Health systems – of the people, by the people, for the people

The health system is the backbone of healthcare service delivery. At a national level, health systems provide the foundation for health policy and legislative framework, resource allocation (financial and human), monitoring and governance mechanisms, provision of healthcare services (primary care, essential medicines, medical products and technologies, life saving vaccines, etc.), and health information systems, among others (Source: World Health Organization. (2010). Key components of a well functioning health system. Ginebra: World Health Organization).

Based on the current state of global affairs, my understanding is that the health systems are designed to deal with the aspects of healthcare delivery mentioned above, leaving out all the rest. Although the building blocks of health systems seem comprehensive, it does not ensure that these systems are completely immune to intrinsic and extrinsic risk factors. This article will explore gaps in the current global health systems – high-income countries, and low-and middle-income countries, especially humanitarian and conflict-affected settings. It will also shed light on the need to design ‘conflict-proof’ health systems for robust healthcare delivery.  

There is a common notion that high-income countries have robust health systems, but this is far from the truth. For instance, the United States (U.S.) is marred by unequal and inequitable health outcomes due to disparate health sub-systems, and discriminate social determinants of health (Source: World Health Organization. (2013). Backgrounder 3: Key concepts), such as employment (Source: Goodman, N. (2015). The impact of employment on the health status and health care costs of working-age people with disabilities. Lead Center Policy Brief), income, education (Source: Hahn, R. A., & Truman, B. I. (2015). Education improves public health and promotes health equity. International journal of health services, 45(4), 657-678), crime rates, poverty, health insurance, among others. In particular, the high number of uninsured people in the U.S., make it one of the most expensive and inefficient health systems in the developed world. This certainly raises the question as to how well a developed and rich country like the U.S. is placed to provide adequate financial risk protection for poor and vulnerable populations. Furthermore, in Canada, though there is publicly funded healthcare, healthcare delivery is fragmented, leading to long wait times, and particularly poor health outcomes among First Nations communities, as a result of living in ‘third world conditions’. An example of such conditions is the national systemic failure to provide potable water, which is one of the critical factors that has led to poor health outcomes among these communities. 

The above cases of healthcare system failures in high-income countries depict health disparities due to the inadequate investment in upstream factors such as primary care, social determinants of health, etc. Increased enforcement mechanisms, and enhanced focus on social and human infrastructure is as important as investments in physical infrastructure (institutions, hospitals, etc.). Global health systems need to be designed in a way that ensures health care and not only sick care. This is particularly critical in countries experiencing war and conflict.

In fragile states, the negative externalities of weak health systems are particularly gruesome. For instance, much of the conflict in Yemen is collateral damage as a result of the U.S. foreign policy. The ulterior motives and selfish interests of the U.S are an implicit factor for a weak political and health system in Yemen. Involvement of foreign governments in Yemen, and Saudi Arabia’s ‘inhumane’ foreign policy have further exacerbated the conflict, especially in the Middle East. Saudi Arabia and the United Arab Emirates have not only bombarded Yemen, but have also intentionally blockaded humanitarian aid (indirectly supported by the U.S.) from reaching millions in need. Over 14 million people (i.e. half of the country’s population) are currently on the verge of starvation. In this case, the United Nations (UN) has also failed miserably in its humanitarian response. This has had further ramifications on Yemen’s fragile health system. Yemen’s case depicts how geopolitics and foreign policy is also a determinant of national health systems. It is high time that the UN addresses this issue by revisiting international humanitarian law frameworks and ensuring those are upheld rather than just ‘managing’ the situation in Yemen and other humanitarian emergency and conflict-affected settings. 

Lastly, the World Health Organization must take a lead on this and reorient health systems, both in research and practice, to counter such crises. The biggest concern is that the current understanding of health systems is limited in scope and design. What is considered essential to be part of a health system and what is excluded and on what basis? Should humanitarian law, human rights principles, and geopolitical factors be an intrinsic part of health systems? 

