeed, what's called the glycemic load of the food has become very important. The carbohydrates in your diet, how quickly do they release sugar and how quickly does the sugar peak? That is what's called the glycemic load. How much of sugar is released and how quickly? And that is the glycemic load which can actually cause overweight, obesity and increase the risk of heart attacks apart from the risk of diabetes. Now this can be offset of course by taking more of fruit and vegetables. Now salt is also a major issue that has been debated considerably. We don't want to take too much excess salt in our diet and somewhere between five to six grams appears to be the optimal as recommended by the World Health Organization.

But one of the things that people don't seem to recognize very clearly is dietary sodium, the effect of which is on blood pressure and of course on stroke and heart attacks can be substantially countered by dietary potassium, which comes through fruit and vegetables, the natural sources.Therefore if you take more fruit and vegetables you are preventing high blood pressure, you are preventing stroke, you are preventing heart attacks. You are preventing a variety of cancers. And this is now emerging as one of the very protective elements in our diet and that's what the global burden of disease studies says, that low intake of fruit and low intake of nuts, all of these protective elements in the diet is now a major cause of disease burden, especially through noncommunicable diseases. Now we recognize that taking fruit and vegetables in a fair amount, particularly more than three times a day, preferably five times a day

can

substantially reduce the incidence of stroke by 27% and lower the mortality due to stroke by 42%, reduce coronary mortality that's due to heart attacks by 24%. Reduce overall cardiovascular mortality by 27% and lower all-cause mortality by 15%. Now if a single dietary item can change the disease burden so profoundly then there are public health implications that we have to make sure there is access to it. However we ought to be really looking at dietary patterns rather than looking at individual food items. And there have been several diets that have been studied like the Mediterranean diet, which

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has been quite celebrated now as being very protective against heart attacks and being very good for health. The DASH diet which looks at low sodium and a balanced diet with better fats and which reduces blood pressure. Then the Okinawa diet in Japan which has been attributed to be responsible for the high longevity in those populations.

Again, a strong fruit and vegetable based diet. Low in unhealthy fats, high in fish. But the Mediterranean diet for example has a composite character. It’s rich in grains, fruit, vegetables, herbs, spices, nuts, beans, dairy food, seafood and healthy oils. Now even when you’re a non-vegetarian, for example, there is a simple rule to remember, fish is better than fowl and fowl is better than flesh. And if there’s a lot of red meat consumption, you’re in danger, but on the other hand, fish consumption is protective.

Now we have seen that in a major secondary prevention trial of coronary heart disease in France that the risk of a second heart attack and sudden cardiac death was substantially reduced by a modification of the Mediterranean diet. But that led to further studies on primary prevention. Can we prevent the first heart attack with the Mediterranean diet? And it has been very clearly shown that in women, and, as well as in men, that the risk of getting a heart attack can be substantially reduced at the composite nature of the diet moves towards the full Mediterranean diet. More of the elements in your diet resemble that of the Mediterranean diet, the greater the protection from a heart attack. There has been a major study called the PREDIMED trial which has actually shown very clearly in Spain that if you have the Mediterranean diet with extra virgin olive oil, then the risk of heart attack and death actually substantially decrease and similarly we also see that if you actually add nuts, then also there is a substantial benefit. So the composite diet really matters in terms of protection. But we don’t have to borrow the Mediterranean diet everywhere in the world. What we are really aiming for is a prudent diet which resembles the Mediterranean diet but can be culturally and contextually adapted. For example, it’s been shown, even in the United States in large cohort studies that those who have a prudent pattern of diet will have a higher amount of vegetables, fruit, legumes, whole grains, fish and poultry. On the other hand the western pattern of diet classically consists of higher red meat, processed meat, refined grains, sweets and dessert, French fries, high fat dairy products. It has been shown, again, as I said, within large American cohorts that as you move towards a higher level of prudent diet from a very low level of prudent diet, you get a 30% lower risk of getting a heart attack or a cardiovascular death. And similarly if you move to a higher pattern of western diet from a low pattern of western diet, then you get a 64% higher risk of getting a heart attack or a cardiovascular death.

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So the dietary pattern matters very much and in each country we ought to be able to provide the population with dietary choices which will enable them to get their culturally appropriate fruit and diet. But this is becoming increasingly difficult. We are seeing vegetable oil consumption rising across the world. Now this may not be a bad thing in terms of providing energy to populations which are poor, but if the oils are unhealthy rather than healthy oils, if they´re mostly rich in trans fats and saturated fat, then actually they’re compounding the problem by creating non-communicable disease.

And that’s where we ought to insure that the oils that are available are the healthier oils. Similarly, fruit and vegetable consumption across the world is fairly low, especially in low and middle income countries. In India for example, the per capita consumption of fruit and vegetables is a 130 grams per day as opposed to the WHO recommendation of 500 grams per day. So we need to correct this situation as well. And unfortunately when we look at the global production patterns we are seeing a fall in the availability of fruit and vegetables, now from a 22% shortage of supply of fruit and vegetables as compared to the need, by 2025, we will see a 34% shortage and by 2050 we will see a 43% shortage. So when we are looking at sustainable development we ought to be able to look at how best we can produce enough fruit and vegetables to meet the population needs and protect health. At the same time we are seeing a huge explosion in meat consumption and meat production. Red meat certainly is problematic from point of view of heart disease, obesity, cancers, but it also consumes a huge amount of grain because the animals are grain fed. And that also causes environmental problems in terms of a huge release of greenhouse gases from these grain fed cattle. But we ought to be able to really look at how we can balance our dietary patterns

by looking at

agricultural livestock systems so that the healthier food options are available which are also environmentally friendly, rather than unhealthy options which are bad for health and bad for environment.

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5.4 : Diet and Physical Activity-II Nutrition requires not just diet, it also requires physical activity. Regular, moderate to vigorous physical activity, which can make use of the nutrition in an appropriate manner without excess calorie or fat accumulation in the body. Physical activity has been clearly shown to be beneficial for reducing all-cause mortality, increasing life expectancy and certainly most of it is through the cardiovascular benefits. It protects the heart and blood vessels. But it also protects against cancer.

Some of the cancers, especially bowel cancer are much less likely to occur in people who are regularly physically active. Mental health improves in people who are physically active. Bone and joint disease is much less in people who are physically active. So physical activity has multiple health benefits. And we are really looking at particular benefits for heart disease and where we find that in terms of the risk of coronary heart disease or heart attacks, 31% of the current disability adjusted life year lost due to heart attacks is because of physical inactivity. And therefore you can derive a huge benefit of averted disease and disability if we are actually physically active on a regular basis. But the social conditions in terms of current modernity are now militating against regular physical activity. As development occurs in low and middle income countries we see people becoming more sedentary. In China for example, we have seen that occupational physical activity, domestic physical activity and travel related physical activity have declined markedly over the last 20 years, whereas there has been a slight increase in active leisure time physical activity, but that does not compensate for lack of physical activity in the other major domains. Indeed, it is a paradox of modernity that previously people used to be paid for doing physical work, now we are to pay for doing physical work by registering for a gym membership. And now we see that we are spending most of our time sitting at a desk or watching television and that has a price to pay. Even independent of physical activity we see that sitting or being sedentary for several hours a day has independent risk of increasing heart attacks and lowering life. So if people sit for a long time, then you're likely to have increased risk of heart attacks. But we ought to limit that as well and start moving around. Even fidgeting in the chair is fine. This of course means that we need societal responses, not just individual behavior change. And we are seeing several factors that Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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are actually acting as negative influences. We are seeing a shift from pre-industrial agrarian economy to industrialization, changing dietary habits and physical activity habits, profound changes in households technology with labor-saving devices and dramatic shift in leisure activities for adults and children. We ought to do some social reconditioning to counter these effects. And most of what we do will also be good for sustainable development. So if we look at the kind of interventions that we need, first of all we must understand the role of the market. Market is aggressively sometimes promoting unhealthy foods as well as devices which reduce leisure time activity and also the kind of avocations that actually make you a couch potato. So we ought to be able to mold the market much more effectively by increasing consumer consciousness, by providing financial incentives and disincentives, better incentives for healthy foods, disincentives for unhealthy foods and so on and alter the industry practices towards producing healthier products. In terms of policy, there has been a tremendous amount of evidence showing how policy can be remarkably effective in bringing about change.

And Finland has been the poster child of prevention. It had the highest ischemic heart disease and cardiovascular mortality rates in the '60s, but by deliberately bringing about policy change to reduce the amount of unhealthy fat intake in food products as well as altering the individual behaviors by health education, in 20 years they brought down the heart attack rates to much lower levels than elsewhere in Europe. Now we are also seeing other interventions like food labeling, reduced salt in processed food.

We're seeing ban on Trans fats and advertising restrictions, all of them being implemented in Europe and elsewhere, in United States. So there are market interventions which are sometimes needed in order to ensure that consumers are provided with healthier options. In Mauritius for example, a mere shifting of the ration oil in the public distribution system from palm oil to soy oil the healthier oil became the cheaper option and which in five years the mean plasma cholesterol concentrations in the population came down by 15%, just by changing the pricing structure. And similarly, in Poland, after the fall of the Soviet Union, there was a greater import of vegetable oils and withdrawal of subsidies on animal fats, along with an opportunity to import more fruit and vegetables into the country. And this within a few years brought down cardiovascular mortality rates quite dramatically in comparison with the neighboring central and eastern European countries. So this is what policy can do sometimes. And of course we have both the individual approach as well as the public health approach when it comes to behavior change. There are of course individual behavior change prompts that are required for people to adopt healthier practices. But

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we must also create a conducive environment through policies for enabling people to make and maintain healthy living choices across the lifespan. And there, urban design and planning for example becomes very important for physical activity and even for diet. Protected pedestrian paths, designated cycling lanes, community recreational spaces, integrated transport systems, reducing vehicular density and emissions, insuring traffic flow and regulation are quite smooth and also permit good physical activity, Land use and housing, Accessible food markets. Having fruit and vegetable availability closer home for example. All of these are measures which can improve not only the quality of life but certainly can improve people's health. Quite often it is said that you know all these are matters of individual choice, why does the state have to intervene? We don't want a nanny state telling people what to do. Whether to smoke or to, what kind of food to eat or how much to work, should be entirely a matter of individual choice. Yes, individual choices do matter. But choice can be conscious condition or compelled. A conscious choice can be on the basis of correct information or incorrect information. But choice is often conditioned by aggressive marketing and promotion by the industry for example of unhealthy foods and also the cultural factors in the community. It can also be compelled by lack of availability and affordability. If fruit and vegetables are extraordinarily expensive, if salmon is very expensive compared to beef or red meat, then clearly poor people can't make that choice. So we ought to create conditions in which choice becomes easy for people. And that is where we need to really look at how best we can actually bring about a social environment which is conducive to healthy individual choices as well as sustainable development which enables people to lead healthy lives free from non-communicable diseases but also protect the environment at the same time. Because the determinants of noncommunicable diseases and environmental degradation are very similar. The foods we eat and produce, the kind of cities we live in or pollute all of these are linked both to non-communicable diseases and the environment. So we ought to be looking at diet and physical activity, not merely as individual preoccupations, but as societal concerns.

And then only we'll be able to provide a holistic response to this major cause and contributor to non-communicable diseases.

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5. 5: Overweight, Obesity and Diabetes Mellitus Today we’ll be discussing the battle of the bulge, which is now the global public health challenge. We recognize now that overweight and obesity are becoming a major threat not only to public health, but also to global economy and to sustainable development. In 1980, about 4.8% of the men were declared to be obese. By 2008, it was 10%. And among women from 7.9% in 1980 to 14% obesity rates in 2008, again a substantial rise in a relatively short time. When we look at the world today we find that the Pacific Islands have the highest rates of obesity. The lowest are among the men in Congo and the women in Bangladesh. But globally it is a problem and it’s particularly visible in the United States which has the highest rates of obesity among the high income countries. In fact this is a country with the most rapid rise in the body mass index, which is the way we measure obesity, in the last 30 years. Overweight and obesity are also major health problems in a continuum. It is estimated by a metric which compares body weight with height, called the body mass index, if that index is 30 or more, then we call people obese. If it is between 25, but less than 30 we say they’re overweight. But both of these carry health risks. It has been estimated that currently we have a billion adults who are currently overweight and 475 million further are obese. It has also been estimated by the World Health Organization that in Asia we probably need lower thresholds for defining overweight and obesity for public health or clinical action. That is because at any given level of body mass index, the Asians, particularly in South Asia but elsewhere too seem to have a higher percentage of body fat and that puts them at a high risk, even at a lower level of body mass index compared to the western populations. So if you take that also into account, the number of obese adults currently is more than 600 million. And globally up to 200 million school children are either overweight or obese. This is not a problem only of high income countries. Indeed, over the years, we have seen that the number of people with overweight and obesity are rising much more sharply in the developing countries and Revista de Praticas de Museologia Informal nº 6 spring 2015

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by 2008, the numbers there have far exceeded those in the high income countries.

Recently, a report by McKinsey Global Institute suggests that among the various threats to global economy in terms of economic and social burdens overweight and obesity are very high up on the list, ranking third in the list of social burdens. How did this happen? There have been several factors which have been accelerating the nutrition transition in the developing countries. Firstly there’s been a shift in the diet structure towards a high fat and refined sugar western diet. And there’s been a shift in a activity patterns with lower levels of physical activity and an increased level of sedentary habits. And all of these have contributed together to overweight and obesity.

And some of this transition has been amazingly rapid. If you look at Mexico, between 1999 and 2006, the rates of overweight and obesity have markedly increased and the rate of rise of this problem has accelerated substantially, doubling in terms of its speed between 1999 and 2006. Similarly in China, over an eight year period, there was a substantial shift in the distribution of body mass index across the population to the right. That means the average body mass index was increasing and when we start applying the metrics of overweight and obesity among the Chinese adults, in the age group of 20 to 45, there was a tripling of male obesity and doubling of female obesity, all in an eight year period. And when we look at what are the factors that actually pushing this process forward we see a huge amount of marketing pressure which is pushing unhealthy foods which are obesogenic. Well nutritionists may come up with nutrition pyramids and suggest what should we eat in plenty and what in moderation and what should only be occasionally taken, but if you look at the way advertising works, most of the advertising campaign is to push the promotion of colas and other sugary drinks, chips and salted snacks, biscuits, pastries and so on and a huge variety of fast foods. The industry is very seductive in appealing to your taste and creates an addiction to unhealthy foods. High salt, high sugar and high fat foods are usually very addictive. And indeed food industry scientists say, cram as much hedonics as you can in one dish. And this condition, hyper-eating, becomes a response to the stimulus created by these foods. But the price of some of these unhealthy foods is also falling.

Just as we start seeing increase in portion sizes, we also see super-sizing of foods and we see that soft drinks for example, the sugar sweetened beverages are becoming not only larger in their containers, but also falling in overall price. And soft drinks now account for 7% of all calories consumed in America. It has been estimated that if the average American drinks water instead of sugary drinks, she or he would weigh 15 pounds less. Aggressive transnational marketing of unhealthy foods also is accelerating

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the obesity epidemic across the world, especially in low and middle income countries.

We see for example between 1989 and 2006 snack imports into the Central American countries from United States rose for a variety of snack foods, all of which were high calorie and low in nutrition. Similarly pastry, biscuit and confectionary imports as well as frozen French Fries, all of these rose markedly during this period. The way trade also acts as a major barrier for promoting health is exemplified by Samoa. Samoa started getting a large amount of turkey tail import from the United States and New Zealand after World War II. It was never a part of the Samoan diet. But now it had actually transformed the Samoan diet into an obesogenic high fat diet. And when the Samoan government decided that because of the high levels of diabetes and hypertension in Samoa as well as the huge levels of obesity with 53% of Samoans being obese, they needed to do something about the food policy. They banned the import of turkey tails in 2007. But when Samoa started entering into the WTO, the World Trade Organization said, you cannot ban turkey tails. You have to import them because that is part of the international trade rules. So this country had no option but to again, lift the ban on turkey tails, subjecting their population again, to an avalanche of unhealthy imports.

Therefore we recognize that overweight and obesity are not simple problems operating at a physiological level in the individual, quite often doctors and scientists will tell you it is an imbalance between energy intake and energy expenditure. Eat less, or exercise more. But there are so many factors that are operating at the societal level. For example, what is the work environment like, the school environment like, and home environment like? Are they promoting leisure time activity or home activity or work activity? Or are they making you chair bound or addicted to the television? Those are factors that come in. There are also factors which operate at the community and locality. Is there a safe environment for pleasurable physical activity? What are the media influences like? What is the transport situation like? Is walking on the streets a health hazard because of accidents? All these factors play a role. Similarly there are national and regional factors. We just spoke of imports, but there are a number of other factors like how the health system is, how the media is responding, what is the education system talking about healthy nutrition, what are the cultural factors? All of these factors play a role and of course transport But also transnational and global factors like for example import policies as well as transnational media influences which encourage some type of new unhealthy eating patterns, greater consumption of soft drinks and so on. All of these factors need to be contended with if we have to stem this epidemic of overweight and obesity. So the causal web is fairly large, but we have to

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act at each step. We therefore must recognize that among the various interventions that are available, there are interventions which are directed at the individual, asking for behavior change and of course information and education, motivating change in health beliefs and behaviors are very important. But there are also interventions that operate at the nonpersonal level, at the population level, through policy nudges, by creating environmental prompts and stimuli and by providing supportive environments for behavior change. The McKinsey Institute again put together a long list of interventions and said, a majority of them are cost effective. But particularly cost effective are those which act at the subconscious level, at the population level through policy interventions, through environmental interventions, which actually nudge the individual to adopt healthy practices rather than just preaching to him or her as to how to change personal behavior. So it is this combination of interventions, particularly those which use policy and environmental reengineering by creating supportive environments which are going to be very critical as we move along the path to sustainable development. In terms of interventions, a single intervention is seldom effective. We need a composite combination of interventions. It is this multi-component intervention that is usually successful whether in tobacco or in the case of obesity and that is what we really ought to be looking at. In terms of national interventions, there have been certain steps that have been recently taken. Recognizing that sugar sweetened beverages are particularly dangerous from point of view of diabetes and obesity, Mexico, which as we said, has experienced one of the largest increases in obesity rates in the last two decades has decided to impose a 10% tax on sugar sweetened beverages in 2013. India too imposed a 5% tax on aerated sugary drinks in July 2014. Mexico also went ahead and imposed a...an 8% tax on junk foods, which again, extends the whole area beyond just cola drinks, but also into the whole area of junk foods which are also dangerous from the point of view of the epidemic. We have been so far talking about born small in size also results in certain types of obesity which are also very dangerous. A child that is born small can during the period of nutritional supplementation between 2 to 12 years can gain a lot of fat instead of muscle. It’s called rebound adiposity. Much of this fat gets deposited in the abdomen, around the liver and inside the abdominal cavity. And this can be particularly dangerous when we start looking at the effects of it, because the visceral adiposity or abdominal adiposity as it is called has great correlation with diabetes as well as certain abnormal blood fat patterns like decreased amounts of protective cholesterol, or the good cholesterol, also called HDL cholesterol, high triglycerides, more likely to have

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high blood pressure, more likely to get heart attacks early. So this whole problem of diabetes is definitely linked overweight and obesity, but also seems rather surprisingly, linked to low birth weight with rebound adiposity. So don’t be surprised if in some of the developing countries like India you find thin individuals with overweight and with diabetes, because most of the fat is in the abdomen and even if it’s not visible elsewhere and that can also make them prone to diabetes. Indeed, if when you look at what’s happening in India, an example is of two diabetologists, one Indian and one British, who are sitting side by side in this picture and they have an identical body mass index of 22.3, which is very good by all international standards. But the Indian diabetologist has almost twice the level of percentage of body fat compared to his British counterpart at the same level of body mass index. That means he has much greater amount of body fat which predisposes him to health problems associated with visceral adiposity. So overweight and obesity are not very simple ballooning of the body. It also means what kind of fat is deposited and where it is deposited. Now in terms of diabetes, we are seeing a huge explosion of diabetes all over the world. And particularly this is happening in the developing countries, adding to the overall global burden of diabetes. And if we have to reduce the incidence of diabetes and also reduce the complications of diabetes, we have to adopt strategies which protect people from developing diabetes in the first place, but also early detection of diabetes and effective treatment so that we avoid complications like heart attacks, strokes, kidney failure, or amputated limbs due to foot ulcers and so on. Unfortunately the developing countries are bearing the brunt of this. If you look at the top ten countries with diabetes, in 2011, seven of the top ten countries are low and middle income countries. By 2030, you will have eight of the low and middle income countries in the top ten league. China and India will continue to lead with huge numbers in both 2011 already happening and 2030 in the future. But if we want to prevent diabetes, we recognize again, healthy diet and physical activity are very effective interventions. In the United States the diabetes prevention program trial compared no action at all versus giving a medicine called Metformin, which is an anti-diabetic drug, versus a lifestyle intervention with regulated physical activity pattern plus a healthy diet and they tried it out in people who are likely to develop diabetes or at high risk of developing diabetes. Not yet developed diabetes, but because of family history, because of overweight and obesity or borderline blood sugars, who are deemed to be at a high risk of developing future diabetes. And when they tried all these three interventions, low and behold, lifestyle triumphed much more than medicines. Compared to the no intervention group or the placebo group, 58%

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decrease in the incidence of diabetes in the lifestyle group, 35% in the Metformin group. Was it an isolated result? No, it got very well confirmed with 58% reduction also in Finland and similar levels of reduction in China, also replicated in India. So we have seen across the world diet and physical activity coming up trumps in terms of effectively reducing the incidence of diabetes if properly followed. And indeed, this can also be supported by some individual interventions for reinforcement of health messages. A trial in India showed that messaging on mobile telephony, on healthy diets and physical activity in a randomized, controlled trial, it was seen that people who received the messages and followed them had substantially lower incidence of diabetes and the amount of dietary energy or calories they consumed was also lower. However, once you develop diabetes and manifest it, there is also the danger of complications if you do not control it well. Tragically, despite all the knowledge that is available about diabetes and how to treat it and what happens if you don’t treat it, there are very few persons with diabetes who are adequately controlled. And that is a problem of the health system. So how do we actually insure that diabetes is controlled? And along with that, the other risk factors like high blood pressure, abnormal blood lipids, all of these are controlled because all of these cumulatively can cause a lot of damage to the blood vessels and cause heart attacks, stroke and kidney failure. It has been shown that we don’t have to always depend only on doctors to do this. For example, in Kwa-Zulu-Natal in South Africa, nurses were able to control 68% of the patients with diabetes, 82% of the patients with hypertension, 84% of the patients with asthma, and treatment adherence also substantially increased. In Iran, similar results were found with trained rural primary healthcare, community healthcare workers where the management of blood pressure as well as diabetes was substantially better once these people were trained and intervened in the community. Similar packages were also tried out through community health worker training in India and Pakistan. So one of the advances in primary healthcare is to use technology enabled primary healthcare providers for earlier detection and better management of diabetes and associated risk factors which is eminently possible, even for the under-resourced health systems of low and middle income countries. So if we really want to tackle these problems of overweight, obesity and diabetes we need dietary changes from high glycemic foods which generate high blood sugar levels in a fast time to a high fiber diet which reduces the sugar peaks and slows down the sugar release over a longer period. We need to move from unhealthy fats to healthy fats. We need to moderate our salt intake because high salt intake also can cause high blood pressure, accentuate the problems of diabetes and, and also of

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overweight and obesity. But now we recognize that even too low salt a diet may be sometimes problematic, so moderate salt diet should be attempted. And in most countries, already the salt intake is very high, so a reduction is perfectly in order. But at the same time we need more intake of fruit and vegetables because they contain more fiber, they contain more protective phytonutrients, but they also contain potassium which reduces the effect of dietary salt or sodium. So if we take this kind of diet and also have regular sustained physical activity, not only at leisure time, but also at work, at home, during transport, then we are much more likely to be protecting ourselves from diabetes and overweight and obesity. But this requires solutions both at the level of personal behavior and at the level of the societal environment which is supportive for healthy living choices. And that is where we ought to link that with creation of a sustainable development framework where all of these choices are available to people and we protect ourselves as well as the planet while doing so.

6: Non-Communicable Diseases – II

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6. 1: Cardiovascular Disease Heart diseases and blood vessel diseases are together known as cardiovascular disease. There are of various types. The leading cardiovascular diseases are coronary heart disease, also known as ischemic heart disease, which is because of blockages in the blood vessels of the heart, ultimately resulting in heart attacks and damage to the heart muscle and sudden cardiac deaths in some instances. Cerebral vascular disease is also called stroke or brain attack. Some of the earlier manifestations of coronary heart disease and stroke are called angina or transient ischemic attack. Also you have peripheral vascular disease which is disease of the blood vessels elsewhere in the body.

Now these, the coronary heart disease, stroke and peripheral vascular disease are all united by common risk factors, which cause these blood vessel blockages and the subsequent damages in the brain or in the heart. And these risk factors are high blood pressure, high blood fats, also called dyslipidemia, diabetes and its precursor impaired glucose tolerance, smoking, both active and passive, physical inactivity and there are several other risk factors also implicated, but less important. For example, genes are also frequently talked about, but they do not contribute to much of the disease variants that we see within populations or across populations. All of these factors often combine to cause serious blood vessel damage. There are other forms of heart disease like congenital heart disease which are cardiac malformations present in birth and which can manifest at different periods of life. Then you also have heart muscle disease which are basically cardiomyopathies. Then there are some diseases of the heart which are related to infections, like rheumatic heart disease which affects the heart valves but is principally because of the body's reaction against streptococcal sore throat. And you have other forms of blood vessel disease also called aorta arthritis. But the most frequent ones which are the major killers in the world are coronary heart disease and stroke. Cardiovascular diseases are now by themselves the number one killer in the world. Indeed, according to the global burden of disease study in 2010, ischemic heart Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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disease or coronary heart disease accounted for about 13.3% of global deaths and stroke or brain attack accounted for about 11.1%. Now if you combine coronary and cerebrovascular disease, then together their contribution to global deaths has risen from 1 out of 5 deaths in 1990 to 1 out of 4 deaths in 2010. And you have other problems also now occurring arrhythmias, or electrical disturbances of the heart are increasing, particularly with aging populations and one of the common problems that we are seeing in the elderly now is atrial fibrillation which has risen over 200% between 1990 and 2010. When we look at what the trends in cardiovascular disease death rates are across the world, then we see that in high income countries for example, the United States we find cardiovascular disease death rates are declining over the last 20 or 30 years. In fact they've risen sharply in the early part and mid part of the 20th Century and they started declining towards the latter part of the 20th Century and seem to be relatively on a stable decline even now. On the other hand, in developing countries like China and India and elsewhere, in Latin America, and parts of Africa, you are seeing cardiovascular mortality rates rising, particularly age standardized cardiovascular mortality rates are sharply on the rise. In China, cerebrovascular disease or stroke is the prominent form of death. Unlike coronary heart disease is the dominant form of cardiovascular disease in Europe or in United States. This variation between coronary heart disease and stroke is happening across different parts of the world because of different stages of health transition. Now early on in health transition high blood pressure which in one of the most important risk factors for coronary heart disease and stroke results in a bleeding stroke where there is bleeding into the brain from the blood vessels, called hemorrhagic stroke, or hypertensive heart failure where the heart model fails because of longstanding uncontrolled high blood pressure. However as other risk factors are added in the population, like for example increased blood lipids because of abnormal blood fats going up due to unhealthy fat intake or smoking or diabetes, the clotting tendency in the blood increases and the same uncontrolled high blood pressure now results in a clotting stroke and coronary heart disease or blockages in the blood vessels of the heart. So the differences that we see across different regions are not because of marked ethnic differences but because of different pace of progression of the epidemic in different regions of the world. Ultimately it is likely that we will see that most parts of the world will have a very high burden of coronary heart disease and thrombotic stroke. Obviously, many of the risk factors are common, both to stroke and to coronary heart disease. Though blood pressure by and large is the most important risk factor for stroke, it also has other risk factors like smoking, diabetes and abnormal

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blood fats. But for coronary heart disease, all of these are almost equally important.