Current social, economic, political and legal systems, especially in conflict-affected settings, do not seem to bridge the gap. This results in further paralyzing already weak health systems; increasing foreign participation and privatization; and fragile states’ overdependence on unsustainable development aid. Development aid agencies must support such states with adequate interventions that aim to support and strengthen weak healthcare systems.  That said, these agencies must ensure maintenance of state sovereignty and autonomy, and sustainability of such systems in the long run. This requires investment in internal health systems strengthening human resources, as well as financial resources. 

A key element of human resources is investing in women, that is, healthcare system leadership by women, women-centred health research, and gender-based medicine. These factors are pertinent to strengthen the healthcare systems in both the developing and developed world. An important facet of reorientation of health systems is to incorporate gender equitable norms, in health and medicine research and development. In the U.S., the National Institutes of Health Revitalization Act was passed in the year 1993, however, two decades later a research study found that the proportion of minority patients enrolled in clinical trials still remains persistently low (Source: Chen Jr, M. S., Lara, P. N., Dang, J. H., Paterniti, D. A., & Kelly, K. (2014). Twenty years post‐NIH Revitalization Act: enhancing minority participation in clinical trials (EMPaCT): laying the groundwork for improving minority clinical trial accrual: renewing the case for enhancing minority participation in cancer clinical trials. Cancer, 120, 1091-1096). Further, in Canada, there is a growing concern for inclusion of racial health data. Thus, it is equally important to make the medico-legal system an intrinsic part of the health systems across the globe. Healthcare system researchers and leaders need to advocate for, and monitor adherence to health-related legislation to ensure scientific rigor via equal representation of minorities, among other vulnerable population sub-groups. Thus, doing away with gender-biased medicine and making way for gender-based medicine must be the way forward.

In conclusion, in order to close the healthcare gaps, it is pertinent to understand that the sum of parts is greater than whole. Strengthening every component of the health system, guided by the principle of ‘gender parity’ must inform future health systems’ thinking and design processes. Health systems must be of the people, by the people, and for the people.

This blog post was originally published in the University of Toronto's Global Health Magazine - Juxtaposition on April 5th, 2020

Peace, prosperity, and happiness: Transitioning towards a healthier world

The Need for Redefining Health

Preamble to the Constitution of the World Health Organization (WHO) as adopted by the International Health Conference held in New York in 1946 and entered into force on April 7^th, 1948 (celebrated as the World Health Day) defined ‘health’ as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. However, this conceptualization of health is not holistic, both in nature and scope. Thus, the WHO Constitution extended this definition to include the socioecological determinants of health (Source: Glanz K, Rimer BK, Viswanath K. Health Behavior: Theory, Research, and Practice. John Wiley & Sons; 2015. 512 p.) such as internal and external environmental factors and the State’s responsibility to ensure health promotion of their respective citizenry, among other factors.

The Ottawa Charter of Health Promotion also emphasized this notion via provision of adequate social, economic, political, and environmental measures to maximize the overall well-being of society (Source: Judd CM, James-hawkins L, Yzerbyt V, Kashima Y. Fundamental dimensions of social judgment: Understanding the relations between judgments of competence and warmth. Journal of Personality and Social Psychology. 2005;899–913). As a result, in general, global public health has shifted from a pathogenic health approach towards a salutogenic perspective to health of individuals, communities, and populations, especially in the recent decades (Source: Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR, Kromhout D, et al. How should we define health? BMJ. 2011 Jul 26;343:d4163). This enhanced focus on external elements related to global public health promotion is inextricably linked to the concepts of attainment of peace and prosperity.

Perhaps, an alternative definition of health could entail critical elements of creating enabling health systems and conducive social environments that allow individuals, families, and communities to not only survive but thrive in an ecosystem that affords individual and societal empowerment via health equity, equality, justice, and access to socioeconomic capital (Source: Venkatapuram SS. Health Justice: An Argument from the Capabilities Approach. John Wiley & Sons; 2013. 236 p.) pertaining to food, housing, education, employment, income, and freedoms from fear, conflict, disease, and poverty (Source: Shilton T, Sparks M, McQueen D, Lamarre M-C, Jackson S, executive committee of the International Union for Health Promotion and Education-IUHPE. Proposal for new definition of health. BMJ. 2011 Aug 23;343:d5359), regardless of age, sex, and gender.

Determinants of Health and Peace Promotion

The Ottawa Charter of Health Promotion identified peace as the foundation for good health. Johan Galtung (Source: Galtung J. A Synthetic Approach to Peace Thinking. :238.), the principal founder of the discipline of peace and conflict studies, noted that individuals require both internal and external peace emanating from individual, political, cultural, and societal harmony. Internal peace is a prerequisite for extending into the external environment, that is, family, friends, and community (Source: Galtung J. Peace by peaceful means:  Peace and conflict, development and civilization. Thousand Oaks, CA, US: Sage Publications, Inc; 1996. viii, 280. (Peace by peaceful means:  Peace and conflict, development and civilization)).

Further, Pathways to Peace, a United Nations (UN) designated peace messenger organization developed the peace wheel model for peacebuilding constituting eight pathways – governance, education, economics, health, science and technology, religion and spirituality, environment, and culture. These interrelated peace pathways identify and engage all stakeholders as peacebuilders, transcending national, ethnic, racial, religious, age, identity, or gender differences. These pathways are interlinked and interdependent with the health promotion principles and socioecological frameworks (Source: Glanz K, Rimer BK, Viswanath K. Health Behavior: Theory, Research, and Practice. John Wiley & Sons; 2015. 512 p.).

Furthermore, health, peace, and prosperity (economic as well as social) are critical elements for ensuring human dignity and self actualization. Goals related to peace promotion are like health promotion (Source: Middleton JD. Health promotion is peace promotion. Health Promot. 1987;2(4):341–5.), with peace promotion acting as a catalyst for achieving health promotion and vice-versa. Health promotion is a bridge to peace promotion and peace promotion leads to health promotion.

Thus, global peace and global health promotion is dependent on both intrinsic and extrinsic structural factors, that is, sociopolitical peace, sociocultural harmony, and socioeconomic prosperity.

Happiness and the idea of ‘balanced’ abundance

An implicit component to achieving worldwide health, peace, and prosperity is happiness – most importantly at individual, familial, and community levels for better physical, social, and mental health outcomes for entire populations across various stages of the human life cycle. Happiness is an equally essential component at the systemic and/or structural level of the socioecological framework, that is, environmental, policy, and societal levels. Although it is difficult to evaluate peace and happiness at any level, The Institute for Economics and Peace measures the average level of global peacefulness via The Global Peace Index. Further, The UN Sustainable Development Solutions Network measures global happiness via the annual World Happiness Report and reports the Global Happiness Index based on six variables such as income, freedom, trust, healthy life expectancy, social support, and generosity. These index measures and key indicators provide some interesting insights to analyze peace and happiness in conjunction and ascertain the enablers and barriers to global peace and happiness.

However, before delving into the analysis, it is critical to understand why happiness is the most vital performance indicator for humans. Humans are distinct from other species for having rationality, which governs thought processes. Aristotle’s Nicomachean Ethics argues that happiness is the greatest good and the end at which all human activities and efforts aim. Most of the ends are means toward other ends, however, only happiness is an end in itself – the all-encompassing primary goal of life. This makes understanding and interpreting happiness in all visions, missions, policies, and programs related to health, peace, and prosperity especially important in the current day and age.

Based on these indices, an international comparison suggests that the Scandinavian countries such as Finland, Denmark, Norway, Iceland, among others, consistently rank better than other countries year after year. These countries tend to rank higher in all the six variables, as well as emotional measures related to overall health and well-being.

On the other hand, The United States, a global economic superpower, and a country where pursuit of happiness is embedded in the deepest layers of society, is also the country with one of the highest rates of antidepressant use in the world. Although the United States ranks higher in terms of economic indicators such as capital and income, it does not even come close to the international leader board on the list of measures that make up a happy country such as generosity, social support, freedom, and corruption.

This is the biggest valuable lesson for countries vying to be the next superpowers of the world, especially emerging economies and developing countries such as India. India was ranked at 140^th place in 2019 on the Global Happiness Index, dropping seven spots since 2018 on the back of an increase in negative emotions, including higher levels of worry, sadness, and anger, especially over the past few years. Compared to this, India’s neighbour, the small country of Bhutan came in at 95th place.