And then of course you have physical inactivity, dietary issues like reduced fruit and vegetable consumption. All of these which contribute both to coronary heart disease and also to raised blood pressure. Now raised blood pressure also can result in kidney disease. So some people look at hypertension as a disease, others would like to look at it as a risk factor. And then look at what causes high blood pressure? High salt intake, low fruit and vegetable intake, physical inactivity and so on. However way we look at it, it is very clear that high blood pressure and smoking are among the most important risk factors along with physical inactivity and unhealthy diets. And we need to act upon all of them. Now the Framingham study which started in 1948 in the United States in a small village in Massachusetts called Framingham, actually came up with the concept of risk factors and identified smoking, high blood pressure, and high cholesterol as some of the most important risk factors for coronary heart disease. Now we know across the world from studies such as the INTERHEART which studied 52 different populations across the world that virtually all of the world has common risk factors for the heart attack. And by studying people with the first heart attack, they identified that smoking, abnormal fats, high blood pressure, diabetes, abdominal fat deposition, psychosocial risk factors, low intake of fruit and vegetables and lower levels of physical activity and variable intake of alcohol have all been responsible for 90% of the risk in populations across the world for the first heart attack. So much as we may differ in the manifestations of stroke and coronary heart disease at different stages of the epidemic, we recognize that the risk factors are fairly common across the world. And now we are also seeing new risk factors coming up in terms of their contribution being identified.

For example we recognize that air pollution is an increasingly incriminated risk factor across the world. Previously this was not thought to be a problem for the heart, it was only thought to be a problem for the lungs. But now we know that air pollution can damage blood vessels everywhere in the body and can result in an increased risk of acute heart attack or even stroke. So we also have to look at other risk factors which are not conventional risk factors. For example, again, in the last 15 to 20 years we have come to recognize that low birth weight also is an important risk factor, particularly if there is a gain in weight between the ages of two and twelve in a low birth weight baby. So what we call rebound adiposity which means an increased amount of body fat at the expense of muscle can happen in such babies and this can set the stage for heart attacks and diabetes and strokes later on in life, especially in early adulthood. We now know that cardiovascular disease is the number one problem

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all across the world. But in terms of the economic impact, it has a very serious negative influence on developing countries because of the prematurity of deaths. As we know, most of the non-communicable diseases are killers at a younger age in the developing countries and this is true of cardiovascular disease as well. Indeed, about 80% of all cardiovascular deaths occur in the low and middle income countries and most of the premature deaths below the age of 65 years that occur because of cardiovascular disease globally are in these countries. So we have a huge loss of productivity. We have high healthcare costs. Indeed, as a cardiologist, I know that all affairs of the heart are expensive, not merely in the poetic sense. So, we now recognize that even as the epidemic advances most of the deaths in the developing countries are going to be occurring below the age of 70 years, especially below the age of 65 years. And in India for example, it has been estimated , we lost about 9.2 million potentially productive years of life because of premature cardiovascular deaths in the age group of 35 to 64 years and if the epidemic proceeds as projected, we will lose close to about 18 million potentially productive years of life in year 2030. This is 570% more than what the United States lost in the year 2000 and will be 900% more than what the U.S. will lose in that age band in terms of potential productive years by 2030. So developing countries cannot afford this hemorrhaging of human resources in midlife. When we look at what happens to individual families as well we see that many of them are pushed into poverty because they suffer catastrophic health expenditure. In China for example, about 37% of the patients who survive stroke were pushed into poverty and 62% of those without insurance went into poverty. This again brings into question not only the devastating economic effect on families, but also the whole health system issue of whether people have financial protection when they have a serious health problem, whether it's a stroke or a heart attack. For example, in Kerala in India, we also observed that about 73% of those who survived a cardiovascular event had experienced catastrophic health expenditure. And 50% of them had distressed financing. That means they had to sell some part of their property. Forty percent of the patients who survived lost sources of income. And this again is essentially because of not only the high healthcare costs but because of lack of financial protection. So we not only need to prevent disease, but we also need to bring in universal health coverage in order to take care of people who do develop health problems. But prevention is absolutely the critical priority. And we look at both the population based strategy as well as the high risk strategy when addressing prevention through risk reduction. Now the population based strategy essentially says that the risk factor is distributed across

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the population. There is a rising gradient of risk at all levels of rising risk factors. So even if you have a blood pressure of 140, you are at a higher risk than a person with a blood pressure of 130 and that person is at a higher risk than a person with blood pressure of 120. So we try and bring about small shifts in the average risk factor levels of the population so that the cumulative benefits across the population are quite massive. But at the same time we try and identify individuals at a high risk, either because of a markedly elevated single risk factor or more commonly because of a combination of multiple risk factors which are modestly elevated. But together they add up to a huge amount of absolute risk. And therefore we try and focus our interventions in terms of therapy which could mean either change in living habits, of diet, giving up smoking, et cetera, or even addition of drugs in people with high risk. But bringing about changes for example in the salt consumption in a population or an increase in fruit and vegetable consumption in a population or increase in physical activity across a population can have huge benefits through population shifts and risk factors. Now even small reductions in the blood pressure, if they occur across a population can result in marked reductions in the number of strokes and heart attacks and the deaths because of those diseases across the population. It might not make much of a difference in terms of clinical management, but across the population, the benefits can be quite huge. And indeed, it has been shown by modeling studies across different countries where the risk factors as well as heart attack death rates have fallen, that more than 50% in most of the countries of the fallen death rates has been attributed to fallen risk factor levels. And less than 50% in most cases in attributable to treatments. We need both but certainly focusing on risk factor reduction through population wide strategies is absolutely a priority. And this is best illustrated by Finland, which in the early '60s was the table leader in terms of coronary mortality across the world. And many of the people were dying young and therefore the government of Finland initiated a major study called the North Karelia Study in which a large number of behavioral shifts were brought about in the population, partly by changing the nature of the food consumption, including salt reduction in processed foods, increased production of berries instead of dairy products and so on. So a combination of policy and public education resulted over the next 20 years in a dramatic decline in the cardiovascular mortality rates in Finland, making it a sort of poster child for prevention in Europe and elsewhere in the world. And much of this could be attributed to shifts in the population levels of smoking, high blood pressure and cholesterol. Now the Finnish success story is remarkable indeed, between 1971 and 1995, cardiovascular mortality decreased in

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North Karelia by 73% and by example, the rest of Finland followed and across the nation, it declined by 65%. So we know great changes can be brought about by these kind of interventions at the population level. But at the same time we must recognize that poverty is a major barrier and that is where the problem is within populations of developed countries and also across populations in the low and middle income countries. We talked about the Barker hypothesis where children born malnourished are at a greater risk of cardiovascular disease in later life. And then as they grow up, poor people consume more of tobacco; they are forced to consume unhealthy diets. They have poor access to information and services. And in adult life, because they cannot access health services, onset of cardiovascular disease deprives them of appropriate healthcare, wage loss, job loss or even death, which affects their families. And in the elderly, if they're uninsured, the high healthcare costs will have a huge out-of-pocket expenditure. We therefore need to act upon risk factors at various levels. And the important thing for us it to distinguish between how we look at risk. Most of the researchers will be looking at what's called relative risk. That is, does a person who is exposed to a particular risk factor, what is the level of additional risk he or she has as compared to a person who is not exposed? Like a smoker versus a nonsmoker. But that does not tell you how widely prevalent that risk factor is in the population. Now if the risk factor has a high risk in terms of relative risk, but has low prevalence in the population, it does not require as energetic a policy response as a risk factor which has a modest relative risk, but is widely prevalent in the population. Smoking for example, therefore because smoking has a huge population attributable risk, because of its wide prevalence in the population, it requires a very strong policy response. Now there is also something called the absolute risk where multiple risk factors combine in an individual to raise the overall absolute risk of getting a heart attack. Therefore, you may have a person with modest elevation of blood pressure, a modest elevation of cholesterol, each of which may not carry much risk by itself at that level, but cumulatively they carry a huge risk. And particularly if you add smoking to the mix. So in terms of clinical decision-making, absolute risk becomes important. And public health also has to insure that health systems recognize the importance of absolute risk thresholds while managing patients in health system practice. So relative risk for research,

absolute

risk

for

clinical

decision-making

thresholds

and

population

attributable risk for policy. All three are important instruments in public health. And if we actually look at risk factors as the major areas for intervention, we will be able to prevent cardiovascular disease across the population. Remember, today's risk

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behaviors are tomorrow's risk factors. Today's risk factors are tomorrow's heart attacks and strokes. So we need to promote healthy behaviors. We need to detect risk factors early and reduce them before they go on to fatal heart attacks or strokes anywhere in the world.

6. 2: Cancers Cancer is the most dreaded of all non-communicable diseases. Indeed, it's been called the emperor of maladies. It caused about 8.2 million deaths worldwide in 2012 and is rapidly rising now to possibly cause 22 million deaths by 2030 as per projections.

The low and middle income countries of Africa, Asia, Central and South America account for 60% of all annual new cancers and 70% of cancer deaths across the world.

Indeed, the most common cancers are those of lung, liver, stomach, colorectal cancer, or the cancers of the large bowel and breast cancer. And these are found almost everywhere in the world. They do differ however across gender in terms of men having more of lung cancer deaths and women having more of breast cancer deaths. But even among women where smoking rates are high, now lung cancer is rapidly rising. Breast cancer among women accounts for about 23% of all new cancer cases and 14% of all cancer deaths. Whereas in men, the lung cancer accounts for about 17% of all new cancer cases and 23% of all cancer deaths. In terms of risk factors, while we do classify cancers among non-communicable diseases and cancers indeed are linked to other non-communicable diseases through common risk factors like low fruit and vegetable intake, high body mass index or overweight and obesity, that is a high percentage of body fat, lack of physical activity, tobacco use and alcohol use. There are other conditions which give rise to cancers as well, including infections. About 30% of all Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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cancer deaths however are related to these major risk factors of non-communicable diseases and are therefore eminently modifiable and preventable. Among the very many risk factors for cancer, tobacco is the single most important one. Indeed, 20% of all cancer deaths and 70% of all lung cancer deaths are attributable to tobacco. The idea that tobacco is a deadly killer also came up from the study of lung cancer in the first place. But we now know that apart from smoke forms of tobacco, which cause cancer, even the chewed forms of tobacco can cause oral cancer. About 90% of all oral cancer deaths are due to chewed tobacco. We also know that alcohol is an important risk factor for cancers of the food pipe and also of some of the other organs in the body. So, given that alcohol and tobacco which are imminently preventable risk factors, we ought to focus a great deal of public health attention on those. But in addition we also know that cancer can be caused by viral infections. Hepatitis B virus, hepatitis C virus and the human papillomavirus which causes cancer of cervix, all of these viruses together contribute to about 20% of all cancers in low and middle income countries.

Urban air pollution is an increasing cause of cancer risk and again, is becoming a problem in many developing countries. Indoor smoke from households use of solid fuels where women burn solid fuels for cooking also is a contributor to increase in cancer risk. Exposure to radiation is a major problem whenever there is a massive radiation exposure, for example, what we found after Hiroshima and Nagasaki. But even other levels of radiation, for example, those who are undergoing repeated x-rays or exposed to radiation and other forms also have an increased risk of cancer. Now we know that cancer is not only deadly but causes a huge economic loss both in terms of life years lost and in terms of the costs of treatment. It's been estimated that about $895 billion dollars represent a loss due to cancer. And when we consider the fact that cost of reducing exposure to key risk factors like smoking, drinking, and poor diet costs only $1.8 billion dollars, there is absolutely no reason why we should not invest more in prevention rather than suffer the huge economic and health consequences of cancer that's not been prevented. We know cost effective solutions exist. By reducing smoking, by reducing immoderate consumption of alcohol, and by promoting healthy diets we can prevent one in three cancer cases. In terms of cancer control, we ought to be looking at different types of strategies at different levels of prevention. Firstly we have what's called primordial prevention that is preventing the acquisition or augmentation of risk in the first place. Like for example, preventing people from taking up smoking, from becoming overweight, or consuming alcohol in huge amounts. Secondly, we also ought to be looking at primary

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prevention. That means people have already acquired the risk factor, like for example, smokers. They need to be encouraged to give up smoking before they run the risk of developing cancer. Similarly encouraging people to shift to healthier diets or abstain or moderate their intake of alcohol, all these come under primary prevention. Now in terms of secondary prevention, this is where screening and early detection of cancer in its early stages is very helpful, where we can prevent it from going into advanced stages, or where we can actually cure it. Now tertiary intervention is where the cancer has actually advanced and we have treated, but we are preventing recurrence and trying to insure that cancer does not become a problem again in the life course of that individual. But we also have to look at people who have reached a stage of cancer where treatment has failed. And their palliative care and end of life care become very important to make the last few months or years pain free and relatively comfortable even if cancer still is an unresolved problem. Now in terms of prevention, again, it is worth emphasizing that tobacco control remains one of the major public health interventions. Promotion of healthy diets is very important. We now know that fruit and vegetables and healthy fats are important for cancer prevention as well. And a balanced diet is probably one of the best things that we can do in order to prevent cancer. Physical activity does reduce the risk of cancer, especially that of large bowel or colorectal cancer. Exposure to sun, particularly in people who do not have much of melanin pigment in their skin can cause skin cancer and we therefore need to reduce the exposure to skin or protect ourselves against ultraviolet irradiation. At the same time prevention of exposure to viruses or treatment of those viral conditions very promptly is also helpful. Alcohol use should certainly be very moderate if at all and that again is an important measure of cancer prevention. Now in terms of detection, there are several tests that are often used in order to detect cancer early, like the pap test for cervical cancer, mammography for breast cancer, fecal occult blood test for cancer of the large bowel or the colon. And sigmoidoscopy for again, looking at colorectal cancer and prostate specific antigen for looking at prostate cancer in men. Now all of these tests are frequently employed, but we need to look at guidelines where they can be most optimally employed in the most cost effective manner. And periodically these guidelines are produced by expert groups to ensure that we pick up the.... We increase the pickup rate of cancer detection without unnecessarily undertaking extensive high cost screening in all people. Now in terms of cancer care, early detection helps us to initiate early treatment. And cancer screening is often used in order to pick up cancer in the pre-cancerous stage or in the very early stages of cancer where definitive

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treatments can be very useful in curing cancer and then subsequently we may have to follow with other therapy for prevention of recurrence. Therefore screening should be fairly optimally employed in order to prevent advanced cancer being the first clinical manifestation and where we can actually pick up very early on and prevent complications. It's been clearly shown that organized screening substantially reduces the age standardized mortality of cancer death rates in populations and that is an important public health measure. In terms of treatment however, we see across the world, huge inequalities between developed and developing countries. For example, many of the developing countries have very few machines or no machines for cancer therapy in their health systems, particularly in their hospitals for treatment of cancer, when already detected. In the United States, there is one machine per 250,000 population, whereas over 20 countries, mostly African countries have no machines at all within their countries. And the existing machines are also poorly maintained or when they are available, do not have trained radiotherapists and physicists to operate them.

And we do see that there is a huge variation of the number of people served by radiotherapy across different countries. Countries which have very high burden have very limited treatment coverage. We also know because of these reasons of late pickup and poor treatment, we have varied mortality rates of cancer across different countries.

And these vary by national income levels. Those countries which belong to low income levels have much higher rate of mortality for any given level of incidence of cancer, whereas those in high income countries for the same level of incidence have much lower mortality. Therefore the case fatality rates are much lower in the high income countries and this is because of their health systems being much better endowed both for early detection and more effective treatment. And one of the clear-cut inequalities is demonstrated in the use of anti-cancer drugs which frequently are very expensive. And we see that whereas the burden of cancer is mostly in the low and middle income countries, for example in the African, in Asia and Latin America, the actual use of drugs is very limited in those countries. And we find that countries of the United States and Europe and Japan use a very large fraction of the anti-cancer drugs in the world just because they can afford it. At the same time, while we are trying to make anti-cancer drugs more widely available, accessible and affordable to all populations across the world, we must also recognize that those who have advanced to end stage of cancer are now suffering in many developing countries because of denial of appropriate pain relieving therapies. This is where palliative care becomes very important. It is an approach that improves the quality of life of patients and their families when they are

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faced with life-threatening illness through prevention and relief of suffering by early identification and management of pain and other problems which require physical, psychosocial and spiritual approaches for their management. Indeed cancer becomes one of the largest reasons for requiring palliative care. And because we recognize that 34% of all palliative care needs globally are due to cancer, of course other chronic conditions also require palliative care when they reach an end stage. We have to particularly focus on insuring adequate pain relief and supportive therapy for cancer patients. And unfortunately, our health services which ought to be better organized for providing palliative care to the terminally ill and also providing support to the patients and their families are found wanting in this respect across many health systems.

Physical, social, psychological and spiritual support of patients with a life limiting illness has to be delivered by a multidisciplinary team. Not merely doctors but nurses, physiotherapists, psychological counselors, all of them are required and Nutritionists.

But unfortunately we do not have in many countries such teams easily available.

Indeed many trials of early palliative care have shown that the groups that have received palliative care have done much better both in terms of quantity of life being prolonged and quality of life being much improved. But one of the main areas of palliative care and pain relief is opioid treatment. And unfortunately opioids for pain relief are not widely available in many countries or even permitted by their legal systems to be used. And therefore we see a huge discrepancy in the amount of opioids consumed for pain relief in palliative care between the United States, which consumes a very large amount per case as opposed to people in China, India, Mexico, Uganda or in Haiti. And this again is a huge inequity, if people are condemned to live in pain, this is indeed an injustice. So we really have to gear up our health systems to be much more sensitive to the issue of palliative care and pain relief of the terminally ill, especially the cancer patients who do not have much hope of cure. And therefore we require a public health approach to cancer, in terms of prevention of cancer, because much of cancer is still very much preventable, whether it is the living habits like diet, tobacco, or alcohol and physical inactivity that need to be addressed or elimination of viral infections which cause cancer cervix, or cancer of the liver, which again are very amenable to public health interventions, or early screening for effective detection of early stages of cancer or precancerous conditions so that treatments can be applied in order to cure and prevent them from proceeding to advanced stages, or in advanced stages too, providing the appropriate therapies with adequately equipped health systems and health services. And finally by providing palliative care and pain relief to all those who

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need it without really denying drugs to people in low and middle income countries, merely because of price related factors. All these become public health priorities and in a global scenario where cancer is becoming an increasing global threat, all of these issues need to be addressed, not merely at the national level, but as a part of a global health response.

6.3: Respiratory Illnesses We will be talking of respiratory illnesses in this chapter. Clearly the lungs can be affected by very many conditions. Infections which are acute, infections which are long-lasting, like tuberculosis or cancers, but what we will be talking about today is one of the major forms of non-communicable disease, the chronic obstructive pulmonary disease, or chronic obstructive airway disease as it is called. COPD is one of the major problems affecting the health of human beings across the world. And in 2010, it was estimated that 329 million people, that�s about 4.8% of the global population were affected by chronic obstructive pulmonary disease. In 2012, it was the third leading cause of death. But these numbers too appeared to be underestimates because COPD is not often registered as a cause of death because cause of death is attributed to other things like cardiovascular and so on which may coexist or which may actually result from COPD, because congestive heart failure is not an infrequent manifestation of lung disease which then stresses the heart. Most countries don't have national registries or good population data for the disease and therefore this disease may be even more Revista de Praticas de Museologia Informal nº 6 spring 2015

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frequent than has been estimated. But even at the level of the burden that has been now measured, 90% of the deaths occur in low and middle income countries. In 2010, it was estimated that COPD resulted in an economic loss of $2.1 trillion dollars globally, half of which was occurring in the developing world. Now if 90% of the deaths are occurring in the developing world but only 50% of the economic burden is in the developing world, that's not because the developing world suffers less, but because the wages are estimated to be lower in terms of lost productivity losses. So the low and middle income countries do suffer hugely, both in terms of health and economy. Of this $2.1 trillion, $1.9 trillion is because of direct costs of medical care, which again is sparse in some of the developing countries. About $.2 trillion are indirect costs of missed work. Tobacco smoke is the biggest single risk factor for chronic obstructive pulmonary disease, followed by exposure to air pollution, which can occur both indoor and outdoor. Of lifelong smokers, half develop chronic obstructive pulmonary disease, if they're not claimed already by cancer or heart attacks. Secondhand smoke is responsible for about 20% of the disease, even in nonsmokers. So lung problems can occur in active as well as passive smokers. COPD is unfortunately not curable. The problem with COPD is that cigarette smoke or other forms of smoke destroy the small airways in the lungs. They shrink the functioning lung tissue which becomes less capable of filling air and extracting oxygen. They also denude the airways of fine hairlike structures which act like brooms to clear the mucous. And when that happens, mucous accumulates and can become the seat of infection. And treatment can slow down the progress but cannot totally reverse the damage that's already been done on infections or respiratory failure can be the frequent problems in COPD. We also know that there are other risk factors like environmental exposures in the form of biomass fuel consumption. Now when solid fuels are burned in the kitchens for example of homes in low and middle income countries, we have smoke emanating from there and filling the lungs. About 3 billion people are exposed annually to such biomass related air pollution. Outdoor air pollution or ambient air pollution is another major cause of air pollution which can damage the lungs. In addition, there are occupational exposures to a variety of dusts. Like for example the coal dusts in so-called anthracosis or sand in so-called silicosis. All of this dust can also enter the lungs and damage the lungs. In terms of air pollution, we now recognize it as the one, the largest single environmental health risk. In 2012, seven million people died prematurely due to air pollution. And in the same year, 2.7 million of these 7 million deaths were attributable to ambient or outdoor air pollution; 4.3 million premature deaths were attributable to household air

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pollution. The ambient air pollution is of particular importance where there is a fair amount of pollution because of a large number of causes, particularly industrial pollution as well as transport related pollution. These pollutants contain ozone, nitrogen dioxide, sulfur dioxide and particulate matter, all of which can damage the lungs and cause chronic obstructive pulmonary disease, apart from some of them being also cancer causing. In terms of particulate matter, this is a complex mixture of solid and liquid particles of organic and inorganic substances. And you have sulfates, nitrates, ammonia, sodium chloride, black carbon, mineral dust and water in a fairly deadly mix of pollutants which can damage the lungs very severely. But the particulate size also matters. What we call PM10, or particulate matter under the size of 10 microns, these lodge themselves deep inside the lungs and can cause cardiovascular disease, respiratory diseases and lung cancer. Whereas smaller particles, less than 2.5, what we call PM2.5 can cross into the bloodstream and cause damage to the blood vessels, can also cause a variety of diseases, including cardiovascular disease. Therefore when we are looking at all of these materials, we are really concerned about the quantity as well as the size of the particulate matter. In terms of households air pollution, about 3 billion people cook with solid biomass fuels. And in low and middle income countries, this is the kitchen's curse, where women cook with these fuels, often holding small babies in their arms or babies have, the children are playing around in the kitchen. And about 50% or more of the under-five deaths in children are due to pneumonia who are exposed to this risk factor, which is soot inhaled from the households air pollution.

Women too suffer and you have diseases like pneumonia, stroke, ischemic or coronary heart disease, chronic obstructive pulmonary disease and lung cancer resulting from exposure to indoor smoke from solid fuels. The countries of South Asia, India, Nepal, and others shoulder the biggest burden of households air pollution. It has been said that having an open fire in your kitchen is like burning 400 cigarettes an hour. And that is a level of pollution to which women and children in these countries are exposed when they use solid fuels in the kitchen. In terms of ambient air pollution, which is outdoor air pollution, about 16,000 cities worldwide monitor and report air pollution. But only 12% of the people living in all of these cities have air quality which meets the standards set by the World Health Organization. The most polluted cities in the world, no surprise, are in the low and middle income countries. Karachi, New Delhi, Katmandu, and Beijing are among the most polluted ones in Asia. Whereas Lima and Arequipa are among the most polluted in Latin America and Cairo in African cities. But obviously many others in these regions also have very high levels of air pollution. If

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you are looking at use of solid fuels for cooking, worldwide it has gone up in the last 20 years and particularly in Africa and South Asia. When we look at the health effects of air pollution, we see a number of diseases which can result. Stroke, heart disease, lung cancer, chronic as well as acute respiratory disease, including infections and a lot of childhood asthma. Childhood asthma can be provoked by multiple smoke exposures, including tobacco smoke or dust. About 80% of outdoor air pollution related deaths were due to ischemic or coronary heart disease, 14% due to chronic obstructive pulmonary disease and 6% due to lung cancer. In 2013, the International Agency for Research on Cancer concluded that air pollution is definitely carcinogenic to humans.