Both these indices depict one thing clearly – the country that grows (both economically and socially) together equally and equitably, stays together peacefully and happily. This simplistic idea and a generic thumb rule are quite straightforward, both in theory and practice. A general trend with respect to the top ranked happy and peaceful countries is that all these nations have a sense of community and shared responsibility (although immigrant inclusivity, social diversity, and race and ethnic heterogeneity might be questionable in some of the Nordic countries) and thus are much more peaceful, happier, healthier, and overall prosperous. Canada, for instance, is the only country in the Americas to make it to the top ten in both health and peace indices, respectively. Perhaps, the biggest contributing factor is Canada’s ‘multiculturalism’ (Source: Brosseau L, Dewing M. Canadian Multiculturalism. (2009):32.) – officially adopted by the government during the 1970s and 1980s. Based on these insights, it can very well be argued that a Canadian dream and/or a Nordic dream (not only in terms of economic migration but all other relative factors that determine the quality of life and standard of living) seems far more rewarding than an American dream in order to pursue a happier and fulfilling life in every sense of the word. However, this beyond the scope of this article!

Conclusion and Way Forward

In conclusion, the way forward to ensure and sustain good health, overall well-being, greater internal and external peace, enhanced socioeconomic prosperity, and universal happiness is to replace the vicious cycle of violence (of all forms) and poor health outcomes with the virtuous cycle of higher levels of peace, prosperity, and health. This can be made possible only if the world transitions towards the idea of sustainable and ‘balanced’ abundance – an intricate balance between excess and deficiency, as noted by Aristotle almost two millennia ago and Mahatma Gandhi a century ago (Source: Dalton D. Mahatma Gandhi: Nonviolent Power in Action. Columbia University Press; 2012. 353 p.). The path to stable and sustainable prosperity requires the non-tangible and dynamic concept of happiness to be embedded in all policies, inherent at all governance levels, and amongst all individuals to transition towards a healthier and peaceful world in the future.

Femicide: A Global Social Evil

Violence Against Women

The United Nations (UN) defines violence against women and girls (VAW) as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life”. Globally, one in three women experience physical and/or sexual violence by a partner or sexual violence by a non-partner. The most extreme form of VAW on a continuum of violence and discrimination against women and girls is the intentional killing of women called  ‘femicide’. 

The term ‘femicide’ encompasses femicide perpetrated by men (current or former intimate partners); female-perpetrated femicide; and femicide involving family members as well. Femicide constitutes an ongoing abuse in the home, threats or intimidation, sexual violence and/or situations where gender power imbalances arise out of resource disparities such as lower levels of education and income as well as women’s low social and economic status. VAW is a major global public health concern and femicide, specifically, is a complex issue as aforementioned femicide categories are not always distinct and quite often overlap.

Femicide – A Global Epidemic

Femicide is a critical public health issue and the prevalence of femicide transcends geographic boundaries. The causes and consequences of femicide are an interplay of a myriad of social, economic, political, and cultural factors. One third of global femicide cases are reported to be committed by an intimate partner, with femicide rates ranging from 3.1 victims per 100,000 females in Africa, 1.6 in the Americas, 1.3 in Oceania, 0.9 in Asia and 0.7 in Europe.

In the United States, for instance, pregnant women are at an increased risk of intimate partner femicide. Evidence from the United Kingdom suggests that femicide has a ‘collateral’ consequence – murder of children, witnesses, and perceived allies, including lawyers, relatives, family friends, and neighbours.

Further, the issue of missing and murdered Indigenous women and girls in Canada has received much national and international attention. Although most of such femicides could be categorized as intimate partner femicide, there is more to it than meets the eye. It is pertinent to understand the ‘intersectional’ element of such femicides – the combined role of intersecting identities of ‘Indigenous’ and ‘woman’ that might be leading to a higher risk factor in such femicides.  Furthermore, Europe (Source: van Eck, C. (2003). Purified by blood: honour killings amongst Turks in the Netherlands. Amsterdam: Amsterdam University Press.), Australia, North America, and much of the Western countries (Source: Gill A.K., Strange C., & Roberts K.A. (Eds.). (2014). “Honour” killing and violence: theory, policy and practice. Basingstoke, Hampshire: Palgrave Macmillan) are experiencing a surge in the number of femicide cases, specifically related to the killing of females in the name of ‘honour’.

‘Honour’ and ‘Dowry’ related femicides – A Sociocultural Issue

‘Honour’-related femicide is usually addressed as ‘honour killing’ which involves “ the murder of a girl or woman resulting from an actual or assumed sexual or behavioural transgression (adultery, sexual intercourse, pregnancy outside marriage, or even for being raped)”. This type of femicide is often seen to protect family reputation and to follow patriarchal and age-old religious traditions or cultural beliefs. The UN estimates that approximately 5,000 women and girls are murdered each year in ‘honour killings’ by members of their families. Honour killings are widespread across the globe, but are especially common in the Middle East and South Asia.

Further, with respect to dowry-related femicides, despite laws in place, dowry-related disputes and deaths are still commonplace, especially in India. In  2018 alone, about 7,000 women (brides) were killed for dowry-related disputes. These ‘bride killings’ occur around wedding time or during the initial years of the marriage, resulting from constant threats (disputes continuing for years) from the groom’s family, and torture (verbal abuse and/or physical harassment) in order to get a larger dowry. Such incidents include ‘bride burning’ (a form of domestic violence and usually reported as ‘kitchen accidents’) in which the bride ends up being burned to death. 

Ending Global Femicide

The global sociocultural menace of VAW and femicides needs to be addressed via stringent legislations (including enhanced surveillance, universal screening, and reporting of intimate partner violence and femicides) and devising global response systems (sensitization of police, media, social workers and healthcare professionals in the developing world as well as developed countries). That is, applying country-specific and culture-specific socio-ecological model (SEM) remedies in order to address this grave issue, holistically. SEM response must strive to address the upstream causes and downstream consequences associated with femicides occurring at individual, family, community and wider society levels (including system and policy/environmental levels).

Conclusion

VAW and femicide have enormous adverse effects throughout global society. No cultural, social, or religious belief is above fundamental human rights. VAW and femicide is an attack on women’s human rights and threatens to devalue the worth of women and treat them as less than human. The world needs to collectively address femicide and end such horrific acts of violence emanating from fragile masculine morality, resulting in targeted elimination of women. Femicide cannot become second nature to the current global culture. This can only be made possible when each one of us acknowledges the dignity of women and girls and the value of their very existence.

This blog post was originally published in the University of Toronto's Global Health Magazine - Juxtaposition on December 18th, 2019.

Evolutionary Nature of the COVID-19 Pandemic: An Impending Endemicity?

It is 2022, that is, two years into the COVID-19 pandemic. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus’s deadly effects appear to be waning globally. Based on the factors such as global case rate, positivity rate, daily death count, virus reproduction rate, susceptibility of the population, social behavior changes (masking, vaccinations, among others), pathogen transitionality, etc., COVID-19 is slowly starting to plummet globally with some nations still experiencing high caseloads due to the much transmissible (compared to the Delta variant) Omicron variant. Currently, the nature of next phase of the pandemic is what is being hotly debated in the scientific community and outside. Is the pandemic about to get over? Are we in the process of transitioning from a pandemic phase to an endemic phase? What would endemicity phase entail? What are other probable future scenarios that could affect public health response to the pandemic? These are some of the questions that would constitute the deliberations in this article.