When it comes to particulate matter, as we have said there is absolutely no safe threshold and therefore we must try and minimize the exposure to particulate matter both in terms of quantity, size and duration of exposure. When it comes to households air pollution, we ought to make sure that we have alternative fuels because biomass cookstoves or safe cookstoves as they've been called, which have tried to protect people who are continuing to use solid fuels, have not had a substantial reduction in the amount of exposure to some of these potential disease causing agents. And obviously we now require better fuel which can be utilized in the form of liquid petroleum gas or a greater supply of electricity which makes it possible for women to use induction heaters. So energy security becomes a very important issue when we're dealing with households air pollution. And it's important for us to recognize that when we're dealing with ambient air pollution too, if we control vehicular emissions by reducing vehicular density, that also contributes to energy security. So we are moving in public health to areas of energy security rather than just looking at air pollution as a health problem alone. When we are looking at ambient air pollution clearly we require a multisectoral approach. We do require to curb industrial emissions which are one of the major sources of ambient air pollution all over the world. We need to reduce transport related air pollution and emissions by reducing vehicular density across the crowded cities of the world. We need to reduce also construction related air pollution in countries which are rapidly expanding their cities. We need to provide more green spaces and by providing greater access to public transport which has an effect on reducing the number of vehicles on the road, we can actually curb a fair amount of air pollution. So by linking up many of these public health measures to urban design, urban transport, energy security and of course tobacco control, we can actually make a dent in what is otherwise an incurable disease.

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6. 4: Mental Health DR. CASH: Hello, my name is Richard Cash. I am a visiting professor at the Public Health Foundation of India and on the faculty of the Harvard School of Public Health. I am here with Dr. Vikram Patel, who is also with the Public Health Foundation of India and the London School of Hygiene and Tropical Medicine. We're here to discuss mental health issues from a global perspective. Vikram, let me ask you, why do you feel that mental health issues are such an important topic to address?

DR. VIKRAM PATEL: Well Richard, the first thing to say is that when we talk about mental health, we're typically actually talking about mental illness and mental disabilities. And I think for many people the word mental illness and mental disabilities tends to reflect a particular kind of, of syndrome, characterized by agitated behavior and disturbed thinking. But in fact when we talk about mental illness, we're talking of an extremely wide range of health conditions affecting people across the life course.

Consider for example we would include conditions like autism and intellectual disability in early childhood, ADHD and anxiety disorders in middle childhood, depression and self-harm behaviors in adolescence, psychosis and substance use in adulthood and dementia in old age. And for a moment if you start thinking of this range of conditions and thinking that almost everyone in the world must know at least one person who is affected by one of these conditions, you realize that the single most important reason why these are of significance is because they're incredibly common.

They affect people everywhere, in our immediate social networks and in our populations in large numbers.

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DR. CASH: But given the commonality of these conditions, which I certainly agree with, why has mental health. Why have mental health issues not been so much a part of the major agenda of global health programs? You hear about it, you've heard about it more recently. But it has traditionally not been an area of broad interest and discussion.

DR. PATEL: I think that's a really important question. You know I think we've been struggling to find out why, in spite of the evidence of the large numbers of people who are affected, there is such little interest to respond to the needs of these people.

And I think there are several possible explanations for this. The first is, I think we've had very little evidence on the impact that these conditions have on people's daily lives. For example, we now know today that mental illnesses are amongst the leading causes of household impoverishment, that poverty and mental illness for example are natural bedfellows. People who live in conditions of poverty are more likely to develop mental illnesses. And if you have a mental illness, you're more likely to slide into poverty. A typical vicious cycle. Another example of an impact is the impact on caregivers and family members. So we now know today that many mental illnesses are associated with the need for informal carers at home. Effectively meaning that family members have to give up work or other forms of productive employment in order to actually care for the person at home. So these are just two examples of impacts that are typically not measured by typical health metrics, in terms of for example, mortality.

These are social outcomes. And today we're beginning to recognize that the social consequences of mental illness are enormous and therefore need attention. The second kind of evidence gap, it has to be said, was that for far too long we only parroted numbers. But we couldn't really describe solutions. And I think that has been a dramatic change in the last decade or so in which we can now talk about effective interventions, but perhaps more importantly, ways that we can deliver these interventions even in places where there are very few specialist resources.

DR. CASH: Let me hone in on this last issue, the issue of what in fact can be done to reduce the impact of this huge number of conditions that you've outlined. What interventions are there that in fact can reduce the morbidity, the caretaking needs of these individuals? And I would probably add, even mortality since there's probably a good bit of excess mortality, premature mortality associated with mental health conditions. What can we do?

DR. PATEL: So before I go to the what-can-we-do, I'd actually like to just build on your last point about excess mortality. I completely agree with you. If one looks at

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the global burden of disease statistics, you will find that mental illnesses account for a relatively small fraction of years of life lost, due to premature mortality. But that's because of a peculiar way in which years of life lost are computed. So for example, suicide is not attributed to mental illness. It counts as an independent cause of death in the injury categorization of the global burden of disease. So you're absolutely correct.

The true mortality, true estimates of mortality that could be attributed to mental illness have been underestimated historically. And if one includes suicide as well as the effects of mental illness on other chronic diseases, the risk of chronic disease like cardiovascular disease, in fact one could argue that the mortality associated with mental illness is very high. And of course you can add dementia to that list as well. So the true burden of mental illness in terms of mortality has been historically underestimated. In countries like India, we've shown that suicide today is the leading cause of death in young people. And in fact this is true of many countries around the world today. And if one argues that the young people of countries like India are the, are the demographic engine of these economies, then the fact that suicide is the leading cause of death in this, this demographic group must be cause of concern to the highest levels of policymakers. But let me come to your, your main question, which is really about how do we deliver these? First of all, what interventions do we have and how do we deliver, deliver them? Actually we've had knowledge about effective interventions, drug interventions. For example, anti-psychotic drugs for schizophrenia, psychological interventions such as for example, cognitive behavior therapy for depression and social interventions such as for example, support groups for people with alcohol abuse disorders. I just give three examples here. But the problem has been that for many people, the impression is that to deliver these interventions you need highly qualified mental health professionals, psychiatrists, psychologists and, and the like. And the reality of course in the global context is there are few of these mental health professionals in most parts of the world. So in effect there's been a sense of nihilism, we can't really do anything about delivering these interventions, because we don't have the requisite human resources for them. Actually I draw a parallel with this nihilism to what we saw with HIV/AIDS and I'm ure you'll remember. It wasn't that long ago when people said, we couldn't really deliver life-saving treatments in Africa because we didn't have the human resource and medical infrastructure to deliver antiretroviral drugs. And we've come a long way since then. And I think in the mental health field we've drawn lessons from the global HIV/AIDS story and begun to apply the same sorts of health system intervention innovations and shown in fact, that as

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with HIV/AIDS, one can deliver effective interventions even in low resource settings by using alternative human resources and alternative ways of delivering services.

DR. CASH: Let me return a bit to this mortality and morbidity issue that we touched on. How do you approach the situation where the individual's mental, mental health may well affect many, many others in the community? Most diseases we look at is how it affects the individual, but in this instance as you pointed out, there are caretakers, there are others and I think it's been shown in a number of studies that, of those individuals incarcerated in prison, very high percentage of them suffer from some form of mental illness. So that the impact of individuals with these conditions on family members and on society itself would seem to me to be rather significant and yet I don't see how this is ever counted.

DR. PATEL: You're absolutely right, it isn't counted. And even though it's not counted, mental illnesses already are considered to be among the major causes, uh, health related causes of loss of economic growth potential in countries. If you actually counted the non-health impacts of mental illness and I think you brought up some great examples, one which we often under count is the impact of untreated mental illness on the criminal justice system. And a good example of would that be disruptive behavior disorders in adolescents and its relationship to you know offending behavior which then leads to a consequence to do with incarceration and so on. So there are many hidden costs or uncounted costs due with mental illness which I think further raise the further highlight why we need to prioritize mental health in the global health agenda. In addition to these uncounted costs is the untold society of the human rights abuses that continue to be played out every day against people with mental illness. I'd suggest to you that there is no human health condition that is associated with such systematic denial of basic human rights, basic as in for example the right to live a life in freedom, a right to live a life with dignity, without being incarcerated against your will, et cetera. I cannot think of any group of conditions that is associated with such a denial of human rights as mental illnesses. Today you will see instances of people being denied their basic rights in communities. People being chained to trees, in homes, being tied to their beds. But perhaps most tragically of all being sent to prison rather than hospital in for example, in some of the richest countries of the world as in the U.S. where prisons have become de facto mental hospitals. And finally in mental health care centers where people are often abused in a variety of ways. `So it seems to me that if one considers one of the driving forces of global health as being issues around human

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rights, then that potentially indicates the great importance of mental health as a global health priority.

DR. CASH: Let me go back again and explore other possible reasons that you noted early on as to why this set of conditions may not be addressed. And that is that of stigmatization. The, the notion that mental illness, that people who are mentally ill are possessed, that they stigmatize families, that is that the very, the very notion of a person who is not following the norms of society is somehow tainted or possessed in other ways that we can't explain. Might that also play a large role in why we are uncomfortable in touching this set of conditions? Or why we, we relegate it to other non-health elements in society that try to expunge these, these ideas and these feelings?

DR. PATEL: Clearly stigma plays a very important role in explaining why people shun those who have mental illness, why people are uncomfortable discussing this topic and why people are reluctant to respond to the needs of people with mental illness. But equally, I should say that stigma isn't unique to mental illness. We have seen in medical history stigma being attached to a number of health conditions. Consider for example leprosy, but also more recently HIV/AIDS, a very feared disease. And the point I, make about both of bringing physical health conditions into this discourse is that there are important lessons to be drawn from the ways that we've been able to address stigma against people living with HIV/AIDS or leprosy, we can learn from and apply to mental illness. And to me one of those important lessons is making effective treatments available. I think that if you make effective treatments available, close to people's homes, in the community of primary care context as opposed to locking people away as they did with leprosy some time ago, do you remember, historically we used to lock people away with leprosy in sanatoria? We did the same thing with people with HIV/AIDS, we took them away from their homes and stuck them in prisons and other sorts of institutions. But instead today what we see with leprosy and HIV, a decentralization of care and availability of care in routine healthcare setting. And I believe that that has been a very powerful force in combating stigma. And I think the same lesson should be extended to mental illness.

DR. CASH: So that the idea that we can actually provide care, let's be more widely, more widely spread and people need to be better educated about this, because you're suggesting that by having care available, people say well okay, we can do something about this. I suspect that if there was no treatment for HIV, we would not be

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nearly as far along as you suggest we are. That is if HIV was still the, the universal killer that it was in the late '80s, we'd be in a different place right now.

DR. PATEL: Yeah, absolutely. Of course. The fact that you can now live with HIV, that you can live a healthy, productive life with treatment has transformed people's view of HIV. It's not surprising though. So if I told you that I could with effective treatment enable recovery from say, depression or schizophrenia, it becomes a less feared condition, naturally it does.

DR. CASH: We have tended to see, it seems to me, mental illness as an individual issue. That is, we have someone who has a condition and we treat that condition. What about looking at mental illness as a societal issue? That is, that, that the way society is structured, the way society puts values on certain things can have a major impact on both the mitigation of this and maybe even the development of medical health conditions. How do you see that particular issue, individual versus a larger population based approach?

DR. PATEL: Yeah. So that's a difficult question to answer because of the very heterogeneous nature of mental illnesses. And so a single answer will not apply to all conditions. So what I mean is that in the range of mental illnesses that I spoke about a little earlier, social determinants, societal influences will play a different role according to the kind of condition we're talking about. There are some conditions that are very heavily influenced by individual vulnerabilities. And those tend to be often biological.

Hallmark examples of that might be autism and schizophrenia and dementia.Then there are other conditions which are much commoner and where I believe societal factors play just as important a role as individual factors. And I think the hallmark conditions there would be things like depression, self-harm behavior, and substance use disorders. Amongst those conditions there's no doubt in my mind that societal factors are important. I'll give you one example. One example might be the way alcohol is perceived by a community in terms of its role as a recreational substance. There is no question that when you have a permissive attitude towards alcohol the proportion of people who will drink will be greater. It's natural. And the more people who drink in a population just by simple epidemiological estimates you will have more people with alcohol use problems. Which is why you often find that the prevalence of alcohol use disorders tends to be higher amongst, in those communities where there is a more liberal attitude towards alcohol. That is not to say the liberal attitudes at fault, it's simply to demonstrate how a societal influence can have an impact on the prevalence of a mental disorder. Similarly with depression, we see that the rates of depression in

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substance use tend to be higher in those populations in which there's greater inequality. I think the best example of this comes from work done in OECD countries where there is a very clear relationship between the prevalence of drug use and depression and income inequality, such that the more unequal a society the higher the prevalence. Now exactly why that happens, it's still unclear. But there is a clear observation of that association.

DR. CASH: Given the extensive prevalence of mental health conditions, it would seem that almost every society then, even if it's ignored by the medical establishment will have developed its own ways of dealing with this, through traditional practitioners or other approaches, religious-wise, non-religious, non-physicians, non-health people.

Do you find that in fact this is the case, that there are, that there are structures, that there are elements within most of the societies in which you've worked and I know you've worked in, certainly in Europe and Africa and in South Asia and so on, that are supportive of or valuable in looking at those elements that might deal more effectively with this condition?

DR. PATEL: So I think your question really points to a very important potential resource in every community in the world to address mental health problems and those are traditional and informal providers. I strongly endorse the role of these providers for multiple reasons. First of all, they're just very much more numerous. Historically, people have felt comfortable going to these providers because these providers share with their local communities a common understanding of the sorts of phenomena that we associate with mental illness. So engaging traditional providers within a public health response for mental health conditions I think seems like a sensible way forward.

Having said that, a couple of caveats. The first is that many traditional providers also commit fairly serious offenses of human rights. So one should not use a, a brush to sort of romanticize the whole of traditional medicine. And in fact, some of the worst abusers of human rights take place in traditional medicine. And also one shouldn't forget that traditional medicine is expensive. It's a private practice. And so I don't see this as an alternative to a publicly provided primary mental healthcare system, I see it as a complimentary system with which we should establish a dialogue with, of mutual respect and insure that people with mental health problems are being well managed with adequate quality in both systems. The second thing I want to say is that, and link to the first point, is that traditional systems of medicine were also used for physical health problems. It's not true to say that there were only for, for mental health problems. It's not long ago when I remember when I worked in Zimbabwe that the

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most common treatment for HIV/AIDS used to be a whole set of traditional interventions like herbs that were used. And, and people completely rejected the biomedical approach. I'm talking of as recently as the 1990s. And I think in that sense, the same analogy could be applied to mental health, that is to say, why have people started using biomedical services in such large numbers for HIV? It is because the service is available. It's affordable. It's accessible. It's of good quality. And I think the same basic principles of healthcare should also be extended to the public healthcare system. I say this only because very often I hear policymakers say, oh but in our country you know we've historically gone to traditional medical practitioners of mental illness, almost as a way of absolving themselves of a responsibility to develop a public mental healthcare system clear that that is not actually the right strategy.

DR. CASH: Since most of the practitioners, be they of the allopathic system or the traditional system, are men, and yet many of the other half of the population has issues that oftentimes are unrelated to their own experience and after all, the, the care that we deliver is often related to our experience, to what we've gone through and, and yet there are very few women practitioners that I'm aware of, maybe more at the village level. Is this an issue and how do you address it?

DR. PATEL: So first of all, I want to just touch on the issue of gender and mental health more broadly, as a social determinant. And I think there's a profound interaction just as there is with poverty and mental illness. There's a profound interaction between gender and mental illness. So for example, women who suffer from severe mental illness often are far more likely to be stigmatized and discriminated against than men. In south India for example in, in fact in India more generally, a man with mental illness is, is much more likely to get married than a woman is, because the general idea is that the wife will look after him. But there's no opposite opportunity for the woman. Gender and, and mental illness interact in many ways. Women are much more likely to suffer depression and that's often to do with the far greater difficulties in terms of life events that they face in their daily lives. But equally men are more likely to suffer substance use disorders. And that's because again, of the definition of masculinity and, and, and the idea that the, the definition of masculinity included within it the idea that, that young men will get intoxicated in many parts of the world. And that makes them more vulnerable to develop substance use conditions. Now the question you asked is a somewhat different one. Should there be gender matching you know in a sense? Should women with mental health problems more likely to be able to discuss their problems with other women or vice versa? I think it's an interesting

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question, I've often thought about that. And certainly all the work that I do with community health workers, most of our community health agents are actually women.

And so it's usually the other way around, that we look at challenges, are men more likely to be able to discuss their personal problems in their substance use problems with women community based workers? And my experience so far has been yes, it does happen, but it's very infrequent. And it's so infrequent that it doesn't really justify a male worker for a male patient and a female worker for a female patient. I think it's logistically quite complex, but also practically, I haven't found in my experience that most men feel uncomfortable talking about their problems with a female counselor, especially if that counselor, a therapist is well-trained to deal with gender issues, which clearly must be an important part of their, of their competencies.

DR. CASH: Vikram, we've spent a lot of time on talking about treatment therapy, let me look at the issue of prevention. Are there things that we can do as societies, as families that could reduce the incidence of conditions either in childhood or later on in life? The preventive aspects of mental health. DR. PATEL: So once again, I want to just remind ourselves that we're talking about a very heterogeneous group of conditions, each which has its own etiology and life course trajectory. So a single answer will not be able to address all of them. There are some conditions which unfortunately the knowledge that we have today about etiology is extremely weak. And so therefore preventive interventions which typically would target risk factors or, or strengthen protective factors therefore have much less evidence to support their design and implementation. But there are others for which we do have much better evidence.

And if I had to answer the question, what are the best buys for prevention in the mental health sector, I would start with early child development. So interventions that promote early child development and parenting interventions across childhood into adolescence to me are the best buys for preventing mental health problems both in childhood as well as in adulthood. The second best buy for me would be strengthening life skills in adolescence. Of course this is done both at home, but importantly also in schools where adolescents and children spend extended periods of their lives, but also where some of the determinants of mental illness actually take place. For example, bullying and academic pressure. So that would be my second best buy. The third best buy would be regulatory and legislative interventions that promote the rights of people with mental illness, prevent discrimination. And in the case of alcohol and suicide, where there are regulatory interventions limiting access, so for example, in the case of suicide, limiting access to lethal means, in the case of alcohol, just as with tobacco,

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taxation is a very cost effective preventive intervention. These would be in my view, I might have missed a couple here or there, but these would be the best buys in the prevention field.

DR. CASH: What is being done at global level to deal with this large burden of disease? We've talked about sort of individual communities and so on. But is there, are there any types of global movements, global initiatives that are trying to address this problem? DR. PATEL: Yes, there are many. And in fact that's the positive story about global mental health is that finally the evidence that has been generated over the last few decades of the burden, the effective interventions and the effective delivery methods in lower resource settings are finally having an impact. So let me give you some examples of the impacts that we're seeing that indicate the importance that mental health is being given in global health and development. In 2013, the World Health Organization passed a resolution unanimously from all the member states for a comprehensive mental health action plan that sought to make every country commit to a set of actions that would improve access to care, promote mental health, strengthen research and governance for mental health by the year 2020. Another example would be at the national level. Countries committing new resources and new ways of thinking about addressing mental health problems. You're seeing this mostly in the middle income countries of the world where there are more resources for health. The best examples would be the sort of mental healthcare reforms you're seeing in countries like China, where more than 4 million people, 4 million people with serious mental illness are now registered with China's universal mental healthcare system, which is called the 686 program and provides a community based care model for people with serious mental illness. You see similar examples in many other countries. Let's look at another example of change which is research. There is now renewed interest in implementation research in the mental health sector. And major funders such as the NIH are committing new resources. By my back of the envelope calculation, since 2011 when we published the grand challenges in global mental health, more than $70 million U.S. dollars have now been committed for new research, to support the grand challenges in global mental health. So these are two very important examples. But I want to really finish with a third very important example which is the mobilization of people with mental illness to speak for themselves, to speak for their rights, to advocate and demand for action by governments to address their needs. And one example of that is the movement for global mental health. It's a virtual movement. It's a virtual platform upon which people with mental illness, professionals and policymakers can stand

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shoulder to shoulder, together as it were, a combined front and demand actions from government and other stakeholders to address the unmet needs of people living with mental illness worldwide.

DR. CASH: Vikram, we talked about interventions, various strategies that countries have used and are using. Maybe you could focus your attention on lowincome countries because the argument always is well we just don't have the resources to make any significant interventions. We can't give these drugs out. That there's a lot of issues that impact on our ability to do anything. How do you address that issue?

DR. PATEL: If I had to choose a single innovation or solution, it would be to empower a cadre of community based workers, using exactly the same model that many low-income countries have used to improve maternal and child health, community based workers with the requisite competencies to detect mental health problems, provide first level psycho-social interventions and refer up the healthcare system to the more specialized providers. Alongside that, mobilize people, raise awareness, et cetera. This would be the single most important innovation I would recommend. Obviously twinned with that, ensuring adequate skills in primary health centers to diagnose and deliver pharmacological treatments and making sure that a, a basic basket of cost effective drugs are available in primary healthcare would be a second important recommendation.

DR. CASH: Vikram, I'd like to thank you very much for a very stimulating discussion on global mental health issues. I'm sure there is much we haven't covered, but I think we've made a good, you have made a very good intro into this very important and up until recently, ignored aspect of human health.

Thank you. DR. PATEL: Thank you, Richard.

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6.5: Injuries (Road Traffic Accidents and Alcohol) In this chapter, we will be looking at one of the major rising causes of death and disability in the world which are injuries, especially road traffic accidents and alcohol which is Frequently related to these accidents and injuries. The global burden of disability study which looked at the contribution of different diseases to death and disability in 1990 as well as in 2010 categorized diseases and causes of death and disability into three major groups. First is the grouping of communicable diseases or infectious diseases with deaths related to pregnancy, early childhood, later childhood, and nutritional conditions which often result in death or disease because of severe under-nutrition in many forms. These are generally considered diseases associated with under-developed economies and are generally expected to decrease in terms of their contribution to the global burden of disease as countries advance economically and socially. The second category is one of non-communicable diseases, which are actually diseases of mal-adapted modernity and which have been rising quite a lot as a result of countries advancing economically, urbanizing and industrializing without appropriate balancing measures to prevent unhealthy lifestyles from becoming established as a pattern in society. These two are now a major cause of concern in the 21st Century.

The third category is one of injuries. These can be intentional or unintentional. Of course injuries have been found as causes of death right from times immemorial.

People could have died by being mauled by a wild animal, or being thrown off a horse, or being struck by an arrow fired by an enemy. But in modern times, you find many more people dying by being mauled by a speeding truck or a car or being shot by a bullet. And as we now see injuries rising in contribution, the major categories of injuries which are rising are those related to road traffic accidents, suicides as well as homicide. And these are contributing to a rising burden which now exceeds the burden contributed by HIVAIDS, tuberculosis, and malaria put together. About 5.8 million people die each year as a result of injuries. This accounts for about 10% of the world's deaths and is considerably more than the number of deaths resulting from some of these major infectious diseases like HIV, TB and malaria. Men are the major victims of intentional as well as unintentional injuries in a variety of forms, whether it is homicide or suicide or drowning or falls or poisoning. And of course markedly in terms of being road traffic accident victims. But women seem to be outnumbering men in terms of being victims of fire related injuries. That's mostly because they are the ones mostly in the, cooking. In terms of the global burden, male sustained about 68% of all injury

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related deaths in 2010. But what is really disconcerting is the fact that many of these injuries strike young. About 40% of all deaths in the age group of 15 to 24 years were accounted for by injuries. Fifty-two percent of deaths in males, age 15 to 29 years were due to injuries. Again, like in case of many of the non-communicable diseases, a large fraction of these injury related deaths occurs in low and middle income countries.

Eighty-nine percent of all injury related mortality is in these countries. South Africa has injuries as the second leading cause of death in that country. And about 95% of deaths and disability adjusted life year loss from interpersonal violence that is often due to fights or homicide. All of these occurring between people, these are found in low and middle income countries. And we know that war and conflict causes a huge number of deaths, almost exclusively in the low and middle income countries, even if the conflicts, geopolitical causes of those conflicts arise from other parts of the world. We also recognize that transportation related injuries and intentional injuries are among the leading causes of death worldwide, among the entire injury spectrum. And of these, road traffic accidents really are at the very top. And they're rising in different parts of the world which are particularly now on the faster development trajectory. And we find that in Africa and the Middle East, the rates of road traffic accident related deaths per 100,000 population are among the highest in the world. In terms of unintentional injuries, we can actually take a large number of public health measures which have been shown to be very effective, like compulsory helmets, use of seatbelts, imposition of speed limits, improved built environments and road conditions. All of these actually help mitigate some of the disease burdens. In terms of intentional injuries we do require a fair amount of counseling from the healthcare system to people who are likely to be having suicidal intent. So treatment of depression, preventing suicidal attempts and providing psychological support systems and counseling to prevent self-harm, all of these are going to be important. Also, conflict resolution and means to prevent interpersonal violence are also part now of the public health agenda. And gun control becomes a very important area. And we now recognize that in countries with poor levels of gun control, homicidal and other interpersonal violence related injuries are very high indeed. In terms of preventing injuries, we also have to look at the response systems, particularly in terms of the emergency healthcare response. We need to look at the pre-hospital stage where for example a traffic accident victim needs to be immediately attended to by first responders, we need improved communications and provision of appropriate emergency transport. At the same time, in the hospital, we need again, a multidisciplinary trauma team to look after the person who is injured,

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who may have multiple injuries which might require different specialized care. But we also require to train nonprofessional caregivers to provide care when trained staff are not available. We also need rehabilitation of people who have had injuries and have survived them and a large number of people living with disabilities, post-injury need sufficient rehabilitation support now. We recognize that road traffic accidents are indeed the major preventable cause of injuries. And about 1.3 million people die on the roads every year. That is about 3,500 every day. Something like ten jumbo jets crashing every day. Now 50 million people are left with injuries, many with severe disabilities. And particularly in the young population of 10 to 24 years age, we find road traffic accidents are the single biggest cause of fatality in that young age group. We recognize that in high income countries some progress is being made by a decline in the rate of road traffic accident related death rates. But in low and middle income countries the death rates are rising. And when we look at the middle income countries in comparison with the high income countries, while the vehicular numbers are almost comparable across these two income groups, the deaths are far, far higher in the middle income group. So these are countries which are modernizing with a higher vehicular density, but are still unable to implement adequate safety measures which can bring down the road traffic accidents and the fatalities associated with it. Now half of the deaths related to road traffic accidents are unfortunately among the very vulnerable road users like pedestrians, cyclists, motorcyclists. That means it’s not just the car drivers and the truck drivers who die because of careless driving, but also the innocents who fall victim are the people who use the roads in other ways. Now we need to take very effective measures in, in order to control the road traffic accident related damage to health and prevent the death and disability in different settings. The five factors that can be controlled for by effective legislation. Speed of the vehicles can be controlled by speed laws. Drinking and driving has to be strictly curbed. And testing alcohol content in the breath and blood of drivers who are suspected to be driving under the influence of alcohol is a very important measure. Applying child restraints in cars prevents them from tossing around and getting injured in a speeding vehicle. And motorcycle helmets must be made mandatory everywhere to prevent head injuries.