Defining Endemicity

What does endemicity actually mean? Epidemic means ‘upon the people’ (epi+demos) and endemic means ‘within the people’ (en+demos). An endemic disease is one that becomes potentially stabilized within a population – not vanishing completely but present with symptoms that could be categorized as mild or harmless or even with low transmissibility. This does not mean that global COVID outbreaks would not occur. That said, it is difficult to predict for sure regarding the next phase of the pandemic. After a global Omicron variant surge registering elevated level of COVID-19 cases, the evolving coronavirus seems to be finally transitioning from a pandemic to an endemic phase. An endemic phase could observe lifting of country-specific COVID-19 pandemic-related travel restrictions, mask and testing mandates, among other restrictions. This does not mean that public should confuse COVID-19 with influenza. Thus, the global community needs to be cautious as ever – aware that we might be entering an endemic phase, however, cognizant of the fact that we need to be well prepared of the difficult days ahead! In other words, we need to be extra vigilant during this crucial juncture wherein the world is at the crossroads of overturning this hopefully once-in-a-century global public health crisis. The evolutionary and transitional nature of the coronavirus is what makes it inherently unpredictable to counter completely worldwide. Different national healthcare system approaches and capacities, seasonality, and unfavorable geographic location/distribution would allow more variants to spread successfully. This in turn could lead to prolonged emergency situation with new waves of epidemics cropping up in distinct parts of the world. One risky factor that is emerging is the spread of Omicron subvariant – BA.2. Thus, it might be useful to start thinking about a global endemic resolution strategy for the purposes of COVID-19 pandemic preparedness rather than becoming a casualty of an ‘endemic delusion‘.

Evolution of COVID-19 – A ‘new normal‘

As discussed above, one likely evolutionary scenario for the future of SARS-CoV-2 is endemicity. Humans currently coexist with four known endemic coronaviruses. Their scientific designations, that is, 229E (llama coronavirus), OC43 (bovine coronavirus), NL63 (NetherLand 63), and HKU1 (Hong Kong University 1) are known as common cold coronaviruses. The immunity to these coronaviruses’ wanes with time. Thus, infections can recur throughout the human lifespan. This is the most likely scenario for COVID-19 pandemic within the realm of possibilities. Additionally, some non-mutually exclusive evolutionary scenarios are contemplated in the next sections of this article.

Modified diseases and symptoms

A likely scenario could be a mutant virus producing an altogether different (altered) disease and symptoms. In this scenario, the SARS-CoV-2 could infect new cells in the human body. That is, the coronavirus could infect and affect other organ systems rather than predominantly infecting and affecting the respiratory system only. The ultimate effect on the human body is difficult to predict as it depends on the severity of organ(s) damaged – intestine, kidney, and the central nervous system.

Recombinant coronavirus

Current evidence suggests that there is a likelihood that SARS-CoV-2 evolves into a novel hybrid – combination of genetic material of the human SARS-CoV-2 and the genetic material of an existing animal coronavirus. Given the huge caseloads of SARS-CoV-2 infected humans, there is a good probability that someone somewhere on this planet might be simultaneously infected with SARS-CoV-2 and an animal coronavirus. SARS-CoV-2-infected humans who have close contact with coronavirus-infected animals could serve as hosts for the novel recombinant viruses. Regardless of where and how novel hybrid variations of coronavirus might arise, the recombinant virus could easily diminish SARS-CoV-2 immunity and could even have different disease genetics than what has been observed in context of COVID-19 and its variants.

Exploitation of human immune response

There is likelihood that the future scenario could entail a variant that exploits human immune response. The major variants of SARS-CoV-2 virus such as Alpha through Omicron (and now reportedly Deltacron) led to virus evolution that helped evade the human immune system. Further, there is a possibility of exploitation of the immune system. For instance, when humans are infected with dengue (not a coronavirus), the immune system produces an immune response entailing illness with high fever and muscle and joint pain. The initial immune response to dengue makes the individual immune to future exposures with that same type of dengue virus. However, if the person gets a reinfection from dengue-type virus, the initial infection increases the severity of disease(s) instead of providing protection against it. This is due to an effect called ‘antibody-dependent enhancement‘ (ADE) of virus infection and disease. This is worrisome because SARS-CoV-2 may evolve to use ADE to increase virus growth and transmission, and a new or hybrid variant could explosively spread through immune populations across the globe.