Again, seatbelts have made a great difference to the degree and number of injuries obtained during road traffic accidents. But very few countries implement all of these laws. If you take any single one of them, you find that the use of these is still limited only to some countries among the huge number of countries across the world. For example, when you look at drunk driving laws, then these are in fact applied very, in

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very few places. Urban speed laws are also applied in very few places. So also child restraint laws. While seatbelt laws and motorcycle helmet laws are more frequently applied, how well they're enforced is also a big question. When we look at what are the contributory causes to some of this, drink driving comes out as one of the top causes of road traffic accidents. Now in South Africa, about 50% of those involved in road traffic accidents had elevated blood alcohol concentrations in 2001. And this is true of many rapidly urbanizing cities in low and middle income countries now. About 3.3 million people die every year due to harmful use of alcohol. In the age group of 20 to 39 years, about 25% of all deaths are attributable to alcohol. This is of course not only because of road traffic accidents, but because of the other harmful effects of alcohol as well. And we know that alcohol is the cause of cirrhosis that is a liver problem which because of alcohol gets fibrosis in the liver. Cancers which are again, attributable to alcohol particularly gastrointestinal cancers. All of these are growing problems now. But alcohol consumption, especially immoderate alcohol consumption is also associated with mental illness. And that can lead to intentional injuries, particularly alcohol provoked interpersonal conflict. Alcohol consumption, especially heavy drinking has been linked to both suicide as well as violence. And all of these can aggravate the number of injury related deaths and disability. We also know that there are huge economic costs apart from the social costs of alcohol. We have direct costs like costs for healthcare services, costs related to law enforcement, costs related to increased crime and accidents, costs related to domestic violence. Now there are indirect costs from loss of productivity, reduced output and earnings as a result of alcohol use.

Absenteeism. Or even people being away from productive occupations because they’re under the influence of alcohol. Then intangible costs which are assigned to pain and suffering and poor quality of life. So given all of this, alcohol has become a major public health challenge again, not only in the context of non-communicable diseases, but in the overall context of development. Many countries have started looking at ways by which they can control the problem of excessive alcohol consumption which is deleterious to health. And taxation has been shown to be one of the very important elements by which public health can address the problem of alcohol, by raising prices and reducing the demand. And the, the taxation in different countries has been linked to the quality of alcohol, quantity of alcohol, the concentration of alcohol and so on. But taxing adequately is important as a measure. Now restricting availability of alcoholic beverages is also an important element. Not only age related restrictions but some countries have also imposed restrictions on the total amount of alcohol that can be sold

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to individuals over a period of time. Implementing bans on alcohol advertisements is absolutely critical. Both direct and indirect forms of alcohol advertisement and sponsorship and promotion must be banned. The other effective measures are measures against drunk driving. The word 'drink driving' itself is very suggestive. It suggests that it's not the human being who is driving, it is the drink that is actually driving the vehicle when the alcohol concentration has exceeded a particular limit. So we do need to enforce that kind of legislation where we have random breath-testing and people who are driving under the influence alcohol are taken off the street and are also stripped of their licenses to drive. And strict penalties are imposed in order to inhibit such practices. We also need of course support systems by way of de-addiction counseling and other support systems, the health system as well as social support systems can provide. And all of these measures can reduce the problem of alcohol in our society and remove one of the important contributory causes to road traffic accidents.

7: Health Systems – I

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7. 1: Introduction to Health Systems Today I want to talk about health systems and in particular, the role of health systems in delivering universal health coverage which you've heard about in another lecture . So what is a health system? According to the World Health Organization, a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health improving activities. So you can see this is really quite a broad definition. And the health system is certainly much bigger than really just talking about public health units and hospitals. And in fact, if one thinks about the entire health system, it also includes the private health sector providers, both in terms of commercial, for-profit providers, but also non-government organization providers of services. But it also includes people caring for sick relatives at home. Another big area of course is in preventive healthcare and things like vector control programs to control mosquitoes for example. Behavior change programs would also be in the health system, encouraging people to lead healthier lifestyle by reducing the amount of fat intake and tobacco and taking more physical exercise. The health system also includes occupational health and safety legislation. Those are all activities that one would typically associate with the health sector, but also in really thinking about the much broader health system, it also includes intersectoral action to promote interventions that improve health. For example, the education of girls is very important for improving health

status.

Encouraging

legislation

to

reduce

tobacco,

alcohol

and

sugar

consumption and road safety measures. These are all what we'd call part of the broader health system. So that's what a health system is. Now what should a health system be trying to do? Now here the World Health Organization have been extremely helpful and

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back in 2000, produced a memorable World Health report all about health systems and improving the performance of health systems.

In this document, they stated that there are three major goals for, for a health system. Firstly, to improve health indicators. Measures such as life expectancy, mortality rates, but also associated with people leading healthier lives. Here we're not only interested in the overall levels of these indicators, but their distribution as well, to avoid the situation of there being big health inequalities between different population groups. Another goal for the health system is that it should be responsive to people's non-medical expectations. That when people interact with the health system they're treated courteously and in a timely manner and with respect as well. And the third major area is that the health system should be fair, particularly in terms of the financial contributions that people make towards financing the health system. So we've described what a health system is trying to achieve, now how does it go about trying to do that? And again the World Health report provided good structure in terms of describing four key functions of a health system. Firstly, in creating the resources that are required to run the health system, the inputs that go into the health system. Here one can think of things like medicines and health workers and computers, the basic inputs that go into the system. The next major area of course is in combining those inputs in delivering services. And this whole issue of how does one deliver efficient and equitable services? This will be the topic of the next lecture. The third major function concerns the financing of the health system. Again, we'll discuss this in another lecture, but here one should consider the functions of how one raises the finances for the health system, how one pools resources, and then also the very important issue of purchasing services efficiently. And the final major function concerns stewardship. The overall management and oversight of the health system, where it's an extremely important role for the state. Now when these functions combine effectively together and work well in an efficient and equitable way, this is how one improves the health system and delivers those outcomes that one's looking for of improved health indicator figures, better fair financial contributions and also a system that is responsive to people's needs. I'd like to just dwell briefly on this very important issue of stewardship and why it's so important that the state gets involved in the running of the health sector. Now why should this be the case? Well firstly because health should be a national priority, all countries everywhere, people, it's very important for them and the welfare of their families that they lead long, healthy lives and don't suffer financial hardship in accessing services. So health really should be a national priority that good governments

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are concerned about. Secondly, it's clear that free markets in health services don't deliver equitable health systems. And really this is to do a lot with what they call market failures in the way that health systems worked. And the, the providers and suppliers of health services have a lot more information than the users of services. And in this type of situation, it's very easy for people to be exploited by unscrupulous healthcare providers. And really this is one of the major reasons that it's very important for the state to be heavily involved in the stewardship of the, of the health system. So the state really should be involved in setting the rules of the game of running the health system. And also in monitoring the performance of providers of services and improving accountability to the population who are paying for them. Now one area that has attracted quite a lot of controversy over the years is the role of the public and private sectors in, in a health system. And here, Professor Julio Frenk at the Harvard School of Public Health has provided a very useful description of the different roles of the public and private sectors, looking at those functions I was describing before. So thinking of that overall stewardship and accountability function, clearly that lies predominantly within the public sector, to set the rules and regulations to the system, with only perhaps a very small role for the private sector there. Likewise, it's becoming increasingly clear that to achieve universal health coverage in an equitable health system, one needs to predominantly be looking at a publicly financed system. However, looking at the issue and function of service provision, it's slightly less clear. And indeed, many countries the, the majority of health service providers are actually in the private sector, contracted, using public financing. So here there tends to be more of a mix of public and private providers. But when one looks at that final function or resource generation, manufacturing the inputs that go into the health sector, here the tendency is more for the private sector to produce the medicines and the computers and the basic inputs that go into the system. Now another area that's attracted quite a lot of controversy over recent years is how one measures health service performance. And countries are very keen to match, to identify how their health sector is performing against others. Now how does one do this? How do you measure performance? Well clearly the indicators you should be trying to use are those around those objectives we were talking about of improved health status, better financial protection, and a more responsive system. And again, we don't want just to be looking at absolute levels of those measures, but how they're distributed across society. Now the World Health report in 2000 did this and ranked health systems across the world and created an index and therefore created a lead table. This was quite a controversial exercise and in

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that, at that time it was the French system that was deemed to be the best performing.

Other organizations have been doing this as well. Most notably the Commonwealth Funds that assesses the performance, particularly of high income countries looking at measures of quality of care, access to health services, the efficiency of the system, equity and also those all-important health indicators. And in the most recent study that the Commonwealth Fund done, they showed that the British National Health Service scored the highest, was ranked the highest performing sector. Of course the system that is predominantly publicly financed and interestingly, the United States, of the eleven countries surveyed was actually bottom of the lead table, largely due to problems with inequitable access to services. Now what was striking is that the United States' health system spend more than twice what a number of other OECD countries are doing, are spending. So it's interesting therefore that necessarily spending more money on a health system doesn't always improve performance. And therefore governments can learn about improving efficiency and doing more with the money that they have available. Thank you.

7. 2: Delivering Health Services In the previous lectures we were discussing the various influences on health and the role of the health system in achieving universal health coverage. There are many influences on people's health, not only within the, the health sector, but also other sectors concerning agriculture, education, water and sanitation, housing, income levels. So the broad health system includes all those social determinants of health, Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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which those of us interested in improving public health must get involved in. However, it clearly is the case that the health sector, delivering health services has an impact on people's health . And the whole movement towards universal health coverage recognizes this. In stressing that people should be covered by a broad spectrum of health services from preventive health services to curative services, rehabilitative services, and palliative care for people's ends of lives. And it's also important that we look not only at people consuming services, but that this is a mechanism to them reducing impoverishment. Now looking at the way that health services impact on health outcomes, one would have thought intuitively, it's the case that the more that people consume health services, the better impact there is on health outcomes. But surprisingly, the, the evidence on, on that score has been relatively limited. But recently some pioneering research done by Peter Smith and Rodrigo Moreno-Serra, written up in, in The Lancet showed that in a 153 countries, countries that have higher coverage of services actually do indeed have better health indicators, lower mortality rates. Also, more recent research has showed that rapid reductions in child mortality in Africa in the last decade were largely due to scaled up health service coverage. And in particular, coverage of one preventive health measure of mass distributions of bed nets to, to counteract malaria. So literally children being covered by these important preventive health measures has reduced mortality. Now WHO have done more work looking at the way that the health system functions and how health services impact on health outcomes. And building on their previous work, they now identify six basic building blocks or functions that lead to improved performance. Firstly, the leadership and governance issue that I'll describe in a subsequent lecture. Then around the information that is required to run the health sector efficiently. Also, health workforce and human resources for health, vital inputs to running health systems properly.

Medicines and medical products and technologies are also vital elements in the armory in improving health system performance. Combining those inputs efficiently through improved service delivery is another key function of the health system. And finally and I'll deal with this topic in another lecture, financing the health system, another key function that needs to be taken into account. WHO and many in the public health world also emphasize the vital importance of primary healthcare in improving health systems.

And here we're talking about essential healthcare based on values of universal access, equity, participation and intersectoral action, working with other sectors that impact on health. With this particular emphasis on the primary or first contact level where people first interact with the overall health system. So looking at service delivery, we're really

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talking about how these inputs are organized and managed to ensure improved access to services, that services are of good quality, that they're safe for people to consume.

And also that there's a continuity of care across services as people interact with the health system. So for example, making a primary healthcare contact, being referred to more specialist care, and then maybe continuing rehabilitative care back in the community. But it's not just really about the supply side. We should also be concerned about raising appropriate demand for services so people access services when they need them. But also that people don't inappropriately use services. For example, consuming antibiotics when they don't need them. It's vital too that the services are integrated. And as you can see, there's a broad spectrum of services and it's important that all the elements work well together and efficiently together. Government should also be concerned about the overall management of the provider network and making sure that it's supervised properly and people doing the jobs that they're meant to do and not providing inappropriate services or for example, charging for services that they shouldn't be doing. And finally the other important element is making sure that the whole infrastructure is organized properly and distributed so that everyone can benefit from the health services that they need. And that the logistical systems work so that medicines are, are available in the health centers and health workers are paid on time.

And mentioning health workers, one of the key inputs and functions of the, of the system that I was mentioning with human resources for health, which WHO identified recently as what they regard as the most important input for the health system. One of the main reasons for this is it's the most costly and typically governments are spending over 50% of their health expenditure on human resources. And it's vital for an effectively running health system. But unfortunately in many countries the, the availability of health workers is inadequate. And in fact 83 countries have been identified as not having the basic minimum of around 23 skilled health workers per 10,000 population. So it's very important that we scale up the availability of qualified health workers and improved their distribution across the country so that health workers aren't just working in say urban centers, catering for the elite but are reaching populations right across the country. It's also important that there's an appropriate skill mix between you know the different professions of doctors and nurses and midwives and ancillary staff as well. And maybe the countries you know trying to improve the efficiency of the system should look to shift tasks that can be done by lower paid workers and free up time for specialists to do the services that they're trained to do.

Now in ensuring that the health workers are you know working efficiently and safely,

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it's very important that they're trained adequately, both before they start their work, but also that there's regular in service training so people are kept up to date with the developments in their field. And the whole health workforce requires extensive management of the health labor market and governments to be involved in the recruitment of health workers, retaining them and making sure that they're working in places where they benefit the population, providing incentives for them to do the correct work and you know making sure that they don't do things that are going to adversely affect people's health. And this also requires keen supervision of the work that health workers do and making sure that when health workers don't behave appropriately, that there are sanctions as well. Now one area that, that a number of countries are looking to expand is, is that of community health workers to insure that health services really do reach remote rural populations. Community health workers are usually recruited from local communities and provide particularly primary healthcare services, both of preventive and curative nature as well. And it's been estimated there are around 1.3 million community health workers at the moment and there's a growing campaign for there being lots of more of the community health workers. Some very good examples of those have been in China where there are the famous barefoot doctors program which started in the 1960s and '70s, was very effective and efficient way of getting primary healthcare services to rural populations. More recently in Ethiopia, they've recruited over 30,000 community health workers and they've been extremely effective in improving child health outcomes and indeed Ethiopia is on track to achieve its child health MDGs. Another very important area is insuring that there are efficient health information systems, because the generation in strategic use of information is an integral part of the stewardship function. It's practically impossible to run an efficient health system if you don't know what's going on and you therefore need good information. So countries need to generate both population data about the health status and health needs of the population, but also information on the way that the health system is responding and facility based data, tracking where people are being treated and whether these services are having an impact. And there are a number of ways of generating this information through censuses, surveys, civil registration systems, public health surveillance systems, medical records and also, systems that measure the performance of health units. Now one area where it's obviously vital to be detecting and using information is, is that looking at public health security. And the recent Ebola outbreak in West Africa is a very good example of needing rapid information about the spread of communicable disease. But it's also

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vitally important that in generating all this information, that it's synthesized and used strategically. And therefore that the management really uses this information to change systems performance. And finally, when one looks at service delivery and improving services, it's vital to address the issue of the quality of services, because just measuring whether people come to an outpatient clinic or they deliver their babies in a health unit, isn't good enough, because these services will only have an impact on people's health if they are effective, they work. And therefore they must be of good quality. And in measuring the quality of services, it's also not just good enough to look at the technical quality, whether the medicines work, but also there's vital elements about the consumer's perception of quality. Are they treated with dignity? Are they seen on time? Those more sort of customer friendly aspects. Because unless health systems look at those, those customer perceptions, people simply won't go to the health facilities and use the services and therefore they'll be useless in impacting people's health.

7.3: Health Systems Financing In this third lecture on health systems I'm going to talk about a very important function of a health system and that is how the health system is financed. You'll remember from previous lectures that one of the primary objectives of a health system is to achieve universal health coverage whereby all people receive the quality health Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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services they need without suffering financial hardship. Now health financing is extremely important. You'll notice in that definition there's a reference to not only people being covered by health services, but them not being financially compromised when they access these services. So there is this aspect of health financing built in to universal health coverage. And in recognizing this, the World Health report in 2010, produced by the World Health Organization, specifically addresses this issue of health systems financing. And if one looks at that definition of universal health coverage, you'll see it's

fundamentally about equity. Firstly, that because it's universal,

everybody should be covered. Nobody should be left behind. Secondly, that the definition talks about health services being allocated according to need, with some people needing more health services than others. Thirdly, and this is the financial aspect, the financial contributions for paying for the health system are made according to one's ability to pay. Now if one combines those two elements you can see that the health financing is really about healthy wealthy people cross-subsidizing the sick and the poor. So what are the major challenges facing countries as they try and finance their health systems to achieve universal coverage? First of all, they clearly need to raise sufficient funds to finance the health system. One needs a certain quantum of financing and recent estimates suggest that around $87 per capita is required as an absolute basic minimum to achieve universal health coverage. But secondly there's this vital element of risk protection, financial risk protection so that people don't face financial barriers which prevent them accessing the health services that they need.

Also, that they don't suffer financial ruin when accessing health services. And the third major challenge is ensuring that one maximizes efficiency in the use of these resources and also making sure that resources are allocated equitably, fairly. Now this whole issue of health financing has been extremely contentious over the years and continues to be so across the world. But the good news is that there really does appear to be a consensus emerging now on how countries should finance their health systems

to

achieve universal health coverage. The first point and very importantly is that market driven health systems which are privately financed never reach universal health coverage. And this is a realization from countries across the world now. Instead there's a very high role for the state in organizing the way that the health financing system is organized, particularly enforcing healthy and wealthy people to cross-subsidize the sick and the poor. This doesn't happen naturally in markets. Now achieving this of course is inherently political because not surprisingly, a lot of the healthy, wealthy people don't necessarily want to cross-subsidize the sick and the poor. So this means that there is a

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very big role for the state in all the main functions of health financing, both in terms of raising the revenues to pay for the health system, in pooling of those revenues to create a big risk pool to buy services and in the allocation of those resources and the way that services are purchased. Now despite this big role for the states in, in health financing this doesn't necessarily mean there's no role for the private sector. Either in the administration arrangements of some of those financing arrangements, but also in the provision of services. What we're talking about is public financing, but when it comes to the provision of services, this can be either done in the public or the private sector. Now other areas where a consensus is emerging, where there's been tremendous controversy is in what are the best financing mechanisms to raise funds to finance the health sector? Now the most obvious way to finance a health sector is people just paying for services as and when they need them, through user fees. But really this is a terrible way to finance a health system because it involves no pooling of resources and is grossly inequitable in that poor people are excluded from getting the care that they need. And in fact, the president of the World Bank has recently said that user fees are unjust and unnecessary. Now other people have been suggesting that maybe a way to finance a health system would be through private voluntary insurance, including community based insurance, which is a mechanism that's being piloted in a number of developing countries. But again, the evidence shows that this isn't really a viable route to reach universal health coverage, because private insurance tends to be ineffective. It often doesn't raise enough money. It's inefficient, it has extremely high administration costs and it's also inequitable because it excludes the poor. Now what does that leave? Quite simply the best way to finance the health system is through public financing. Now here there are two major mechanisms. Firstly, tax financing, out of general revenues, but then also through compulsory social health insurance contributions which in effect are a tax on wages. And you can see that the difference between the two is quite subtle. And in fact, what many countries are doing now is actually mixing those mechanisms of tax financing and social health insurance contributions. But the key point is that they're compulsory and that they're publicly governed. And another thing that countries are recognizing though is that where there are large informal sectors, it's actually very difficult to get health insurance contributions from the informal sector. And really if you want to cover the entire informal sector you've got to predominantly use tax financing. Now as I mentioned, this has been quite a controversial area over the years and there have been great disagreements about the roles of these different mechanisms. But even people who 20

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or 30 years ago were advocating a more privately financed health system are now recognizing that in fact public financing is better. And in a recent Lancet commission report called 'Investing In Health', the authors of the 1993 world development report that were advocating a more privately financed health system now acknowledge that public financing is best. And in fact they, a quote from one of the lead authors saying that, 'the path to universal health coverage cannot work with reliance on voluntary private insurance.' So there is this consensus now that public financing is best. Now given that, how can countries increase their public financing? And here there are a variety of methods that countries might look to do. Firstly, to improve existing tax collection, making sure people pay their taxes and clamp down on tax avoidance schemes. But also of course, introducing new taxes, particularly in developing countries, it's often difficult to tax people's income. In which case it's a good idea to introduce new taxes on things like alcohol and tobacco, so-called 'sin' taxes, which actually these are products that adversely affect people's health. So to tax them is a very good idea. But also potentially taxing remittances sent from abroad, or introducing a new value added tax like has been done in Ghana which is funding its national health insurance scheme largely out of this VAT levy. Another way of course is for governments to reallocate funds within the budget from less productive and less useful areas. For example, in reducing military spending or maybe trying to reduce subsidies that don't make sense, either economically or for the environment, for example, in reducing fuel subsidies. And the third major area where countries can free up more resources for the health sector is in improving efficiency. WHO estimates that the countries can realize efficiency gains in the order of 20% to 40% and therefore get more health for the money that they have. And here, mechanisms can be reallocating money from specialist hospitals towards primary healthcare services and more cost effective community services. The area of medicines, where there are tremendous savings to be made in switching from branded medicines to generic medicines and improving procurement systems and reducing prices. And also in adjusting the skill mix and for example, investing more in community health workers who are very effective at reaching people in remote areas. These are good mechanisms for countries to follow, but how might a country start off on this route towards financing its health system?

And a typical situation that countries find themselves in when they're starting this process is that the richest quintile of the population are covered, maybe through social insurance schemes or they're so rich that they don't mind paying user fees. Also governments often make an attempt to cover the absolute poorest strata of society,

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maybe giving them a free health card. But unfortunately, these services often tend to be very poorly financed and really not adequate for, for people's needs. But of course the major problem is that the majority of the population are still uncovered. And this is clearly not good for their health status, but also politically it's not a good idea to leave these people in the cold. Now how do countries move away from this situation? One approach is to do it quite slowly and incrementally and from the top, down, maybe extends the health insurance schemes. Also from the bottom up, one can perhaps be a bit more generous with these basic safety nets as schemes. But unfortunately this process can take an awfully long time and leave a lot of people still uncovered. And what a number of countries are finding for example, in Indonesia or in Vietnam and the Philippines is that about a third of the population remain uncovered. Now another approach is to move much more rapidly to basically cover the entire informal sector at a stroke by injecting a large amount of tax financing into the system and not differentiating in the informal sector between the poor and non-poor. Now this is a strategy that's been employed in many countries worldwide in the last 20 years, particularly right across Latin America and in Sri Lanka and in Turkey. And one very good example, which figures prominently in the World Health report is in Thailand.

Thailand in 2002 had a situation where they hadn't reached full coverage and a large proportion of the informal sector were uncovered. But on one particular day the government announced they were going to introduce a universal coverage scheme. And this at a stroke basically covered the rest of the informal sector and meant that everyone was now part of the health insurance program. This had the impact of increasing the utilization of services dramatically across the population and reducing unequal acecss. It also had the impact of reducing out-of-pocket expenditure and medical impoverishment which went down 82%. Also, satisfaction with this universal coverage scheme increased from 83% when it started to over 90% now. So you can see on all these measures of a health system that we're tracking of utilization of services, financial protection, and satisfaction with this system, this is a very sensible thing to do. And it's this type of approach that other countries seem to be looking to as they move towards universal health coverage.

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7 .4: The Politics of Health Systems and Universal Health Coverage In this final lecture on health systems I want address a topic that's often neglected in these discussions and that concerns the politics of health systems and universal health coverage. Universal health coverage and health systems reforms are fundamentally political. One could see this all over the world, not least in the United States, which is having great debates how it moves towards universal health coverage.

But this is true in every country across the world. Now why is it that this issue of health coverage and universal health coverage is so political? It really is for a variety of reasons. Firstly, everybody wants good quality health services with financial protection.

Universally it comes out in polls that this is the expectations of people across the world.

So it matters a lot to people that they get this financial protection and they get the health services they need. Secondly, it's actually a very easy concept to understand.

And politicians find it therefore very easy to sell to electorates that this is something they're going to bring to them. And in fact people demonstrate specifically for universal health coverage and an expectation that the states will deal with the healthcare financing. Now as I've mentioned in the previous lecture, universal health coverage requires public financing and a lot of it as well. It also must be done progressively with the healthy wealthy cross-subsidizing the sick and the poor. Now delivering this is inherently political. Finally, universal health coverage and health systems reforms can actually bring nationwide results very quickly. This is quite unusual for a government policy to have an impact right across the country, benefiting virtually all households so quickly. It doesn't happen with infrastructure reforms and other economic reforms.

Therefore it can bring very quick political benefits to people and that's really why politicians are so interested in it. Now because it is so important to so many people, and it is so political, it's absolutely essential that health reforms like this are led by the

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head of state. If it's just done by the ministry of health, often this doesn't work. There are so many political benefits to be gained, but also costs to be taken care of that this really is a head of state's issue. Also, successful universal health coverage reforms really need the full cooperation across all of government. It's way beyond just the remits of the ministry of health to deliver on this, but across cabinets and local governments as well. Often what you find though is ministries of health are actually often rather weak ministries within the cabinets. And ministries of finance often actually don't want to suddenly increase public financing, maybe doubling the health budget.

And really the only way they'll be persuaded to do so is when they're instructed to do so by the head of state. We've mentioned that big UHC reforms require significant increases in public financing. And the decision on, on doing that is therefore one that must be taken right across government. And in particular, the head of state, needing to take control of the situation, mobilizing supporters behind this political strategy, making sure that the public financing is, is raised properly, but also tackling the opponents which there will undoubtedly be for these reforms. What's also interesting to note is that universal health coverage reforms are particularly popular in post-conflict states, or in new democracies. And this is really for the reason around the quick wins that these policies can deliver. And new heads of state are often looking to demonstrate to the population that they brought around change that's benefiting everyone. So universal health coverage could be quite a good way to legitimize the state and particularly a new state, because it provides tangible benefits to the population very quickly. And here's some examples of countries that have done this, include the, the United Kingdom in the immediate aftermath of the Second World War, in introducing the National Health Service. Also right across Latin America, in the, in the last 20 or 30 years where there have been transitions, particularly from military dictatorships to democratic governments, often one of the first things the governments have done is introduce massive universal health coverage reforms. And other examples include Nepal in 2008. The new ANC governments in South Africa in 1994, one of their first policies was universal free healthcare for pregnant women and children. In Liberia, Sierra Leone, Burundi and Rwanda, these are all countries that have come out of periods of conflict and one of the first major policies they've introduced is universal health coverage reforms. Now looking at the transition that countries make from a system of privately financed system where there isn't universal coverage to one where there is, what are the economic and political determinants of that process? Well firstly it's undoubtedly the case that it's economic growth and more resources that drives up

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health spending. Not surprisingly, as countries get richer, they spend more money on health. But what's interesting to note is that as a proportion of GDP that rises as well.

As countries get richer, people want more money to be spent on health. But another thing happens as well, which is very interesting is that as countries develop, the proportion of the financing of the health sector, that is public financing usually increases as well. You get this switch from a private voluntary financing system to one that is more governed by the state. Now that process is inherently political. And we've seen this process happening in countries all across the world, particularly in making the transition from being low income to middle income countries. But this process isn't a slow and gradual linear process, what you tend to find happens is that suddenly there's a step when countries make this transition to covering the entire informal sector, which as I mentioned before, invariably requires a big increase in public financing. Typically in the order of about 1% of GDP, which is a lot of money. Now what prompts that is usually political windows of opportunity. A new government coming to power, a contested election. When a politician announces that they're going to run on this platform and you see this sudden transformation. And therefore these processes are very associated with particular individuals and very strong charismatic leaders. And it's very striking that across the world one can name almost the year and the politician that prompted these reforms. So for example, Nye Bevin in 1948 in the U.K. President Park in Korea in 1977. So if this is a good idea to move towards universal health coverage through a publicly financed system, why is it so difficult? Why do you find these processes are so contested? And really it's because in making that move towards universal health coverage, there are undoubtedly winners in terms of people who are now covered, but also financially there are losers, people who now have to pay more into the public pool. The costs and the, the...associated with that transition tend to be concentrated in organized groups who possess a lot of political resources. Powerful groups like the medical profession like pharmaceutical industry and insurance companies and the urban elite who will have to, to pay more for their health services.

Whereas the beneficiaries, the people who really like these transformations tend to be more in unorganized groups, lacking political resources, particularly the rural poor population. Now I'd like to describe one or two countries that are making this transition to illustrate these, these points. One country where there's been a fascinating transformation or ongoing transformation of the health sector is Indonesia which recently elected a new president, President Joko. Now he previously was the governor of Jakarta and in becoming governor of Jakarta only in 2012, one of the first measures

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he introduced was universal health coverage in the city of Jakarta. And it was largely on the basis of the popularity of that scheme that he became so popular nationwide and in the election campaign announced that he was going to extend the benefits of this to the, the whole Indonesian population. And he was elected president only in July and has already started implementing this universal health coverage program. Now interestingly he's financing this through increased tax revenues that he's secured by reducing fuel subsidies. Indonesia had very high fuel subsidies. In fact they were spending three times as much on subsidizing fuel as they were on their health system.

And now by removing these fuel subsidies he has the resources to be able to pay for universal health coverage. Now this is quite an interesting political tactic which seems to be followed by other countries as well and makes a lot of sense in terms of the broader sustainable development goals. Because many governments have found themselves historically now subsidizing fuel which they recognize isn't a good idea economically and it's also not a good idea for the environment as well. But unfortunately, these fuel subsidies are very popular and the population have got used to them. So therefore, in removing these subsidies, one needs to give something back to the population in return and give them benefits that they see relatively quickly.

Governments therefore looking for quick win policies that can benefit all households and people being able to make the tradeoff between having subsidized fuel and other services. Now universal health coverage reforms fit this bill perfectly because all households require health services on a pretty regular basis. And governments are very cleverly looking now at linking increasing access to health services, in particular, access to medicines with removing fuel subsidies. So this is happening in Indonesia, but it’s also happening in Iran which has recently introduced universal health coverage reforms and likewise is linking these reforms to reducing fuel subsidies. So maybe this might be a trend for us to encourage thinking about the sustainable development goals. Other countries where this could be highly relevant are Nigeria, where there are to be elections in February, 2015, which now has a GDP of $3000 dollars per capita, relatively high and higher than Thailand had when it introduced universal health coverage 12 years ago. And Nigeria has a lot of oil resources that really one feels ought to be made available for providing universal health coverage. India is another country that spends a lot of money on fuel subsidies and surprisingly little on its health sector.

Only about 1%, 1.2% of GDP. And it would be interesting to see as a, as a political strategy where the Indian population would be like other countries in recognizing that them getting better access to health services is a good deal as fuel subsidies are

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removed. Now one can't really talk about health financing and universal health coverage without mentioning the United States as well, where President Barack Obama has invested enormous amounts of political capital in trying to improve the health financing situation in the U.S.'s notoriously inefficient and inequitable health financing system. And he's taken big steps moving towards more of a mandatory health financing system which may indeed form a precursor towards more of a socialized health financing system in the future. So in concluding, universal health coverage is really as political as it is anything to do with technical issues, especially in moving towards a more equitable public financing system. Universal health coverage is also popular with people and politicians across the world. It really brings politics in to the health systems debate. And worldwide political actors and not really technocrats are the driving force behind universal health coverage. And really looking to the future that health developmental agencies should engage much more in the political economy of these health reforms and promote these health benefits and political benefits to political leaders.

8: Health Systems – II

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8. 1: Access to Medicines-I DR. REDDY: In this chapter we’ll be looking at access to essential medicines.

Very clearly the introduction of life-saving drugs has made a great deal of contribution to improving life expectancy as well as reducing disability. And when we are looking at global health, the access to medicines becomes a very important element of universal health coverage . Essential medicines are those that satisfy the priority healthcare needs of the population. Obviously there are several medicines, some of which are taken for relief of very temporary conditions, some are often taken as supplements to diet, some are taken for example to relieve cough or something like that. But essential medicines are those that are really required for protecting the health by reversing disease and reducing disability They’re selected with due regard to public health relevance, evidence on efficacy and safety and comparative cost effectiveness. Clearly there can be a wide range of medicines for treating the same condition but you need to be very sure that they’re effective, safe, at the same time, cost effective. Essential medicines are also intended to be available to the health system so that we are not uncertain about their regular availability for being provided in various healthcare facilities as needed. They should be available at all times in adequate amounts and in appropriate dosage forms with assured quality. Now quality is going to be an absolutely important criterion because without that, you cannot be sure either of effectiveness or of safety. And there should also be adequate information available about each of these drugs, not only for the physicians but also for the patients who are receiving it. And they should be available at a price that the individual and the community can afford and certainly the health system also should be able to afford it as a part of the public financing. Access to medicines has become a worldwide challenge and the World Health Organization estimates that about 1.3 to 2.1 billion, depending upon the criteria that are employed, do not have access to medicines. Unfortunately many of these are in the Revista de Praticas de Museologia Informal nº 6 spring 2015

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countries where there’s the greatest need in terms of unmet health challenges that is Africa and India. Access to essential medicines is closely related with the other aspects of the health system performance. That is, we find wherever there is a high level of disability- adjusted life years lost because of major health disorders, there, access to medicines which ought to be assured is unfortunately deficient. In terms of inequities in production and utilization, we ought to be able to really look at where the population lies and where the actual money is being spent in terms of purchase and prescription of medicines. Whereas the largest populations lie in the low and middle income countries and the low income countries and a much lower proportion of the population, about 16% is in the high income countries, the actual expenditure on medicines at the global level is the highest in the high income countries that is about 78.5%. Whereas in the low income countries, the expenditure is only 1%. This is a huge inequity in terms of availability and affordability of medicines across the world, reflected in the utilization patterns. When we are really looking at access, there are four critical elements which promote access. The World Health Organization says firstly there should be rational selection based on first quantification of the medicines that are there in the overall pharmacopoeia and then trying to select among them according to the criteria of essential medicines and forecasting the need according to the disease burdens and the various health system priorities within that country. And rational selection of course goes as I said, on the basis of effectiveness or efficacy, safety, and cost effectiveness.

That brings us to affordable prices because we need to really look at how affordable these medicines are, both for public procurement by the health system and also for personal purchase by an individual patient. So that becomes the second element of how we actually ensure that the prices are within easy reach. And then we actually look at the procurement process which then brings the medicines into the health system.

And we definitely require reliable supply systems. Unfortunately many public procurement systems and distributions systems do not pay attention to regularity of supply and there are frequent stock-outs that means non-availability of medicines within the facilities. And that means that many of the people who actually go to these facilities do not have the opportunity to get them on a regular basis as needed. And similarly if they’re also not available on a predictable manner in the open market for purchase at affordable prices, that again deprives people of access. So having reliable supply systems is absolutely critical. Rational selection refers to choosing safe and effective medicines which are appropriate to the country’s health situation. Accordingly, essential list of medicines will have to be prepared by each country. The World Health

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Organization, since 1977, has been providing a reference list of essential medicines, which actually serves as a guideline for individual countries which will adapt it for their own use based on their own national requirements. So each country has to have its own national list of essential medicines. And sometimes within large countries, provinces or states also modify the national list to suit some of their regional priorities.

The number of countries which have essential list of medicines is of course is fairly large. But the number of medicines that enter the lists varies based on the national income. Low income countries for example have much lower number of essential medicines on their lists as compared to middle income. But the high income countries have a far higher number. The low income countries have had on an average, 355 drugs. The middle income countries have 441. Whereas the high income countries have a total of 1700 drugs as a part of their armamentarium in their essential list.

Sustainable financing is the next step that we need to really look at, and here we need to increase the public funding for health system in general, but especially for essential medicines. Unless public financing of health through universal health coverage programs increases to a level where essential medicines can be procured and distributed at no cost or low cost we will find that there will be a continuing barrier to essential medicines for most of the people in that country. So we need to raise public financing and use a substantial fraction of that for procurement of medicines. We also will get an added benefit in that because much of the out-of-pocket spending in many of the countries is related to private expenditure on purchase of medicines. Of course by expanding various forms of health insurance, particularly social insurance or government subsidized insurance, we will be able to provide greater coverage and we need to bring in medicines also into the ambit of insurance programs which frequently do not cover outpatient care or provision of medicines. And of course there are other financing mechanisms that we ought to be looking at, including debt relief as well as international supply by various donor agencies. Sustainable financing of course requires a fair amount of public expenditure, which is predictable. As a paradoxical situation, high income countries seem to be having a greater degree of public financing as compared to private financing. And this situation has remained unchanged or even worsened over the years, when you compare 1996 to for example, 2006. In the other categories of countries, which are in the middle income or the low income bracket, we find that the private expenditure on medicines is increasing, which is again, quite indicative of the fact that public financing is at low levels as a response to the needs of the people and certainly fall short of the objectives of universal health coverage. When

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we look at the overall global situation in relation to sustainable financing, out of the high income countries, categorized by the WHO, the share of pharmaceutical expenditure in high income countries is about 18.2%. Whereas in low and middle income countries, it’s about 26.6%. And the low income countries, it’s 29.5%. Which means that these countries, despite the fact that they’re unable to invest adequate amounts of public financing into the universal health coverage program, or even into the health system as it exists today, are still having to spend a fair amount of their health budget on medicines. Unless the overall health financing goes up as public financing for the health sector, we will be unable to raise within the limitations of the currently available funding the expenditure on medicines to meet the huge gap in access to medicines.

8. 2: Access to Medicines-II DR. REDDY: When it comes to reliability of supply systems we need a good distribution system that ensures the availability of all essential medicines at all levels of the health system- primary, secondary and tertiary. And we can have several strategies for this. Firstly we need to integrate medicines in the health sector development. We cannot look at this as a separate problem of a pharmaceutical department which is often not even in the health ministry. And if pharmaceutical production is seen more as a commercial or an industrial activity, divorced from the needs of the health sector there can’t be anything worse than that for universal health coverage. So we need to Revista de Praticas de Museologia Informal nº 6 spring 2015

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integrate the whole availability and production and supply of medicines into the health sector development program. We also need to ensure that there is a fairly efficient and well-functioning public-private NGO mix in terms of the approaches to supply delivery.

So the supply chain, while it may be driven substantially by the public sector, ought to be able to accommodate the private as well as NGO sectors also because they’re also often very major contributors to supply. We need to assure the quality of medicines through regulatory control. This is absolutely important particularly where we are now seeing a huge need for medicines across the world which are being met by generics, but these generics will have to be quality assured. And this requires appropriate drug testing and regulatory control. We need to explore a variety of purchasing schemes and pool procurement often reduces the overall pricing of medicines. Because if you actually have procurement cooperatives, or pool procurement, you’ll be able to eliminate the middle man and then remove multiple intermediate stages where there is price markup and ultimately get almost directly from the manufacturer a bulk procurement which can be substantially low priced and very close to cost of production, rather than the traditional market price which has multiple layers of markup. So we have to look at pool procurement and procurement cooperatives. At the same time we need to look at also procurement of traditional medicines. We’re not only talking about allopathic medicines here, many countries, especially in low and middle income countries have traditional systems of medicine which form a part of the health system and which are frequently accessed by the people and are often affordable. So we ought to be able to look at the supply of traditional medicines as well in healthcare provision.

Coming to the whole area of stock-outs, you can see this happening not only across countries, but even in health systems within countries. For example, in India where there are multiple states with different health system capabilities. The health system in Tamil Nadu, which is very well-functioning, has a very little problem of stockout. On the other hand, Bihar has much lower availability and a much higher level of stock-out at any given point in time, though recent improvements are beginning to change that situation. So we need to address this whole problem as an issue of health system capacity for effective functioning.

And that the global level, we actually meet other challenges. We see the whole area of trade coming sometimes as an opportunity but quite often as a barrier to access. Trade in pharmaceutical products has been heavily influenced by international trade agreements, intellectual property rights, and globalization. And pharmaceutical companies have been researching on development of new products which are mostly

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based on the market expectations of utilization in the rich countries and not by the needs in the developing world which constitutes the majority of the global population.

They are looking at who is likely to buy and particularly at a high cost rather than who actually needs them in terms of life-saving medication. And therefore, we find that many of the neglected tropical diseases do not have medicines and some of the medicines available for even common diseases are not often available at affordable cost. Many of these companies are also exploiting patent laws for their own profit. For example, stretching of patents, even when the patents are supposed to be expiring and the drugs are supposed to be coming into common domain for production by other companies, some of the companies are actually resorting to what’s called evergreening, which is a method to retain the patent protection and royalties from products, either by extending patents or buying out competitors, particularly by minor changes in formulation. Or in the manner of delivery in terms of the time of release of the actual drug by minor changes in pharmacokinetics. They’re actually declaring a drug to be a new product and are trying to extend the patent and stretch the patent out. And these are some of the things that actually are becoming barriers in terms of pharmaceutical company practice and challenge to countries which want to really take drugs off patent and then put them in the health system in the form of generics. But trade agreements are not entirely dispensable. Sometimes they may actually provide support to the less developed countries in other domains, like for example, traditional knowledge and genetic resources. So some of these actually by patent protection may help some other low income countries and the middle income countries generate more resources for their own health system. So the challenge of global trade is to ensure- yes, there should be some degree of intellectual property rights being protected, but at the same time, we need to ensure that this does not become a major barrier for access to medicines. And we have to look at the availability of medicines as a social contract between the industry and the wider population in the world in which the need for livesaving essential medicines outweighs commercial considerations. And the whole area of affordable pricing has become a subject matter of TRIPS- the trade related aspects of intellectual property rights. This agreement was first signed in 1995 at the Uruguay Round Agreement of the World Trade Organization. This mandated minimum standards for patent protection for pharmaceuticals. Clearly the pharmaceutical industry, particularly concentrated in high income countries, had an interest in ensuring that their products were patent protected so that they could make profits out of them from their exclusivity of production. But between signing of the TRIPS and the WTO Doha

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Ministerial Accord, the world witnesses a major crisis in terms of access to the drugs for HIV/AIDS. And especially in Africa and this became a major global issue. When some of the generic antiretroviral drugs were being supplied to South Africa by an Indian generic manufacturer, there was a major challenge from the multinational company which was producing the drugs. Indeed, the Mandela government was sued by this pharmaceutical company, much to the consternation and shock of the rest of the world.

But fortunately the public outcry and the revulsion as well as civil society action across the world, including communities in the high income countries compelled not only the pharmaceutical industry to withdraw and permit the utilization of generics, but it also led to the global community to look at how trade agreements ought to be modified in order to protect the interests of patients who most need life-saving drugs. And that is why the WTO Doha agreement then came about. In 2001, in Doha, there was a declaration on the TRIPS agreement and public health. While reiterating our commitment to the TRIPS agreement, that’s what the countries said, we affirm that the agreement can and should be interpreted and implemented in a manner supportive of the WTO members right to protect public health. And in particular, to promote access to medicines for all. So public health could now start trumping to some extent the right to intellectual property which became restrictive on occasions. Especially for public health emergencies. So this was a very important victory for looking at how public health could be still advanced despite some of the drugs being on patent. And in 2003, in Cancun, adjustments and provisions were made in the TRIPS agreement to allow improved access to essential medicines. So we have to really look at the whole area of trade and evolving developments in the trade agreements and trade related treaty discussions from the point of view of global public health. And when we come to chronic therapy, long-term therapies for cardiovascular diseases, cancers and diabetes, these countries are going to be bankrupted if the drugs are high-priced and people are going to be dying prematurely if they do not have access to life-saving medication.

So access to effective non-communicable disease related drugs remains a high priority for the rest of the world, especially those in the low and middle income countries who do have access at the moment to drugs produced by pharmaceutical industry in the high income countries, mostly for those markets. Even when we look at generic drugs, there is a disparity across the world in terms of international generic drug pricing. There is really no consensus on how generic drugs should be priced. There is a fair amount of opportunistic pricing which is being employed by different manufacturers. If we look at the potential for lowering of the pricing of generic drugs

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by domestic manufacture as opposed to internationally available generic drugs, we see a huge disparity. Like for example in South Africa or Kenya or other countries or Brazil, the domestically manufactured generic drugs are far lower than the internationally branded products or the internationally sold generic products.

We therefore need to ensure that in as many countries as possible, at least in the middle income countries, we ought to be able to increase the capacity for domestic production of quality assured, low priced generic drugs. When we look at improving access, we can look at seven major strategies. First is enhancing capacity for generic substitution and the specific solution there is to expand the scope of the WHO prequalification project and build capacity of local regulatory, drug regulatory authorities to fast-track registration of generics. Secondly is to expedite generic availability by overcoming legal barriers related to patents and licensing. This we can do by increasing the use of compulsory licensing under Article 31 of TRIPS. Compulsory licenses are where countries in extraordinary situations, where public health needs are to be prioritized, can actually issue license to other companies, even for a drug which is still under patent protection. Optimizing local procurement practices in the public sector is absolutely important and this is done by recruiting local support for better supply chain management and using mobile and information technology to map stock-outs.

We have the capacity now to use information technology to forecast the needs, to track the availability, to spot where the stocks are diminishing and readily replenish them and we ought to use that technology much more effectively than is presently being done.

We also need to broaden global procurement where third party price negotiations. As we said, pool procurement at the national level can be very effective in reducing costs, especially for the public sector, or for networks of private sector hospitals. But even at the global level pool procurement is possible because agencies whether they are WHO or other international agencies, or a community of countries can actually negotiate jointly to try and obtain drugs directly from the manufacturer at a much lower cost by assuring a very large market size, When it comes to engaging the private sector to differentially price medicines in low and middle income countries, there is a movement in that direction. Many of the large companies are now looking at the market size in the developing countries and saying, okay, we will differentially price medicines for high income countries and for low income countries. And we will ensure that people who need it in low and middle income countries can get it at a different tiered pricing arrangement.

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We can regulate retail markups in the supply chain by use of government controls to restrict markups. Price control is an important mechanism that countries must utilize judiciously in order to reduce unnecessary markups. Finally, we must eliminate tariffs on medicines. We must adhere to international treaties to eliminate import tariffs and preferably eliminate national sales taxes. These are not luxury goods.

These are goods required for saving people from death and disease. And therefore, to have import tariffs and sales taxes is absolutely improper because we are playing with people’s lives. So by adopting a variety of strategies to provide access to drugs of assured

quality,

preferably

generic

drugs,

preferably

obtained

through

pool

procurement with affordable prices, and ensuring regular, predictable distribution through a supply chain that eliminates stock-outs, we can ensure access to drugs. But this cannot be done only for high income countries, or even for middle income countries, it has to become a globally assured supply of drugs which are needed. And this can only be done if universal health coverage becomes not only a national aspiration, but a shared global value.

8.3: Health for All - The Moral and Social Case for Universal Health Coverage DR. REDDY: In this chapter we’ll be dealing with universal health coverage as one of the key requirements of providing health for all citizens across the world.

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Quite often we have looked at health as a very important investment for accelerated economic development. And indeed, the need to protect and promote productivity among individuals who contribute to economic growth in a society has been emphasized often enough to make sure that governments continue to provide increasing investments to health year round. However, while increased productivity is an important ingredient for making the argument for improved investments in health and for universal health coverage, we must recognize that merely a utilitarian argument of improved economic growth would not be appropriate because we need to bring in the equity argument as well and position health as a right. Otherwise a large number of people who are not contributing to increased economic growth, either because of age or because of illness and disability may be left out of that whole equation.

The reason why universal health coverage has become a major global priority in the last 15 years is because of the huge amount of impoverishment that healthcare expenditure is causing across the world. The World Health report of 2010, published by the World Health Organization estimated that every year about 150 million people face severe financial hardship and a 100 million are pushed below the poverty line because they fall ill, use health services and pay out-of-pocket. Many have to sell assets or go into debt to meet the payments.

And it is because of this healthcare related impoverishment, especially exacerbated by catastrophic health expenditure, but also because of a continued chronic drain on personal finances that ill health imposes, that we have to look at a more caring healthcare system in which we provide financial protection along with quality health services. And that adds up to universal health coverage. In terms of private, out-of-pocket expenditure, many countries, especially in the low and middle income countries, impose a huge burden on their citizens in terms of personal, private, out-of-pocket expenditure on health. Which means that beyond what the government provides, they’re spending quite often upwards of 50% from their own personal finances.

This is not acceptable because it is indeed a huge burden which results in healthcare related impoverishment. And we see this happening in different countries of Asia. If we look at 11 countries of Asia and look at what the out-of-pocket payment is and the proportion of people who are being pushed in to poverty each year, then we recognize that those countries which have low levels of out-of-pocket expenditure have low levels of impoverishment, especially due to healthcare expenditure. On the other

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hand, countries like India which have had high levels of out-of-pocket expenditure, have much higher levels of impoverishment annually, of people being pushed below the poverty line.

So we do really need to move towards a system which is much better and that is universal health coverage. Universal health coverage offers a way of sustaining gains from and protecting investments in the countries that have already invested a fair amount on attaining the millennium development goals, which are related principally to maternal mortality, child mortality, poverty reduction, relief for undernutrition and so on. Now clearly some of these goals have been attained partially and we need accelerated progress on attaining those goals. But a health system which is relatively inefficient or inequitable cannot bring about the required momentum.

Universal health coverage on the other hand can galvanize the health system to perform better and achieve the goals which are only partially met. It also accommodates the changing agenda of global health which as we know, because of health transition is bringing a host of non-communicable diseases to the fore.

So universal health coverage by definition is the practical expression of the concern for health equity and the right to health. Moreover, access to services when needed also provide financial protection and also provide the comfort and assurance that people will get the services they need.

The Rio+20 United Nations Conference on Sustainable Development recognized the importance of universal health coverage for enhancing health, social cohesion and sustainable human and economic development. The U.N. in that meeting pledged to strengthen health systems towards the provision of equitable universal coverage. The countries participating in that meeting called for the involvement of all relevant actors for coordinated, multi-sectoral action to address urgently the health needs of the world’s population.

So universal health coverage as a goal, a strong health system as the vehicle, but also supported externally by concerted multi-sectoral action which will align actions in other sectors to the health needs and to the objectives of universal health coverage.

And universal health coverage does provide financial protection which is the critical aim of universal health coverage. But beyond that, it insures greater health equity within countries and across countries. It also provides the population with improved health outcomes. Longer life, better quality of life, greater healthy life expectancy, far less disability. It also enables the creation of efficient, accountable and transparent health systems.

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At the same time, it reduces poverty It leads to greater productivity, a healthy population is definitely going to be better for the economy through greater productivity.

Most importantly, by creating a strong health system it can actually increase employment opportunities for a large number of young people and women because if universal health coverage is going to be focusing strongly on primary health services, in a world where there are the health workforce crisis, a great shortage of doctors, nurses, allied health professionals, you need to create more jobs on the front line.

Many of them won’t be doctors, but a number of technology enabled front line health workers will have to be pressed into service for energizing primary health services. So in an era where the economic situation is not promising a lot of employment for young people seeking to enter the labor market, the health sector by embracing universal health coverage can actually provide a much larger pool of employment for a lot of young people who are aspiring for gainful livelihoods.

When we come to the implementation of UHC, there are two very important interconnected components. Firstly, coverage with the needed health services, prevention, promotion, and treatment and rehabilitation as well as coverage with financial risk protection for everyone. Since we said we will not be able to do everything overnight when we are introducing UHC, unless the country is very rich, many countries the low and middle income grouping will have to prioritize primary healthcare.

Many countries look at primary healthcare, most of secondary healthcare, especially comprehensive maternal and child health services, essential surgical services and the emergency services as the initial package which they must introduce for universal health coverage and then expand by addition of other elements.

But again, primary healthcare becomes the absolute mandatory, initial component of any universal health coverage initiative. But at the same time, when we come to financial risk protection, we have to look at multiple sources. Virtually no country has achieved universal health coverage without a substantial infusion of tax revenues. That means a good part of universal health coverage has to be tax funded.

Depending purely on health insurance, particularly employer provided or personally purchased health insurance doesn’t usually help because we need a large risk pool for insuring that there is sufficient sustainability for the program.

When we talk about a risk pool, we are talking about a number of people contributing to an insurance program where the sick minority is being subsidized by the healthy majority at any given point in time. Of course those who are sick can be healthy tomorrow. Those who are healthy today can become sick tomorrow. But it

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assumes that at any given time, the majority are healthy, they continue to pay insurance, but they’re subsidizing the sick. What we recognize is that in many of the countries, people are not always in the majority in the organized employed sector. Like for example in India, 93% of the workforce is in the unorganized sector. So you can’t have payroll deductions which automatically go into an insurance program. Many of the people are poor, they can’t afford to purchase private insurance. Even if the government provides substantially subsidized social insurance, many of the poor may not be able to get enrolled.

So as the risk pool shrinks, then the principle of that kind of an insurance where the healthy subsidize the sick or the rich subsidize the poor does not operate. On the other hand, in a tax funded health insurance system for universal health coverage you have the largest risk pool possible. And there the rich do subsidize the poor by paying higher taxes as a part of their social obligation. And the healthy majority does subsidize the sick. Therefore tax funding becomes an inescapable component of any financing for universal health coverage virtually in most parts of the world. And even in those countries, which have been really talking about insurance based systems, there is a substantial amount of government funding, even in the United States. So we need to look at a mixture of different funding sources with tax funding as the base and possibly other forms of insurance like employer provided insurance or government subsidized social insurance as additional components. One of the best known health economists, Bill Hsiao, or William Hsiao from Harvard writes that empirical evidence indicates that a free market for insurance cannot achieve social equity and that serious market failures allow insurers to practice risk selection.

That means they leave out the most vulnerable and make them uninsured. So if you are cherry picking and taking only relatively healthy people, for whom you do not have to pay much in terms of healthcare reimbursements, the people who really need healthcare are left uninsured. Dr. Hsiao also says that adverse selection among insurance buyers impairs the functions of the insurance market and deters pooling of health risks widely. Moreover the insurance markets high transaction costs yield highly inefficient results. However, there are some advantages. Dr. Hsiao indicates that evidence suggests that reliance on market competition for the provision of healthcare may hold potential for more efficient and higher quality care. What we are really looking at is the weaknesses of multiple competing insurance systems which adopt an adverse selection process. On the other hand, we still would like to bring in quality and

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efficiency into the healthcare system and even if we are going for a tax funded system, that is a requirement, to look for efficiency and higher quality of care.

Many countries have grappled with this problem and have adopted different models of universal health coverage, basically looking at their own country context and resource scenario. Indonesia has a social security providers law which replaced the previous community health insurance. And under this, 95% is paid by the government with the holder contributing 2% and the employer paying the remaining 3%. This has been particularly effective in Jakarta and is likely to be expanded across the country later.

Now in Canada, Medicare includes coverage based on health on need rather than the ability to pay. Provincial and territorial governments are responsible for the management, organization and delivery of health services for their residents. In Mexico, there have been a combination of different health insurance programs, substantially tax funded or government subsidized. Even though they are called insurance in the broad sense, they’re bringing a lot of government funded and government provided health services. And here particularly the introduction of Seguro Popular in 2003 brought financial risk protection to a further 50 million persons in the population. So that was a huge leap in terms of the number of people provided some assurance of healthcare with financial protection.

In Thailand, the universal health coverage scheme started off with what was called the 30 Bhat Scheme where people paid less than one dollar and that plan added about 14 million previously uninsured people to the Thai system. And this scheme has now been transformed with even greater coverage and a greater degree of financial protection at even lesser contribution at the personal level. In China, where there was previously an urban employer provided insurance scheme and the rural and migrant populations were left uncovered, since 2003, two more schemes have been introduced.

One for the rural population and one for the migrant population. And between these three schemes now the coverage by some form of health insurance for provision of healthcare with some financial protection has extended to 96%. That means 96% of the Chinese people have some form of coverage.

But since the depth of services is still a bit limited, they’re still seeing the effects of out-of-pocket expenditure and catastrophic expenditure. As public financing increases, this is likely to decrease, even in China. In Brazil, the unified health system which is the nationalized program, provides primary healthcare while a network of public and contracted hospitals deliver specialist care. Primary care provision has

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substantially

increased

since

its

inception.

And

this

also

includes

a

national

immunization program. And Brazil has adopted universal health coverage as an objective because the constitution has a right to health incorporated and therefore UHC is an important value.

In the United Kingdom, where the National Health Service started off as a model for many other countries which are now aspiring for universal health coverage, the government is responsible for funding access to healthcare and for supplying health services. And this is now a very important area where we find tax funded services reaching all sections of the people with assurance.

The whole world is now moving towards universal health coverage it appears, because in 2005, the World Health Assembly adopted a resolution asking all countries to adopt universal health coverage as a goal. In 2010, the World Health report focused on health financing for universal health coverage and then introduced the concept of the cube and how the cube can be progressively filled. We recognize that in most countries you can’t fill cube all at once. But you have to start visualizing the cube, recognizing that universal health coverage will be incomplete unless we try and fill most of the cube, but start moving progressively by prioritizing on each dimension as to where you begin and how you move forward, moving from the essential to the optimal.

In 2012 the U.N. had the Rio+20 conference, which again adopted this as an important goal. And then surprise, in 2012, the United Nations had a session on health and foreign policy in which they brought universal health coverage as an important component, recognizing that universal health coverage is important for global development and therefore for global stability and therefore for global security and therefore must form an important component of foreign policy initiatives as well. So whether it is the World Bank or the WHO or the United Nations or even diplomats or public health experts or economists, now universal health coverage has become the common currency of development discourse.

One of the important things that we must remember is that as we move towards universal health coverage, we are also moving towards a higher civilizational state because universal health coverage cannot exist without social solidarity. Unless society feels that they’re responsible for each other’s health, that they’re willing to support healthcare for another citizen who is in need, by contributing to the risk pool of ensuring that the health of every individual in that society is adequately cared for, you will not have universal health coverage as a successful model. Therefore the moment we adopt universal health coverage, not merely as a political slogan, not merely as a

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public health system goal, but as a societal commitment, then we are moving towards social solidarity. Without that we will not have UHC. But we have to make it effective through a functioning health system and through adequate financial investments to provide financial protection.

So in the context of the sustainable development goals, we now are likely to see universal health coverage positioned as a part of the health goal in the post-2015 agenda. but it is important that all countries start understanding first what universal health coverage entails and then start preparing not only their health systems, but their financing mechanisms as well as multisectoral coordination processes in order to pave the way for successful introduction and implementation of universal health coverage to promote health equity within countries and across countries.

8. 4: Governance Mechanisms When we talk of global health with all its complexity and challenges, the issue of governance becomes very important. The concept of governance of course arose from the feudal times when you had a ruler or a ruling class and those who are ruled or are governed. But even with the advent of democracy we had elected governments which were entrusted with the responsibility of providing a method of organizing the society and insuring the rule of law in an orderly fashion so that the society could function very well.

The notion of governance goes however beyond the formal mechanisms of government and refers to the totality of ways in which a society organizes and collectively manages its affairs. Because now we are living in a state of democracy when we recognize that it is not merely for the government to decide on how the society should be run. There are multiple actors in a society and all of them need to act concertedly after adequate consultation among themselves. So it’s a collective decision in which the responsibilities are shared, but ultimately the process of governance is contributed to by every one of the stakeholder groups.

In terms of global health governance, the concept of governance now extends across countries. It has been defined as the use of formal and informal institutions, rules and processes by states, intergovernmental institutions and non-state actors to deal with challenges to health that require cross-border collective action to address effectively. Where many of the determinants of health actually act transnationally, you’ll require international cooperation- better now known as global cooperation and global concord for collective action. And when we say state, we are talking about the

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collective, governmental, as well as societal image that captures a country’s interest and provides governance for that particular country.

But there are non-state actors who are acting independent of the elected state and those also need to be recognized as important contributors. In terms of the governance for global health, global governance for health refers to all governance areas that can affect health, implicitly because global health is fundamentally geared towards promoting health equity and reducing inequities. Global health can make the normative claim that health equity should be an objective for all participating sectors which goes beyond the health sector as well.

So, When we are talking about governance of global health, we are talking about governance with the health systems, when we talk about governance for Global Health we are talking about all sectors of development in human activity being aligned to the objectives of global health and being geared to promote global health equity.

There are multiple global challenges that we are now seeing. For example, the threats from the past, infections, maternal and child health challenge as well as a host of emerging challenges like non-communicable diseases, zoonosis, antibiotic resistance.

We’re also seeing challenges arising from globalization, increasing inequity in multiple areas whether it is access to drugs or even some of the problems of health systems compounded by migration of trained health workers from countries which need them to countries which can afford to purchase their services. We’re also seeing climate change and trade policies having an increasing influence on global health. So we recognize that no single nation or organization is currently capable of single-handedly addressing all its health challenges by itself. So we do need a global health platform in which countries can work together and multiple groups which represent different societal interests can work in concert.

At the global level we have apart from the World Health Organization and the individual national governments, we also have a number of other actors who are now coming into play. We have multilateral organizations which provide technical or even economic assistance for health. We have bilateral organizations which establish country to country collaborations. We have philanthropies which are now playing a much larger role across the world. We have academia. We have the civil society organizations. We have the private sector. We have the media. And we have hybrid partnerships which often link some of these actors. But at the level of the global health we find security becoming an important issue and health security is an important challenge for most countries now.

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At the same time, we are finding other issues like migration, education, agriculture, environment, and a large number of other issues like trade and investment, all of them becoming important contributors to our debate on global health governance.

So we are now reaching beyond the health sector, but we’re also bringing in a multiplicity of actors into play. But there are several challenges in this complexity. First is the sovereignty challenge. There is no government at the global level obviously. Even if the United Nations exists, it is more of a platform for consultation rather than a single authority which can dictate what should happen across the world. There is inherent tension between national sovereignty and international action. Most countries would like to collaborate with each other as long as their national interests are not affected.

And therefore when we ask for shared sovereignty in the area of global health, there is always a concern that nations experience whether they’re actually surrendering their sovereignty. So we do need to find a healthy way media in which nations are comfortable with working with each other rather than feeling that they’re being compelled to act in the interests of another country.

There is also a sectoral challenge. There are multisectoral influences on health and all of these are not embedded in the health sector, therefore we require crossdisciplinary policymaking which is largely absent in global health. Many of the agencies which deal within countries or across countries with agriculture and trade for example are totally insensitive to health concerns. There is also the accountability challenge.

There is a democratic deficit related to the legitimacy of international government organizations, or inter-governmental organizations. Also there is a lack of clear mechanism for accountability of non-state actors. So the question is if intergovernmental organizations as well as non-state actors have a considerable influence on the health policies of a country or a group of countries, then are they really accountable in some manner just as national governments are? If they are not, then how can they actually be held to account?

The big question is which is the organization that really represents global health? The World Health Organization was established in 1948 in the aftermath of the Second World War. It is the first multilateral global health organization and the most respected. Its imprimatur is particularly valuable in the low and middle income countries which see it as an honest broker in global health. It functions through its headquarters in Geneva and six regional offices, which are located in the Americas, in the European region, and in what’s called the Eastern Mediterranean region, the Southeast Asia region, as well as the Western Pacific region and the African region.

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Now each of these encompasses many countries in that region. The Pan American Health Organization for example covers north, central, southern American countries as well as the Caribbean.

Many of these regions, despite the heterogeneity that exists within themselves do try to act in concert at the regional level and are accountable to the regional committees which represent the governments of those regions. And overall, they work in concert with the headquarters in Geneva. But there are often disconnects in that relationship.

The WHO remains the only actor in the current global health system that has universal membership of all sovereignty nations. There are of course several importante international treaties and initiatives that the World Health Organization has taken in the interest of global health. One of the landmark treaties, the very first public health treaty negotiated by the WHO is the framework convention on tobacco control which was adopted in 2003 by the World Health Assembly. And now 180 countries have signed up to the framework convention on tobacco control. There are also the international health regulations to address acute public health risks. There has also been a great deal of work done by the WHO for advancement of the millennium development goals. The WHO also takes the global leadership role or it is the coordination role in mobilizing emergency response, relief work, management of outbreaks, for example recently in Ebola.

While the WHO is a globally respected organization, whose leadership still remains widely acknowledged, the role of WHO has become somewhat diminished or even contested by the emergence of multiple other actors, particularly those who fund major health programs, whether it is individual high income countries, or intergovernmental organizations, or philanthropies. And we now see that there has been a call for a reform of WHO, partly because the WHO’s original role of being a predominantly normative and technical agency which provides guidelines to countries has been supplanted to some extent by having to provide response to multiple health system challenges which it may not be able to do entirely on its own.

There is also the major problem that the WHO is grossly underfunded and as a result has become increasingly donor dependent to run its own programs. To what extent are these donors influencing individual countries, or even now, using the WHO platform to advance their own prioritized agendas for health? So this concern has again started to increase within the global health community. At the same time, there is recognition that many of the regional offices are not performing very well, or perform in

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a manner that is quite disconnected with the headquarters and there is no real global coordination. While ‘One WHO’ was given as a slogan by the former director general, Dr. Gro Harlem Brundtland, there is little evidence to suggest that WHO functions in smooth unison across the world, because each regional office has a regional director elected by the countries of that region and therefore there is no real accountability to the global health community beyond that region. So we have multiple challenges which the WHO faces currently.

While there has been progress in health brought about by WHO initiatives, the question that has come up is, is the WHO capable of meeting the complex challenges of an altering global health scenario? The Chatham House which is an independent organization based in the United Kingdom, put together an expert group which recently reviewed the WHO’s performance and its changing role and came up with some recommendations for WHO reform. It suggested that the core functions of WHO should be much more explicit. It also suggested reviewing and restructuring regional offices and, and indicated that they should function with far greater accountability to their regions and spend lesser money for more results. It has suggested new avenues for collaboration which must be explored by WHO. It has also called for a reviewing of the skill mix that requires to go into WHO under separation of the technical and governance departments of WHO. Now these recommendations of course will have to be considered by the countries who are member states of WHO and to see what extent the WHO can actually re-position itself as an important lead public health agency of the world. But that the global health has become a very crowded stage with multiple actors, there are about a 175 global health initiatives, funds, agencies and donors currently existing. Can WHO act as a convening platform for all of them without being unduly influenced by any of them? That’s the big question. At the same time, can WHO engage with other agencies which are dealing with issues like environment, trade, migration which have a substantial influence on health and effectively align them to the interests of global health? That again is a role that the WHO has to define for itself.

At the same time we recognize that the United Nations itself can also play a role as a convening platform for multisectoral action. It has indeed catalyzed broad development platforms initiating action on global health, for example the millennium development goals or the MDGs which were adopted by countries in the year 2000. And now the sustainable development goals which would be adopted by the countries in 2015 are also now likely to have a strong platform for global health action. At the same

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time, the United Nations held two high level summits, one on HIVAIDS in 2001 which led to the formation of the global fund for AIDS, tuberculosis and malaria and brought in considerable amount of funding into that field, with concerted donor coordination. It also had another high level political meeting on non-communicable diseases in September 2011, which is again, paving the way for global action on NCDs. It has recently constituted a task force for concerted international action on Ebola. The Ecosoc, or the Economic and Social Council of the United Nations is again another platform where the United Nations can actually coordinate action across its multiple agencies. Whether it is the World Health Organization or the food and agriculture organization, or whether it is the World Trade Organization and the World Bank, this multi-agency platform has been effective in initiating work on tobacco control after the FTCT was adopted. And now that has been transformed into the U.N. task force on non-communicable diseases. When we are looking at multiple agencies now contributing to global health, we also have to look at not only conflicts between them, but also potential synergies. For example, the report for cancer research in U.K. in 2011 suggested that partnership between public authorities as well as charities for medical research could actually bring about great benefits in the form of shared costs, pooled risks, and more stability in family. However the issue of donor engagement brings in the whole question of accountability and responsible behavior by donors.

Donors cannot set agendas which are not in the interests of the recipient countries.

They also have to be accountable for the manner in which they conduct themselves.

So the Paris declaration of 2005 defined the roles and responsibilities of donor organizations to promote aid effectiveness and enunciated five principles: ownership, alignment, harmonization, managing for results, and mutual accountability. Now all of these are very important, providing ownership to the countries, a greater alignment with national priorities, harmonization among donors and effective managing for results and mutual accountability. It’s not just the countries which are accountable for the aid received, but the donors too are accountable for the way they conduct their business in the countries.

However, one of the major problems has been the multiplicity of donor organizations.

With

all

the

good

intentions,

there

have

been

several

donor

organizations stepping into countries, for example in the area of HIVAIDS, you have had Ethiopia with 27 donor organizations in that area of health alone. Kenya with 26, or Tanzania with 25, Zimbabwe with 25, Rwanda with 23. It’s a whole crowded field. This imposes a huge burden on countries because they have to coordinate and liaise with all

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of these donors. They have to have separate reporting system for these donors. And the under-resourced health ministries of these countries crumble under the pressure of having to deal with multiple donors. So there is a great need for harmonization among the donors.

There is also the increasing role of civil society. Civil society groups can range from those which advocate for patient rights, or those which can advocate for better accountability of different health programs and voice the concerns of the communities.

They can also participate in delivery of services. So the participation of civil society from policy to actual service delivery is becoming an important component of global health and these include both national NGOs as well as international NGOs. However, with the increasing number of NGOs we also have to differentiate between the nature of NGOs in terms of their intent and their origins. It has been humorously described that there are three categories of NGOs: the PINGOS or the public interest NGOs, the BINGOS are the business interest NGOs, or the GONGOS which are the government sponsored NGOs. So we’ll really have to deal with all of these, recognizing what their main interests are.

But there is yet another challenge in terms of global health governance, even when we recognize that the WHO could be an effective convening platform for multiple agencies, including civil society and the private sector, apart from the governments.

The WHO itself is a soft governance organization. It provides guidelines and recommendations that members states can adopt or adapt based on their own discretion. They’re not mandatory. The member states can take them or leave them.

Whereas organizations like the World Trade Organization are hard governance organizations. Their policies canbe much more definitive and binding for the member states. And they’re not always conducive to good health.

So we have to again, try and see how this balance of power nor asymmetry of power between different global organizations representing different interests can be reset and corrected so that the WHO get greater traction when it has to deal with agencies such as WTO or even others like FAO, or the World Bank.

So the implications are that WHO remains the lead public health agency of the world, but its influence and its role are now coming in for greater debate and to some extent, are being contested. We need to move towards a better defined global health governance system in which the WHO continues to play a very important role as a convening platform, the honest broker as I said, giving an effective role to each of these major players whether they’re individual governments or philanthropies or the

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private sector or the civil society, but insuring that the interests of global health predominate over any sectoral interest and also insuring that the roles played by all of these groups are complimentary rather than in conflict. And that is where the WHO has to now become a very new kind of organization, setting the agenda, coordinating and at the same time, becoming the conscience keeper of global public health.

9: Environment and Health

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9. 1: Climate Change and Health When we talk of global health in the 21st Century, one of the most important things that comes up is climate change and what its impact on global health is going to be and how can we actually respond to this major challenge, which is not merely environmental or ecological, but also threatens global health in very many ways. When we look at the temperature changes that have happened over a long period of human existence, over the last 20,000 years there have been some fluctuations in temperature, mostly because of changes in the way the earth has a planet has changed its ecology. However over the last 10,000 years we have had fairly stable temperature patterns which have helped humanity to thrive and progress. But towards the end of the 20th Century we have seen human interventions change the nature of the environment to the detriment of the climate, by raising temperatures high and at a very rapid pace so that the planet really is not prepared for this level of change. And this inevitably has an impact on health and nutrition. There is unequivocal evidence on climate change. We recognize that there are rising sea levels and global temperatures, retreating glaciers, extreme weather events. And despite some climate change deniers, there is absolute global consensus that climate change needs to be recognized as an important threat to humanity and that we need to collectively do something about it.

Since the Industrial Revolution, atmospheric carbon dioxide has increased by a third.

And the International Panel on Climate Change projects an increase in global temperatures by at least 1.8 degrees centigrade by 2100, by the end of this century, as the best case scenario. But there are other scenarios, if we do really nothing, of a doomsday scenario where the temperature can actually rise to up by about 5.8 degrees centigrade. And an increase in sea levels between 9 and 88 centimeters is very much possible in the next century, depending upon how much the temperature rises. Most of this change is related to human activity. That means it is anthropogenic. It is not mediated by natural changes in the earth's environment or its geology, but it's contributed entirely by humans. We recognize that there are very many scenarios possible with a wide range of temperature changes that are likely to occur based upon the International Panel on Climate Change modeling. But we do recognize that even in the best guess scenario we are likely to have a two-degree temperature rise or more if we do not do anything. Apart from the natural variability that occurs in the earth's own environment, anthropogenic climate change will contribute substantially. And the kind of hazards that occur because of a variety of environmental distortions can actually

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accentuate global health challenges depending upon the amount of exposure that different population groups have, how vulnerable they are to these effects, and the impacts will automatically vary according to that. But there are also appropriate responses in terms of socioeconomic actions that we can undertake for mitigation as well as adaptation and how we can actually insure that there is a concerted global response to reduce some of the mediators of climate change. And they all will impact upon global health ultimately. In terms of human exposures there can be fairly acute events like heat waves or extreme weather events, also more steady rises in temperature as well as alterations in precipitation which can play out their effects over the longer period of time. Quite often the skeptics say, where is climate change because of global warming when we see sometimes extreme cold weather? That's because global warming itself can disrupt weather patterns substantially resulting in what we can call freaky weather. Beyond global warming we are actually seeing global harming in very many ways. Based upon what the contamination pathways are, what the transmission dynamics are, and what's the nature of changes in agro-economic systems and ecological systems and hydrology as well as the degree of socioeconomic and demographic disruption that takes place as a result of some of these exposures, you can have a variety of health effects. These will be temperature related illness and death, extreme weather related health effects, air pollution related health effects, water and food borne diseases, vector borne and rodent borne diseases. Effects of food and water shortages, particularly when agriculture and water supply are substantially affected. Mental, nutritional, infectious, and other health effects. Cumulatively, climate change can play havoc with human health over a period of time. There are direct effects of climate change, mainly from extreme weather events. Like for example, temperature extremes. In 2003, we had the major European heat wave. And most deaths were in the vulnerable populations, especially elderly with preexisting diseases.

France particularly experienced this. And over 70,000 people were estimated to have died in the hottest summer that the world experienced since 1540. But there are also indirect effects of climate change which act via changing patterns of disease. Vector borne diseases, for example those due to mosquitoes or rodents. As the weather warms up, mosquitoes will start breeding at higher latitudes and at higher altitudes.

And therefore you'll see the spread of malaria to places which did not experience it before. Water, sanitation and hygiene related diseases are also going to be a major public health challenge. Reduced crop yields at lower latitudes will result in food shortages, accentuating food insecurity. At the same time, there will be migration

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compelled by climate change and related extreme weather events. So you'll have climate refugees and population change will occur also as a result of that. We also recognize from the IPCC's report that there will be negative impacts on crop yields. But while the whole world is going to be threatened, there will be some vulnerable populations within countries who are likely to suffer particularly more severe effects of climate change. The very old and the very young and the very poor and those who are socially and culturally marginalized are likely to suffer most, particularly you can imagine the plight of the homeless who have to live in very hot climates in the outdoor, exposed to extreme heat. Vulnerable cities. There are about 16 of the 23 global mega cities which are located in coastal areas. And they will have greater exposure to extreme weather events and storm surges. We'll also see that climate change will accentuate conflict. It has been recorded that deviations from temperature and precipitation patterns correspond to significantly marked rise in conflict. And these are statistically significant rises. One degree increase in temperature, a rise in temperature increase the frequency of interpersonal conflict by 2.4% and inter-group conflict by 11.3%. So when we talk of hot weather, we must also recognize that people become hot tempered as a result. And the effect of rainfall on inter-group conflict is also interesting. As climate change reduces the amount of rainfall and accentuates water shortages, it has been noted that there is likely to be a greater possibility of inter-group conflict where they're vying for scarce water resources. There is also a big challenge of how to adapt and how to mitigate. Mitigation is reducing the possibility of global warming through effective action. Adaptation is trying to adjust to some of the effects of climate change as it occurs and trying to improve our opportunities for survival despite some of the changes that we could not prevent. So the IPCC again suggests that the adaptive capacity is intimately linked to economic and social development. But this is unevenly distributed across countries and within countries, across population groups. Adaptation plans must be place and context specific. Like for example, heat action plans for different cities or looking at disaster response for different coastal cities. Action is needed at all levels, from individuals to governments. And the first step towards adaptation is reducing vulnerability and exposure. In terms of climate change, the mitigation strategies of course are very important to reduce the projected rise of temperature, even to limit the temperature rise to 2% or less is going to be a major challenge. And for this, we need to act in the main domains that are contributing to climate change. Food and agriculture. Our food and agriculture systems are now causing environmental disruption. And they themselves will again in turn suffer

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because of the effects of climate change. So this mutual degradation is something that we must stop because our food and agricultural systems are becoming water intensive, they're also resulting in a lot of deforestation and all of this is something that we must take into account when we plan mitigation strategies. The use of household fuels, the increasing use of vehicular transport, and the way we generate power through coal plants, all of these are going to be important elements that we must look at as we design strategies to reduce the kind of forces that accelerate climate change and thereby we plan effective mitigation. When we look at some of the health co-benefits of climate change mitigation, we must recognize that the determinants are fairly common and the benefits are likely to be also complimentary. For example, when we talk about public transport and we promote cycling in cities, or more safe pedestrian pathways and reduce the dependence on vehicular transport, obviously in addition to reduced carbon emissions there is improved physical activity. There is also reduced air pollution with benefits for prevention of respiratory illnesses. And the improved physical activity itself will reduce the risk of diabetes, heart disease and other non-communicable diseases, including some cancers. Similarly, reduced meat consumption is something that we must look at, because livestock breeding is now responsible for 50% of global methane emissions, so it's important that we address that even from the point of view of the environment. The WHO has come up with a work plan. It suggests that we must act, actively engag in advocacy to try and mitigate climate change but also promote appropriate plans for adaptation across the world, especially country level plans. It also suggests that we must promote partnerships to insure that health is well-represented in the

climate change

agenda. Climate

change is

not merely a matter for

meteorologists or environmental experts or energy experts. After all, the consequences are going to be felt in terms of human health and nutrition. So the health community has to be there at the table when climate change agenda is being discussed. The WHO also says that we must coordinate reviews of links between climate change and health to develop a very strong research agenda which can inform and influence these debates on climate change from the health perspective. It also calls for strengthening of the health systems in countries and would like to assist countries in addressing their health system deficiencies and build capacity to reduce health vulnerability to climate change, the whole plan for adaptation. There are also main research areas in the climate change and health area. Firstly we need to establish baseline relationships between climate change and health. We must gather evidence for early effects of climate change. We must develop predictive modeling techniques and try and anticipate what

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are the likely consequences of positive or negative changes in the weather and the environment. And in terms of looking at the adaptive options and evaluating their comparative cost effectiveness in different country contexts, we must also estimate the benefits and costs of mitigation and adaptation overall. It is not far-fetched to think that if we do not control the forces that are accelerating climate change, human health would not only be degraded over the century that we live in, but in future centuries it may actually result in elimination of humanity itself. So it is from the public health perspective, from a global health platform that we must now engage in the debates on climate change and demand that climate change must not occur to the extent that humanity's life would be threatened and also plan for mitigation and adaptation in the most effective manner possible in every country on earth.

9. 2: Disasters While public health is generally expected to be dealing with the regular challenges of a health system trying to address the problems of health across the usual life course in stable societies, we also must recognize that disasters of various kinds can post a serious public health emergency. And public health needs to be ready not only to meet them, in terms of coping with them and providing appropriate relief through well geared up health services, but also to try and mitigate their impact through proper planning and preparedness. What we know about the changing environment is that temperature extremes are more likely with climate change and they will be an increased frequency and intensity of extreme climatic events. And these extreme weather events are likely to result in a variety of natural disasters. And these are likely to cause a huge amount of death and disability apart from economic loss. In the last four decades, natural disasters have caused more than three million deaths and more than two trillion dollars in economic losses. The Indonesian earthquake and tsunami of 2004 as well as the earthquake in Haiti in 2010 had the highest death toll from all natural disasters in recent times. In terms of human actions, which increase vulnerability to disasters, deforestation leading to landslides is a very good example of improper resource management by humans leading to avertable disasters. All of this is quite often seen in number of developing countries which are rapidly denuding their forests and leading to soil erosion and landslides which kill people and cause a lot of challenges to their health and wellbeing. In terms of urbanization, while it is inevitable Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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that we will see more of urbanization, unplanned, rapid urbanization results in informal settlements being built poorly with poor access to services and unhygienic conditions.

And should a disaster strike, these would be extremely vulnerable population groups.

About nearly 200,000 new citizens are added to urban populations every day, globally.

And urban slums are also growing proportionately with this increasing urbanization.

When we look at how a disaster develops, it's not as though it strikes suddenly and leaves devastation in its wake. There is also a huge amount of vulnerability which is built up ahead, which makes the disaster even deadlier than it should have been. There are individual factors like vulnerable age, gender and disability which enhance the vulnerability of individual persons. But at the level of the society itself, we also recognize that there are unsafe conditions, like the way buildings are constructed and way urbanization takes place in an unplanned manner with fragile slums. Also, with poor access to health services where needed in the wake of a disaster. Reduced capacity to cope which is created by inability of different planning systems. Also, lack of access to information as to what might happen in the case of a disaster, or even advance warning of a disaster. All of these enhance vulnerability of persons and people.

But the trigger event is an environmental hazard which comes in the form of a natural disaster but the vulnerability that exists aggravates the damage done. When we're really looking at a disaster, in terms of the income status of the countries, not unexpectedly, low income countries have much higher mortality in relation to the middle income countries and high income countries from disasters, because they're low in resources and also low in preparedness. How do disasters affect human health?

Quite often the images that spring in our mind are of people being washed away by flood waters, or being swallowed by the earth when earthquakes strike. But disasters can harm human health in very many other ways. For example, there can be severe damage to buildings and supply chains which can affect health. If there is damage to civil engineering structures and water sources, then you can have heavy contamination of water. You can also have personal shortages. The movement of emergency relief can be impeded if either people are unable to reach the spot or if they themselves are incapacitated and the transport systems are disrupted. The availability and access to drugs also becomes a problem as well as emergency relief equipment if the supply chains break down. Further, there is also the threat of vector control being thrown out of gear. We can have proliferation of breeding sites for example of mosquitoes and other vectors. There is increased human vector contact, created by the disaster zone.

And there is a disruption of the routine disease control programs which provide the

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protection in usual times. Food handling also becomes a major issue and food safety is a matter of serious concern. Power outages can result in spoilage of refrigerated foods.

There can be damage to food preparation facilities. And even the relief supplies that are being rushed can be contaminated or degraded by a disaster. At the same time, one of the critical challenges is the provision of clean water supply and adequate sanitation, both of which are compromised in a disaster situation. Emergency water supplies can be greatly impeded in terms of both quantity and quality. And the management of waste matter is a big problem and if that starts contaminating water supplies, then you can have a huge proliferation of water borne diseases, various infections that come with water contamination. When we come to management of disasters we really ought to be looking at vulnerability and risk assessment. And that starts with planning and also with organization of systems in order to provide a good response in a timely and efficient manner. And whenever there is a disaster, we have to quickly assess what the extent of the disaster was and what its impact has been, provide the right response and then go in for rehabilitation and reconstruction immediately after the disaster. But we also have to look at disaster mitigation, reducing the probability of a disaster or reducing the likely damage from a disaster. In terms of disaster management, we ought to be really looking at a cycle where we have the immediate response and relief followed by rehabilitation, reconstruction and then we go in for mitigation and prevention of a potential recurrence of the next disaster. But at the same time, should it happen, we should be even better prepared. So while trying to mitigate, we must also prepare for an eventuality where disasters might strike again. In terms of further steps in disaster management, we ought to be really looking at vulnerability assessment. By determining the spatial proximity of the population subgroups to potential hazards, according to personal and socioeconomic characteristics which increase the vulnerability. We also ought to take actions from mitigation by reducing the impacts of future hazard events and reduction in the susceptibility of high risk groups by proper planning. But further on, we must insure that there is adequate emergency preparedness through strengthened capacity building, to manage all types of emergency

and transition quickly and efficiently from relief through recovery to

sustainable development. We need to have adequate planning at all levels from individual to community to national and international levels. And this planning has to be reflected both in terms of policy as well as in capacity building again, at all levels. In terms of the response itself, this is adequately conditioned by preparedness if the planning has been well done. And we'd require experienced, trained personnel who are

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absolutely vital for providing the right kind of relief and the relief phase much merge with recovery and development over time in a seamless manner. In terms of rehabilitation, reconstruction and recovery, we ought to pay attention to the physical, social, as well as psychological elements in terms of restoration of community life, appropriate environmental health infrastructure, ensuring that sanitation, water supply, shelter, all of these are provided without delay. At the same time as the rehabilitation takes place, there are important mental health effects of a community that has been shocked and shaken as a result of the damage due to disaster. So we ought to provide the necessary support also for mental health.

10: Public Health in the 21st Century

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10. 1: The threat of antibiotic resistance DR. REDDY -I'm in conversation with Professor Ramanan Laxminarayan, who is vice president research and policy at the Public Health Foundation of India. Ramanan is a health economist by training, but in the area of public health he has become one of the world leaders in infectious diseases, especially in the area of antibiotic resistance.

While many people thought that infectious diseases were only a problem of the 20th Century, in this century antibiotic resistance is now being seen as one of the foremost threats to public health. Ramanan, why is it that antibiotic resistance is being feared so much across by health professionals, policymakers, and even economists? I understand that IMF has now declared it as one of major four threats to global economy.

RAMANAN LAXMINARAYAN: So as, as you know, we've had antibiotics only relatively recently, since 1942. Propensity for resistance has always been known. In fact, Alexander Fleming mentioned the possibility of resistance in his Nobel Prize winning lecture. And every antibiotic that has been introduced has been followed by resistance in a space of anywhere between five and ten years. And this is because the use of antibiotics, there are like four strains that are resistant, while killing off the strains that are sensitive. Now all of the antibiotics we have now are dependent on the same 16 or 17 basic compounds from which all antibiotics are derived. And we have not had very much new drug development over the last 25 or 30 years. The huge increase in antibiotic use globally has placed enormous selection pressure for resistance to increase and as a result of this selection pressure in many parts of the world, both developing and developed countries, bacterial infections are no longer responding to antibiotics. This is a much more serious problem today than it was even ten or fifteen years ago. Many of the infections that we used to only see in hospitals are now common even in the community. And because the use of antibiotics truly global, the spread of resistance has also become truly global.

DR. REDDY: What are the reasons for this? I mean bacteria seem to be becoming resistant fairly quickly to antibiotics. And many killer bacteria are now emerging across the world threatening large numbers of people. What are the reasons why this has become such a huge problem now?

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LAXMINARAYAN: So the single most important reason for drug resistance is selection pressure which is simply the quantity of antibiotics that we use. Now rising incomes, particularly in low and middle income countries have resulted in a huge scaleup in antibiotic use in places like India, China, the BRICs countries. In fact a paper we published earlier this year showed that total antibiotic consumption in humans has gone up about 36% between 2000 and 2010. And of that increase, three-quarters is just in the BRICs countries. Now this is a good thing because it means that many people who didn't previously have access to antibiotics now have access to antibiotics.

But what is bad is that many of the antibiotics are now being used are very powerful antibiotics that are not necessarily being used by people in rural areas to save lives, these are being used in urban settings by people who can simply afford new antibiotics and have no barriers to purchasing them and therefore go out and buy them. The other trend that is worrying is the worldwide increase in demand for animal protein. This has meant that in places again like India, China, Brazil, that there's a demand for livestock meat, chicken, pigs, and cattle you know for consumption. And to produce the amount of livestock that is necessary to meet this demand, we have to intensify production which immediately means that antibiotics have become an essential part of that production process, also leading to resistance.

DR. REDDY: Well we have seen that antibiotic resistance is being contributed both among human strains emerging as well as in animals because of profligacy of use of antibiotics. Is it mainly a problem of the prescribing doctors, whether they are physicians or veterinarians? Is it a problem of patients being, using antibiotics irregularly and improperly? Or is it a problem of the regulatory systems which is unable to provide the right guidelines and checks and balances? Or, a combination of all of these?

LAXMINARAYAN: It is a combination of all of these. I think you mentioned that economists have increased interest in antibiotic resistance. You know drug resistance is a lot like climate change in the sense that it involves this idea that each of us, whether we're patients or a veterinarian or a livestock owner, we don't take into account the impact that we're having on overall resistance when we choose to use antibiotics, in much the same way as none of us really thinks about climate change when we decide whether to drive a car or get on an airplane or go somewhere. Now this just means that we use vastly more antibiotics than are necessary or warranted. And at the end of the day no one is really responsible for worrying about the problem as sort of a residual thing. That you know no one is, is in charge of antibiotics. And it's sort of like this

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global commons that belongs to everyone like the Earth's atmosphere or climate, but no one is really responsible for. Therein lies the problem.

DR. REDDY: From you comment it's very clear that it's not merely a problem of biology, but also of sociology, of political economy. Now is there that kind of an interdisciplinary learning coming in for multi-sectoral actions to provide the right kind of response to this threat?

LAXMINARAYAN: Sadly not yet. I think we still see antibiotic resistance as primarily a medical problem, driven by prescriptions. It turns out that you know a lot of people worry about you know patients in India for instance getting access to antibiotics without a prescription, just going directly to the shop and buying an antibiotic. It turns out that physicians unfortunately are not very good guardians of antibiotics in the sense that a physician doesn't necessarily do a better job prescribing antibiotics in the studies that we've seen in India for instance than what a shopkeeper might actually provide. All that the physician is doing is acting as a cost barrier to the antibiotic. And therefore we do need that sort of multidisciplinary learning to figure out what drives demand for antibiotics? Why do people behave the way that they do? And in that sense we need the sea change in, in norms with respect to antibiotics, the same kind that we've seen with tobacco for instance. You know today it's no longer acceptable to, to smoke in an office or in a public place but it's completely acceptable to go demand an antibiotic from your physician whether you're in the United States or, or in China. And we have made it a different norm with respect to tobacco. We need to change that norm with respect to antibiotics as well, to make people aware of the fact that these are powerful drugs, they have important side effects and should not just be used whenever people have a, a sniffle or a common cold.

DR. REDDY: You convened a major global conference about three years ago.

And I know that a number of ministers from several countries also attended that. Is there a global movement building up against this, including the required political will?

LAXMINARAYAN: A number of countries led by the U.K. and Sweden have convened many meetings around the world to help the World Health Organization convene a global action plan to deal with the threat of resistance. And, but this has really increased awareness in many countries. Just early in November of 2014, South Africa convened a large meeting of multiple stakeholders from all of the various sectors to promise to do something against antibiotic resistance. A similar action is underway in many other countries. So there's never been political awareness of the kind that exists now, but we need to push on in order to really do something to solve the problem. The

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U.K., the U.S., all of these countries are willing to act, but that is not sufficient because even a few countries misusing antibiotics can have global consequences. DR. REDDY: What's the role of technology and information systems? The drug resistance index or the online resistance map for instance? How can they advance our action in this area?

LAXMINARAYAN: So one of the reasons why the problem of resistance had not received the traction that it really required was because people could not visualize it, they could not see it, they could not see where resistance was, was increasing, where it was remaining flat because of antibiotic use not going up

And tools like the drug

resistance index and also the resistance map have been important for that visual connection to the problem, because people don't get to see resistance. No one that they know dies of drug resistance in the way that they can understand it. Those tools are very important. I think there is also room for other tools which involve big data and so forth to be able to extract data on antibiotic use as well as resistance to further drive home the importance of dealing with this problem.

DR. REDDY: Across the world there's a huge scatter of data related to the production of antibiotics, the purchase and utilization of antibiotics and the emergence of resistant patterns and so on. How can big data actually contribute to a better and quicker understanding of this problem?

LAXMINARAYAN: So a great example is the fact that we don't really have state on drug resistance in most countries, including India for instance, just because to set up a network to do this is, is incredibly expensive. However, many patients do send their blood samples on the advice of their doctor to a lab network. And the lab network will turn back a test result which says, yes, you have a bacterial infection and yes, you may have a resistant pathogen. What we're trying to do is connect up multiple lab networks which collect thousands of samples every day, not to inform surveillance, they do it just to serve a patient need as a provider. But by connecting up these data we're able to create snapshots of resistance that are only a week old to be able to inform both prescribers as well as policymakers. And this is possible only because of our ability to link data sets and to make that sort of connectivity possible. It was certainly not possible ten or fifteen years ago. But now these networks of data sets are giving us information that, that is extremely valuable. DR. REDDY: If you were to make major recommendations to global policymakers in the context of the sustainable development solutions network where we are looking at environment and health and other areas of development together and position antibiotic resistance in that framework, what would those recommendations be?

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LAXMINARAYAN: I think the recommendations would be pretty straightforward in the sense that first of all, the main way to deal with antibiotic resistance is to reduce the need for antibiotics which is improved public health, improve vaccinations, improve water and sanitation. These are common goals but particularly important because when we don't address these, we use too much antibiotics. The second is to phase out whenever possible the use of antibiotics in animals because the benefits of these are not very large but the consequences for resistance is extremely high. The third is to invest in good surveillance. It really doesn’t take a lot of money, it really takes these kind of innovative methods to connect up large data sets, to get a better understanding of the situation to do with resistance and antibiotic use within countries. The fourth is to invest in new tools. We need new antibiotics but we also need other tools like better diagnostics because for instance if we had a diagnostic device that would tell us within 20 minutes whether the patient had a bacterial infection, imagine the amount of antibiotics that we could not use and still make the patient better. And fifth, we need political commitment. This is a problem that is not going away. And as far as we can see, our grandchildren and their grandchildren are still going to need antibiotics. We have not found a good substitute for antibiotics yet. And knowing that the bacteria will always fight back, this is a problem that's going to stay with us for a very long time.

DR. REDDY: Thank you Ramanan. Bacteria will always fight back, but humans must respond intelligently. If the production and use of antibiotics for human health and welfare has been a product of human intellect, then the growing problem of antibiotic resistance is a problem of our foolishness and how we are using them. So I think antibiotic resistance, while it's a major public health challenge of the 21st Century is something that can be met with if we take the kind of steps that Ramanan has advised us to take. Thank you.

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10. 2: The challenge of ageing populations DR

REDDY:

The

last

hundred

years

have

seen

a

huge

rise

in

life

expectancy.That should be a cause for celebration for all interested in public health.

However it also brings some concern about the health of aging populations. Indeed, when we are looking at the large number of people who are reaching the age of the elderly which is about 60 years or the very elderly which is about 80 years, then we have to regard it as an important area of public health action in the 21st Century. And therefore it's not surprising that when we are really looking at what sustainable development should really look at as a goal then it is logical to think of a life course perspective which not only looks at the health of the newborn baby or the young child, but also of the elderly person. This life course approach can be spelt out through a goal which says achieve health and well-being at all ages. We expect this to happen through universal health coverage and also pro-health policies in all of the sectors which create a healthy society. But we must ensure that in the broad sweep of our health system and social development that persons who are elderly and in great need of public health attention are not marginalized. When we look at the world, we recognize that already there are a fairly large number of people in the category of the elderly and the very elderly. But these are mostly in the high income countries or in the middle income countries where the life expectancy has risen sharply over the last century. But we are going to see a different phenomenon over the next forty years when by 2050 while the high income countries would continue to have a fairly substantial proportion of the population in that elderly age group it is the low and middle income countries which are going to see the largest rise in the numbers of the aged and the elderly. In China, for example, between 1990 and 2050 we are going to be seeing a huge change in the demographic profile from a pyramidal age structure to a very cylindrical age structure where those who are in the middle age and in the elderly age groups are going to be dominating rather than the young. We also recognize that as we move along the number of persons aged about 60 years is going to be rising progressively in all parts of the world and particularly in the developing countries this is where the maximum rise is going to be witnessed over the next four decades. In the low and middle income Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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countries by 2050, two billion people will be aged over 60, that's the elderly. And 80% of them will be living in low and middle income countries. By 2050, 400 million persons will be over 80 years. That's the very elderly and 100 million of them will be in China alone. Chile, China and Iran will have a greater proportion of old people or older people than the United States of America, so that is where the major presence of the aging populations is going to be. And when we look at what are the factors affecting population aging, clearly increasing global life expectancy is the principle propellant of this change. Life expectancy has increased globally on an average from 47 years between 1950 and '55 to 65 years between 2000 and 2005, but by 2050 we expect to reach an average global life expectancy of 75 years. At the same time we are also seeing a decline in global fertility rates from a fertility ratio of about 5 in 1955 to '55, we are likely to see this coming down to 2 by 2050. Early in the century we had already a major decline where the fertility rate had come down to 2.6 but when it reaches 2 then we are going to see a very large number of elderly people. At the same time we are also seeing that in the developed countries restrictions on immigration are also going to affect the age structure. Previously, in pursuit of accelerated economic development, high income countries invited a large number of young and productive immigrants. But now for a variety of security reasons and because of mounting xenophobia, there are crackdowns in immigration and that is again going to result in a closed door policy which will raise the age profile of the developed countries and restrict the number of young people in those populations. We also recognize that this has an impact on the dependency ratios. When a country has a larger number of people who are in the elderly age group or are children, they are going to be dependent on the working age population. When we look at the ratios of the dependents to the working age population in the high income countries because of declining birth rates and increasing life expectancy we have seen that already changing that there is a high dependency at the moment. But in the developing countries, where the birthrates have started falling only recently but aging has now started climbing as a major factor in altering the population age profile we are going to be seeing an increasing dependency ratio in countries like China. Countries like India are still fairly young in terms of their population profile, but even they by 2050 will see a much higher dependency ratio. And this has health consequences in terms of what happens to the health of the elderly as well as the nature of the support their society provides them. The demographic and the epidemiological transitions are closely linked in populations. Older people are likely to live longer but we have also to ensure that they live healthier. It is to be expected that

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as people age the number of cases of chronic illness and disabilities will rise. There will be increased spending on nursing, palliative care and end of life treatments and we require also long term care for irreversible conditions. All of this is going to be an important health system priority as we move along to a larger aging population in most countries. In terms of some of the other consequences there are challenges in elderly care in terms of provision of formal care as the living arrangements for the elderly are changing globally. What has happened in general over the last fifty to sixty years is that unlike homecare which used to be the norm prior to that, people have moved to institutional care and now in some of the high income countries, they're also moving back to assisted homecare. But countries which are now facing the problem of health systems which are under resourced, but also the challenge of catering to the needs of the elderly will now have to look at how they can provide institutional or assisted homecare. And the whole area of social security also needs to be clearly addressed.

Unfortunately we are also seeing a negative side of the societal response in terms of increasing neglect and abuse of the elderly.We have seen in several societies a greater abuse of the elderly which is partly because of poverty and lack of resources for care which results in neglect and the stress of having to provide care with low resources also pressures families into abuse. There is also poor training and education of caregivers and there is job related stress in institutional care facilities where instead of empathetic care there is very indifferent attention or actual abuse. Therefore we really must look at what happens to the elderly and particularly poignant is the state of elderly who live alone. Because of the changing population structures, one in every seven persons in the elderly age group now lives alone. That means 90 million elderly people across the world live alone and this is much more true in case of woman then in case of men and particularly an elderly woman who is a widow is often without adequate family support and lives alone in penurious circumstances with very little attention even from the healthcare system. And when we look at long term care for the elderly, we have to look at different models like institutional care, formal homecare and informal care. In high income countries like Japan which has the largest proportion of the elderly population because of the longest life expectancy we have a very large proportion of the elderly population living with adult children, though this is also showing a declining trend. In the low and middle income countries about three-fourths of their elderly population in Asia and Africa and two-thirds in Latin America stay with their families. But that has been a tradition and a part of their culture. But that is rapidly changing with urbanization, with the growth of nuclear families, with migration of the working age

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children and therefore the probability of the elderly getting care in the family environment is now diminishing even in these countries. When we are looking at long term care for the elderly, insurance coverage or some form of coverage under a universal health coverage scheme is absolutely important for providing healthcare to the elderly. Whether it is a wide ranging insurance which particularly caters to the needs of the elderly or a universal health coverage system which is foolproof in terms of its attention to the needs of the elderly, we need to ensure that financial barriers do not arise in providing the needed care. All high income countries presently provide public insurance coverage for hospital and physician services to the elderly. However, even the best among them provide very poor coverage for drugs and long term care.

And that can be a major impediment to good health among the elderly. So we are really looking at the need for long term care financing as well. Even in high income countries, public expenditure accounts for less than 1% of spending on long term care for the elderly. The United States and New Zealand have the highest proportion of private funding. Now if you happen to be a poor person living in those countries or if you happen to be a person living in a country without adequate sources and low per capita GDP, then long term care can become a major problem indeed. Now in terms of aging and the healthcare costs, while it is natural to associate that aging itself is driving up the healthcare cost, that's not the major factor. Health costs will continue to rise in any case in the future because of other reasons. Changes in health seeking behavior, new medical technologies, rising wages of healthcare professionals, increasing cost of drugs, health insurance premiums rising, and inefficiencies in health service delivery.

While healthcare costs are spiraling up, we need to ensure that the people who will pay the maximum price for that will not be the elderly and again, universal health coverage will have to provide adequate protection for that. So when we look at the sources of payment for healthcare services and what are the major contributors to that kind of payment which is not covered by insurance or sparsely covered by the insurance, then we recognize that prescription drugs and long term care facilities are the ones that have the maximum cost attached to them. And these are seldom adequately provided for in any insurance program. So we have to make a very careful planning for ensuring that prescription drugs as well as long term care are built into the system of universal health coverage so that the elderly do not suffer deprivation. There are obviously some solutions that we need to implement on a priority. We need to develop health policies with an increased focus on sustainable financing of long term services for the elderly.

And we must ensure adequacy of healthcare personnel and these are not merely people

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who treat in a hospital for a medical emergency or a chronic condition. We are talking about rehabilitation personnel, we are talking about physiotherapy, we are talking about mental health counselors, a variety of medical social support systems and we must incentivize the existing workforce and also provide task shifting because the health systems of many of the low and middle income countries have a great shortage of human resources and we can not leave the care of the elderly only to very specialized categories who are anyway not available in large numbers. So we ought to really ensure that some of the frontline health workers and even laypersons are provided the requisite training for providing the kind of care that elderly need and giving them the support that will make their lives healthier and more comfortable. In terms of addressing the increasing need for home-based long term care as family structures undergo changes. Again, countries have to have some definitive planning for that just as families need to do that because we can't allow people to go abandoned by families without care if the overall health system itself is inattentive to it. We need a better legal framework in support of the elderly and we must ensure that age discrimination is not a factor for employment of fit elderly in the labor markets. Really we ought to be looking at the possibility of using this gray power to the advantage of developing societies by using their intellect and experience to greater advantage in a variety of ways. And when we also look at policy we must ensure protective mechanisms against abuse and neglect. That's also a critical element that we must actually ensure so that people in the elderly age group do not suffer unnecessarily. So we are really looking at developing a society which is much more caring in terms of addressing the needs of the elderly but we do not always have to presuppose that the elderly will inevitably be feeble and debilitated. If we adopt a healthy life course approach and build a health society where people can actually adopt healthy living habits and have an environment which supports the choice of healthy living habits across the life course, we will see many more elderly as fit and functioning rather than frail and feeble. But when they do need care and support we must also ensure that the health system in particular but the society as a whole springs to their support.

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10. 3: Health and sustainable development- I The word development means many things to many people. Mostly people think of it as economic development. Others think of it also as social development. Some would like to think of development only when it is truly inclusive development, when the fruits of development are available to everybody in society. But now we're also moving on to the concept of sustainable development where development not only happens, but it happens in a manner that is sustainable across generations taking into account the need for planetary health as well as human health and a very balanced economic and social development across the global community.

At the beginning of this century the focus was much more on bridging the huge gaps that existed between the levels of development across the world both in terms of high income and abject poverty and also huge gaps in health equity. So the whole idea was- can we begin the century to try and promote greater equity in terms of development including some of the critical areas of health? But now we are moving on to a period where we are actually beginning to discuss sustainable development as the goal for this century and beyond. Therefore, the Brundtland Commission looked at sustainable development from the point of view of the development not only of the current generations but also the future generations. It titled its report in 1987 as Our Common Future. And sustainable development was defined as one that meets the needs of the present without compromising the ability of future generations to meet their own needs. Therefore it was very important that the inter-generational equity concept was also integrated into the idea of spreading greater equity along with progress in the present day world.

The Millennium Development Goals which were annunciated and adopted by the global community in the year 2000 under the auspices of the United Nations reflected the urge of that time to try and bridge the inequities that were very manifest in the different developmental profiles of the countries. Poverty, ill health, lack of educational opportunities, all of these were clearly reflective of those inequities. So eight goals were designed to end extreme poverty and multiple deprivations with specific targets to Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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be achieved by the year 2015. And these eight goals reflected various areas of developmental concern.

The first one was to eradicate extreme poverty and hunger, the second was to achieve universal primary education, the third to promote gender equality and to empower women, fourth to reduce child mortality especially under the age of five years, the fifth was to improve maternal health, the sixth was to combat major infectious diseases like HIV/AIDS, malaria and other major killers, the seventh was to ensure environmental sustainability, and the eighth was to build global partnerships for development. All of these were considered absolutely essential for altering the developmental gaps that existed across the world.

Three of these Millennium Development Goals directly related to health. Goal four was to reduced child mortality and a specific target was identified for action up to 2015. The target was to reduce by two-thirds between 1990 and 2015 the under five mortality rate, taking 1990 as the base year. Goal five was to improve maternal health with two targets, one was to reduce by three-quarters between 1990 and 2015 the maternal mortality ratio. Target two was to achieve by 2015 universal access to reproductive health recognizing that there was huge gap in the access to reproductive health services in many countries and virtually all across the world. But the whole area of maternal health can not only be reduced to maternal mortality. We also have to look at maternal morbidity issues. That was implicit but not directly measured as a target.

Goal six was to combat HIV/AIDS, malaria and other diseases with three specific targets. Target one was to have halted by 2015 and begun to reverse by then the spread of HIV/AIDS across the world. HIV/AIDS was the big specter that was haunting the world at 2000, as the big killer. Target two was to achieve by 2010 universal access to treatment of HIV/AIDS for all those who need it. The whole are of access to essential drugs was becoming a major concern, especially because HIV/AIDS was killing people who could potentially have life saved with access to anti-retro-viral drugs. Target three is to have halted by 2015 and begin to reverse by then the incidence of malaria and other major diseases. These other major diseases were left unspecified but it is very clear that HIV/AIDS, malaria, and tuberculosis are the main areas of focus among infectious diseases at that time.

The other goals also indirectly affected health, even though they did not specify health as their primary objective. Goal one was to eradicate extreme poverty and hunger and we know that ill health is related both to poverty as well as malnutrition.

Goal two was to achieve universal primary education and we know that education

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actually promotes health by improving knowledge and the ability of individuals and communities to take better care of themselves. Goal three was to promote gender equality and empower women. Women have suffered health inequities more than other groups in the society and in every society we have seen unless we promote gender equality and empower women we can not achieve better health indicators not only for them but for their children and for the families of the whole.

Goal seven was to ensure environmental sustainability. For the first time we were bringing in health and environment close together along with other areas of development because we now recognize that unless the environment is also protected, health will suffer.

Goal eight was to develop a global partnership for development, obviously this included partnerships for health as well. So all of the goals in some way or the other related to health, though three of the goals were specifically directed at health related targets.

We have achieved a fair amount of progress on the MDGs by 2014 when the review was conducted it was found that as far as tuberculosis and malaria were concerned, three million malaria deaths were avoided between the year 2000 and 2012. Twenty-two million lives were saved from tuberculosis between 1995 and 2010.

About 17,000 fewer children are dying per day. And between 1990 and 2010 there was a 47% reduction in maternal mortality though that has not been uniform across the world. Over 2.3 billion people have gained access to improved water between 1990 and 2012. There's been a greater enrollment of girls in schools and greater political participation of women. Extreme poverty has been reduced by half between 1990 and 2010. About 50% of the population on less than $1.25 which was the state of affairs in 1990, to 22% of the global population at that level of extreme poverty.

So we have had much to celebrate as a result of the success of the efforts to advance the MDG goals to their targets. However, the agenda is very much unfinished.

In several cases we have fallen short of the targets. For example one in four children are still undernourished. Child mortality from preventable diseases is still a problem.

About 800 women die daily from pregnancy related causes. Hunger has declined but still over 800 million people still go hungry all over the world. Nearly one billion people still resort to open defecation. So the ambitious agenda of the MDGs while having achieved several benefits still remains to be pursued in order to attain the targets if not by 2015, soon thereafter.

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We have had several learnings from the Millennium Development Goals. They helped to position health very firmly in the development agenda of the world. They helped to focus attention and action on the major health problems of poverty, infectious diseases, under nutrition, as well as maternal and infant mortality because the failing health systems which particularly afflict poor people. They help to mobilize resources to achieve targets. The global community responded by committing more resources, if not in totality for all the MDGs, for selected MDGs of their choice. They helped to create platforms for multiple stakeholder partnerships and they strengthened global monitoring systems by affixing targets and by monitoring progress towards those targets. But having said all that the MDGs also fell short in very many ways.

They covered only the low and middle income countries and excluded the high income countries. So they were not universal in any way. They only focused on a set of countries, the targets, and the implied obligations were only applicable to some of the countries, not all of the countries in the world. They fragmented the health system through vertical programs by directing the programs only at maternal health or child health or TB or malaria or HIV/AIDS, they fragmented the health system and made it weaker in some respects and also created an opportunity cost by which the other programs suffered. Further, even the programs themselves which were the primary focus of the MDGs did not achieve their targets because you can not force fit a vertical program into a weak health system however well-designed the program may be. So we even fell short for example of tuberculosis control and we are seeing the specter of multi-drug resistant tuberculosis coming up.

At the same time the MDGs also segmented by age group. They looked at child mortality, then at maternal mortality, forgetting that adolescent girl in between. They did not look at the elderly, they did not look at the adults who were suffering from noncommunicable diseases. They monitored only national aggregate indicators. Now that was helpful to say India or China or Zimbabwe for that matter reduced child mortality or maternal mortality but did it happen across all social groups? Were only certain social groups benefiting from this kind of mortality reduction? And the poorer sections still remained behind? Did the gaps in health equity actually widen even as the aggregate health indicators fell across the country? So that was something that was not really measured at all or not even intended to be measured.

They also measured mortality but not morbidity. It is not just enough to be alive. You are to be alive and healthy so that element of healthy life expectancy was ignored by the MDGs. While these are justifiable critiques of the MDGs, we must

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recognize that the MDGs have given us a platform to build upon further and that's the knowledge that we need to transfer as we move across to the sustainable development goals after 2015. Therefore, we need to redefine some of the global health priorities for the period 2015 to 2030 which is the next period the SDG era, and there we need to accelerate the progress on MDGs because they're not a done deal. Maternal and child health still require our attention, infectious diseases still need concerted action and under nutrition still remains a shameful challenge and we need to act upon them and provide momentum for their progress. At the same time we need to act upon the previously excluded priorities, non-communicable diseases, the number one killer in the world today.

Mental health, the number one contributor to disability in the world today.

Injuries and disabilities, adolescent health, health of the elderly, all of these were out of the radar screen of the MDGs. We need to now bring them back into a composite picture of the global health agenda. In terms of the other priorities for 2015 to 2030 we need to create a strong health system platform. The health system needs to become the vehicle for all concerted actions directed at health MDGs or SDGs, because otherwise we will continue to fragment it and fail in our objectives. So we need an integrated delivery of a wide range of health services, we need an emphasis on equity, efficiency,

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sustainability we have to talk about also fiscal prudence of how the health system can manage to do all of this without really overrunning the budgets in a very imprudent manner. So we now have to build in all of these elements as well.

We need to implement the universal health coverage as the framework for achieving these goals through actions at national and global levels. We need to enable coordinated multi-sectoral action to influence the social determinants of health. Clearly we know that much of health depends upon actions in other sectors. And the sustainable development goals are addressing some of those other sectors as well, not as separate entities but as synergistic and complementary components of a single unified agenda of SDGs. We need to link health to other elements of sustainable development, not only achieve benefits for each of those elements but to maximize the co-benefits. Health for example benefits education. Sick children can't gain learning. At the same time, education benefits health, so there are clear co-benefits working together across different SDG and developmental goals. So all of these domains will have to be really brought together and that is wherein the strength of SDGs will come

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in, including for global health between 2015 and 2030 and beyond that as well. But we do have some optimism when we look at the future.

While we regret that we've not been able to achieve some of the MDGs related to maternal mortality or child mortality or infectious diseases by 2015, in terms of their entirety we now know we can substantially bridge the gaps between high income countries and low income countries on those MDGs by year 2035 if we invest wisely and adequately in our health system and specific programs. And here, the Lancet Commission on Investing in Health in 2013 proposed goals that for the under five death rate per thousand live births which is the under five mortality, it can come down to 16 in the low and middle income countries as well as being very close to that in the high income countries now. Similarly, annual AIDS deaths per 100,000 population can come down to eight. Annual tuberculosis deaths per 100,000 population can be brought down to four. Which means the huge gaps that now exist between high income countries and low and middle income countries can be substantially bridged and we can have a grand convergence by year 2035 if we invest properly in the health of these countries and where the global health becomes a priority and a concern and a commitment that everyone shares under the overall umbrella of SDGs.

10 4. Health and sustainable development- II This century began with the Millennium Development Goals but after fifteen years moved on to the Sustainable Development Goals, to build up on the gains of the Millennium Development Goals but also to pursue a much more comprehensive agenda Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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of interlinked and inclusive development. Beginning with MDGs, and then subsequently having a strong focus on social determinants of health through the WHO commission on social determinants of health as well as a major thrust towards universal health coverage brought about by the World Health report of 2010 which focused on health financing, particularly as a foundation for universal health coverage, and then also looking at different emerging public health challenges of the 21st Century, the whole area of non-communicable diseases which in September 2011 formed the subject of a UN high level meeting resulting in a political declaration calling for concerted global action to prevent and control NCDs. All of these in the last fifteen years have coalesced together towards the Sustainable Development Goals, but the clarion call for the SDGs came from the Rio+20 meeting in 2012 where the world pledged that they would work for sustainable development and said that collectively we will create the future we want. Basically at Rio+20 and subsequently through the actions of the United Nations for framing the Sustainable Development Goals three pillars were identified which were economic, social and environmental. Clearly, health is linked to all three of them. But along with this we also need to position another underlying element, if not as a pillar at least as the platform, and that is good governance.

The economic case for linking health to sustainability is very clear. Healthcare costs pushed 100 million people below the poverty line and this was from the World Health Report of 2010 published by the World Health Organization. Catastrophic health expenditures are commonplace not only in lower and middle income countries but also in some of the high income countries, for example in the United States we have seen a fairly large number of uninsured people suffering the problems of either inaccessible healthcare or impoverishing healthcare. Universal health coverage ensures financial protection through risk pooling and reduction of out of pocket spending. Clearly, therefore, there is a case for linking health to the economic development and ensuring that economic inequities do not affect health and also we provide greater health equity through suitable financial pathways like the universal health coverage with built in financial protection.

We also meet to ensure that households avoid spending their disposable incomes on avertable health problems so that that can be spent on other goods and services, improving the welfare of households like nutrition or even to give a fill up to the global economy by spending on other consumer goods. But if you're spending money on avoidable angioplasties and coronary surgeries and so on, you do not have

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money to buy other consumer goods and that affects the pace of recovery in a sluggish global economy.

Clearly there is also a social case for linking health to sustainable development.

We cannot talk of sustainable development or of health for that matter without talking about gender equality and human rights. They're intimately linked to health. We recognize that these are important inputs into advancing health of societies and bridging gaps in health equity. So they become fundamental to any concept of sustainable development.

Other social determinants of health like education, social stability, and social networks, all of them are integral to good health. We see the co-dependency of many of these on health of societies so the social case for health is also clearly made.

When we look at the environmental case, while this was not very clear and not explicitly made in the past, we now increasingly recognize that we must place health alongside environment and the overall framework of sustainable development because there are many linked determinants and that framework will allow inter-sectoral policies that promote health as well as improved environmental sustainability simultaneously. For example agricultural sustainability. We can't think in terms of food and agriculture systems merely as commercial activities because ultimately their purpose is to provide healthy nutrition to every citizen at every stage of life across the world. And if they're not aligned to health, then clearly we see that agriculture and food systems are failing in their primary objective.

There are other elements as well, like resilient cities. When we talk about resilient cities, we are talking about cities that are not only resilient to climate change but also to natural disasters. We're talking about promoting active means of transport which will reduce vehicular density, vehicular pollutions, and reduce environmental degradation at the same time protect the lungs and bodies of people and we recognize that air pollution is a major threat to health of people and we need to link that to environmental concerns. And therefore, bringing in the environment and health together into a common platform is very critical to both and that is where sustainable development provides that kind of a linkage.

We also recognize that all of this is not going to happen unless health challenges are seen as something that all of society must respond to, because they cannot be tackled in isolation. We required the engagement of multiple stakeholders, the government, the civil society, academia, the media, the private industry. It has to be an all of society effort for inter-sectoral action to take place because all of these are

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interlinked goals which can only be advanced by collective action. And at the same time in order to make sure that policies are not misaligned, we need health in all policies.

For example, when we look at the non-communicable disease prevention and control plan of the World Health Organization, we recognize that the multi-sectorality implied in that action plan is something that warrants the active engagement of multiple ministries and multiple agencies and unless we link them together we will fail in preventing or controlling NCDs. Similarly even for a number of other areas of health, we need multiple stakeholders to come together. So health in all policies becomes absolutely critical as an important area of advancing health, but in the same time that provides a very smooth passage to sustainable development as the common agenda.

Margaret Chan, the director general of the World Health Organization has said that universal health coverage is the single most powerful concept that public health has to offer. However, there are some questions that have been raised about UHC when we talk about it as a SDG goal. Is it measurable in a comparable way across the world? What are the targets and indicators? Is it related only to financial protection or does it include other health system components? Does it balance vertical equity which is gap filling with horizontal equity which is equality of access? Does it ignore the social determinants of health by focusing only on health sector actions? These are legitimate concerns. But fortunately the global discourse on SDGs over the period when they were actually being debated actively by the global public health and development communities has brought us now closer to a consensus, that UHC needs to have a core component of financial protection but UHC cannot be delivered unless the other elements of health system are strengthened but at the same time health cannot be assured by UHC alone acting through the health sector.

But it has to now bring in actions into other sectors especially on social determinants of health to the fore by ensuring that there is synergy between the health sector actions as well as the actions in other sectors to advance the social determinants of health as well. So we now recognize as we move towards implementation of SDGs that action is required in each of these areas.

Finally there is a big question that had been asked of the SDGs while they were being developed. UHC is of course relevant and must be part of the goal but in the health goal something that we can develop which is applicable to all countries, the MDGs were not applicable to all countries, they were only applicable to the low and middle income countries, so how can we ensure that the new goal in the SDGs is something that all countries subscribe to and become accountable for? So UHC is one

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where it matters to everybody high or low income. We have seen that. Even countries like the United States still need to address the UHC as an important part of their agenda. Progress on MDGs is also needed but it's still relevant to low and middle income countries. But non-communicable disease targets are relevant to all countries.

They're a bit more challenging for low and middle income countries where the epidemic is on the upswing rather than for the high income countries where the epidemic has stabilized or is on the downswing. But nevertheless, the whole world faces the challenge of NCDs so we need an income percent goal which combines all of these three elements. So we are really looking at the goal of a healthy planet with healthy people as our ultimate objective and for this it's been proposed that firstly we must accelerate progress on the health MDGs, we must also reduce the burden of major NCDs and for these we need core enablers which are universal health coverage and access as well as action on social determinants of health. They provide the platform. So if you can combine all of these we have set the goal for health within the SDG context.

So we do require what will be the ultimate way the Sustainable Development Goal is worded or interpreted, there are several actions which are needed for implementation.

First is to build on addressing the gaps in achievements of the MDGs four, five and six which were the health MDGs or the health Millennium Development Goals. We also need to adopt a life course approach to health promotion, disease prevention and healthcare. We know that human beings live one single life. And therefore their health cannot be segmented and health of one stage of life impacts upon the health at other stages of life. So we need the life course approach.

We also need to increase public spending for health. Allocate at least 5% of the GDP as public financing for health. Without adequate financing health systems will remain feeble, they'll not be able to deliver on UHC, they'll not be able to deliver on health as an important part of the sustainable development agenda. And high income countries must do at least .1% of their gross national income as overseas development assistance for health. Of late, we have seen the declining trend in this kind of financial assistance that's being provided except possibly to the least developed countries. Many of the low and middle income countries need that kind of a continued assistance without which their health systems cannot really be strengthened. So the high income countries must fulfill their social obligation to support other countries through an increased overseas development assistance.

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All countries must provide high quality healthcare based on comprehensive primary health services. That is the foundation for good health and therefore a health system must prioritize primary health services.

We must create and support a skilled, adequately resourced workforce for health. We have a global health workforce crisis, particularly reflecting poorly on the health systems of low and middle income countries. We need to create a multi-skilled, multi-level workforce which is competent and motivated to deliver on the UHC and SDG agendas. We must ensure access to essential medicines, vaccines, commodities and technologies using pooled procurement and distribution of quality assured drugs.

Whether it is HIV/AIDS or whether it is cardiovascular disease and diabetes, we need essential drugs to be available to all and pool procurement and distribution of quality generics is the way to go. Effectively implement comprehensive tobacco control programs. The Framework Convention on Tobacco Control, this is absolutely critical because tobacco is the major killer even in the 21st Century, it's expected to kill about a billion people so we have to ensure that people do not die because of tobacco consumption whether it's active or passive consumption and the various provisions of the FCTC or the Framework Convention on Tobacco Control is implemented in earnest can actually bring down tobacco related mortality and morbidity.

We must align agriculture and food systems to ensure nutritional security. We must align them with health, with a nutritional goal so the population at each stage of life, so our goal must be to deliver caloric adequate but also nutritionally appropriate diets to every citizen on this earth at each stage of his or her life. And that is where agriculture and food systems must deliver.

We must ensure availability of good quality water, sanitation and hygiene reduction and exposure to air, water, light and sound pollution and we must start up pro health policies in all sectors which are conventionally not regarded as part of the health sector but which nevertheless have a profound impact on the health sector.

So when we look at all of these we recognize that when we talk about economic growth, social equity and environmental protection there are a number of factors like urbanization,

transportation,

air

pollution,

food

and

nutrition

security,

labor

productivity, healthcare expenditure, all of these are so interlinked and education, gender, all of these are so intertwined with health that we cannot really tease them apart and that's why bringing them into the framework of sustainable development is very critical, even for advancing global health.

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And we must learn to recognize that some of these connections are not apparent. For example when we think in terms of tobacco, we only think of the one billion deaths that may happen in the 21st Century, bad enough, but we must also recognize that tobacco is also a major cause of deforestation. Therefore it is an environmental threat because in order to cure tobacco leaf, one has to burn wood. For three hundred cigarettes smoked anywhere, someone somewhere has killed a tree. It's also a cause of air pollution. It exacerbates poverty. It's a cause of food insecurity. It's absolutely unacceptable that four million hectares of arable land are now devoted world over for this killer crop than for nutrient crops. It is also a very water intensive crop and therefore, it again is an environmental threat from that point of view by exacerbating the water usage.

So when we think in terms of connection of health with other Sustainable Development Goals, especially environment, the connections really extend beyond the conventional. Similarly when we talk in terms of emerging infectious disease threats, we cannot talk in terms of zoonotic pathogens from wildlife which are now increasing threats whether it's H1N1 or SARS or H5N1 or avian influenza without recognizing that we are actually creating conditions for this spread by extensive deforestation and by creating a conveyor belt between viruses and vectors from the forestry and the captive veterinary habitat and into the human habitat. Similarly when we are talking about drug resistant pathogens, anti-microbial resistance coming up, whether it's antitubercular drugs or other forms of super bugs, we have to recognize it's the weakness of the health systems that are really giving rise to this and also the nature of our rapid transportation and modern communication which is also resulting in their spread. So there are multiple areas in which we ought to be able to look at all of health as linked to different areas of human activity and all of those domains are built into the Sustainable Development Goals. In the 20th Century, medicine and nutrition evolved to come under the broad umbrella of public health. In the 21st Century public health must evolve, whether it's considered as public health within countries or global health across the world must evolve under the umbrella of sustainable development if it has to survive and thrive as an important objective of human development.

Ultimately the thread of human life extends from pulse to the planet, through persons or individuals, through people or communities or populations or nations, health has to be linked ultimately to the overall goal of sustainable development.

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10 5: The Future of Public Health We now come to the conclusion of this introductory course on global health.

Global public health has now a very large mandate in the context of sustainable development. It has grown from the foundations of public health, which itself is not relatively new. Even prior to the 20th Century, public health was deemed to be very important. Many of the important investments in public health, whether in the form of water, sanitation, or healthy nutrition, came about in the centuries preceding what we call as modernity. However in the 20th Century, marked advances in science and technology enabled us not only to understand the links between health and disease much better in terms of what causes disease and how best to protect it, but also to organize health systems around dealing with disease and promoting health. When we look at how the scientific knowledge has helped, we must also recognize that to some extent it started fragmenting our approach to public health. Epidemiology has been a remarkable science which advanced the understanding of the factors that cause disease, whether it is an infectious agent or smoking. However it is in the very nature of epidemiology that we start looking for independent associations which can be attributed to that particular risk factor over and above anything else. And therefore, necessarily we start becoming reductionist in our approach. But we also need to position that reductionist knowledge in a much more holistic context and that is where public health comes in. We have previously separated out different knowledge and practice domains like epidemiology, health economics, behavioral sciences and also to some extent management principles. But now we need to integrate all of them into the discipline of public health and to some extent we have succeeded in doing that in the Revista de Praticas de Museologia Informal nยบ 6 spring 2015

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21st Century. But we now need to position it in the context of global public health, because global public health has now become a common concern for all of humanity whereas public health previously did look at what was happening in different parts of the world but confined its actions mostly to national or regional contexts. But when we recognize that the determinants of health now act across geographical boundaries and cause common challenges that have to be faced by the world as a whole, then global public health becomes a very necessary unifying platform and here we need to integrate all of our knowledge in order to address these challenges. So while epidemiology for example provided a very necessary insight into what caused disease, public health provided a better perspective on how a complex system should be addressed, so from linear thinking to complex thinking, a complex system approach, we started having a transition. But global public health now brings in much more dynamics into the picture. It brings in the whole global economic profile of development and distribution of the products of that development. It talks about equity as an underlying value. It shows how economic inequities within countries and across countries can accelerate health inequities. It also shows how global cooperation can advance the common objective of reducing health inequities and protecting people against the spread of disease. So we now need to look at how global health has evolved from public health, how global health is now looking at the determinants of health transition across countries, the varied measure of these determinants, but how they act in concert in order to determine whether countries are going to face a huge burden of disease in one form or the other or whether they can actually telescope the transition by averting much of the disease that could have otherwise occurred. We now have a better understanding of some of the specific problems related to maternal and child health including child under nutrition. We also have a better understanding of the spread of infectious diseases as well as the methods for their control. We recognize the big threat posed by non-communicable diseases, and how these are happening in the context of health transition which again has multiple determinants and driving forces.

We have seen how health systems have to be better organized in order to respond to this combination of challenges and how when we talk about health systems we are not only talking about financial protection or health workforce or access to essential drugs and technologies in isolation but we are talking about all of them and again as a combination. And where we now look at the health systems as a platform for universal health coverage, this becomes even more important to look at how universal health coverage can deliver a variety of services needed by the people while providing them

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adequate financial protection. This again becomes very important in the context of economic development and reducing health inequities which can be perpetuated by ill health which affects the poor people predominantly. So the interrelationship between poverty and ill health is again brought into focus not only in the area of public health at the national level, but in terms of global public health as well. So all of these complex interactions become very integral to our understanding of global health and become the basis for our action. When we really look at how we need to respond to some of these global public health challenges we further realize that we are require an all-of-society approach which brings in multi-sectoral action in order to advance global health by dealing with the multiple determinants which have impact upon health. Those within the health sector as well as those outside of the health sector, whether it's trade, whether it is urban development, whether it's agriculture and food systems, all of these will now have to be studied and also motivated to become better aligned to public health objectives. And this is where global public health has to now become positioned in the framework of sustainable development because we cannot really think of sustainable development without having healthy people. But we also can't think of having sustainable development without a healthy planet and interestingly, we cannot think of healthy people without a healthy planet because environmental degradation will certainly undermine the health of the people and even imperil their very existence.

So bringing together all of these elements under the framework of sustainable development is very critical not just because the United Nations wants to call them Sustainable Development Goals but because these are very important goals for humanity itself. But while all of this happens we have to contend with a huge number of social forces and decide how they can actually be driven in favor of public health. We recognize that there are different models of economic development based on ideologies, there are the free market model, there has been the state controlled model, there are people who are looking at blending some of these systems in a mixed economic system as well as in a mixed health system. While all of these debates go on, we must really recognize what works best in favor of global public health. And therefore, we need a vigorous debate on ideas but we also need to embody those debates and a set of fundamental values and global public health actually brings forth global solidarity and partnership as those values. And of course the very underlying value of public health anyway is equity. So when we are really trying to promote equity in all dimensions but use solidarity as one of the motivating forces for moving us toward that ideal of equity, then global public health becomes a very important unifying

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factor across the world. And therefore, irrespective of some of the ideological struggles that are inevitable, and are likely to take place even in the 21st Century, we must overcome the struggle of these competing and conflicting ideas and ensure that we have a common blending of values which will triumph over these kind of sectarian ideological battles and those values will have to reflect a commitment to global solidarity, because without that solidarity, we will not be really looking at all of humanity as one family where the concerns and problems of one section will have to be addressed by the whole family together. We must recognize that as we move towards the implementation of the Sustainable Development Goals, health is absolutely pivotal for the economic, social and environmental development and protection. And then we must also ensure that health in turn benefits from equitable development in other sectors. For all of this to happen, the Sustainable Development Solutions Network is providing a unifying platform for looking at sustainable development in all dimensions from all directions. Health and global public health are important components of the mandate of the Sustainable Development Solutions Network. We hope that after this introductory course in global health has set you in motion, you will now become important contributors to global public health and to sustainable development.

Therefore, this is not the end of the course. This is the beginning of our partnership to work together for global public health and for sustainable development which are a global public good, and which are important not only for this generation, but for generations to come.

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Bibliography Institute of Medicine. The US commitment to global health: recommendations for the new administration. Institute of Medicine, Washington, DC; Dec 15, 2008http://www.iom.edu/CMS/3783/51303/60714.aspx. ((accessed Feb 19, 2009).)

Porter, R. The greatest benefit to mankind: a medical history of humanity. W W Norton & Company, New York; 1997 Winslow, C. The untilled field of public health. Mod Med. 1920; 2: 183–191 Institute of Medicine. The future of public health. National Academy Press, Washington, DC; 1988 Last, J. A dictionary of epidemiology. Oxford, New York; 2001 Brown, TM, Cueto, M, and Fee, E. The World Health Organization and the transition from “international” to “global” public health. Am J Public Health.

2006; 96: 62–72 Piot, Peter “ No Time to Lose: A life in pursuit of deadly viruses, New York, Norton & Company Inc Sachs, Jeffrey D (2015). The Age of Sustainable Development, New York, Princeton University press

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Heranças Globais Memórias Locais é uma revista semestral que apresenta os resultados do projeto de investigação ação em curso no Centro de Estudos Sociais da Universidade de Coimbra financiando pela FCT com o nome “Heranças Globais: a inclusão dos saberes das comunidades no desenvolvimento integrado do território” (SHRH/BPD/76601/2011).

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Apoios: Muss-amb-iki – espaço de memória e saber

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Heranças Globais Memórias Locais é uma revista semestral que apresenta os resultados do projeto de investigação ação em curso no Centro de Estudos Sociais da Universidade de Coimbra financiando pela FCT com o nome “Heranças Globais: a inclusão dos saberes das comunidades no desenvolvimento integrado do território” (SHRH/BPD/76601/2011).

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Apoios: Muss-amb-iki –

espaço de memória e saber

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