Conclusion

All of the above listed future scenarios are equally likely, however, my hunch is that SARS-CoV-2 will enter a phase of endemicity in the months to come. That said, other scenarios discussed in this article are within the realm of possibility – altered disease, recombinant viruses, and/or exploitation of immune response. Some other scenarios (not discussed in this article) that might take place is infection transmission from humans to animals and spillover effects of reinfection from animals back to humans. Further, there could be a situation where there is an uptick of transmissibility from chronically infected people with ‘long Covid‘ to immune populations. All these scenarios could decide how the COVID-19 pandemic end game will play out. A new coronavirus variant could emerge anywhere in the world and spread like wildfire in a matter of few weeks as has been the case with successive variations of the evolving coronavirus. The hope is that COVID-19 would recede rather than intensify from the current scenario.

In closing, we are about to reach there but we are not quite there yet. This translates to public health policy measures to be centered around masks and vaccines (including booster shots to counter variants). Therefore, the pandemic end game still seems like a waiting game! It remains to be seen which way the wind blows.

Antimicrobial resistance (AMR): A leading cause of global deaths

At least 1.2 million people died from antibiotic resistant infections in 2019, making it a leading cause of death outpacing malaria or AIDS, according to a recent Lancet study. The estimated deaths and disability-adjusted life-years attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen–drug combinations in 204 countries and territories in 2019. The study noted that low and middle income countries, especially in sub-Saharan Africa and South Asia are the worst affected. The findings provide a clear signal to take urgent action that involves increased global health funding to combat this hidden pandemic.

The way forward is to ensure that public health spending needs are directed towards preventing fresh infections; making sure existing antibiotics are used judiciously. The private sector also needs to contribute to end AMR by investing more in research and development of new antibiotics. The new antibiotics are then required to be brought to the market at affordable prices.

National Nutrition Week 2019: Malnutrition Crisis in India

Hello! I am back, after what I realized was an extended blog break that lasted for over a year (yes, my last blog post was in June 2018!). Going back to school ain’t that easy…is also what I realized during the past year 🙂 ! So, the reason that compelled me to make a blogging comeback of sorts is the one public health issue that is very near and dear to my heart – ‘MALNUTRITION’!

The high rates of maternal and child mortality from under-nutrition and anemia in India and rather much of the low and middle income/developing world was one of the foremost reason why I took up public health as a full time life and/or career goal. That said, this blog is not at all about myself, however, it is definitely about India’s malnutrition problem, the real reasons behind the high rates of malnutrition, and how we can end malnutrition or at least keep trying to do so!

As a public health student and young (or rather that’s how I like to think about myself!) global public health professional, it is disheartening to see India from afar (now that I am based out of Canada) not progressing, both in terms of direction and velocity in which many of us would have liked. I believe that it is certainly partly Government’s fault and partly media’s (print, electronic, digital, social, etc. communication modes that exist in the current day and age) lack of attention devoted to health and/or allied healthcare issues. Malnutrition issue in India has further exacerbated due to lack of proper devolution of public financing (healthcare) schemes (in terms of reach, relevancy, sufficiency, and channelling of funds), lack of decentralization and autonomization in relation to States’ (regional and local levels) respective public health systems (especially among high burden backward districts), and monetary/non-monetary corruption (decay in terms of both moral and ethical values), among myriad of other social and behavioural factors.

That said, in the past few years all the efforts by the Government and media were not in vain. For starters, I understand that India is currently celebrating the National Nutrition Week (NNW) 2019. The NNW in India is not something new and has been around for nearly four decades now. But it is only in recent years, that the NNW has gained attention in terms of media coverage and has got a Government push due to improved governance mechanisms and regular reporting requirements regarding social and health indicators (thanks to Government of India’s premier policy think tank NITI Aayog’s Aspirational District Programme, among others).

NNW is an annual public health nutrition event launched by Food and Nutrition Board within the Ministry of Women and Child Development, Government of India in the year 1982. NNW is observed throughout India during the first week of September, that is, September 1st – 7th. The main objective for launching the NNW was to acknowledge ‘malnutrition’ as health and economic crisis in India. Further, the NNW was launched to tackle the public health problems and create awareness among people about the importance of adequate nutrition and balanced diet. Furthermore, NNW is celebrated with an overarching goal to raise awareness on the importance of nutrition for health which has further implications on labour productivity, economic growth and ultimately the nation’s economic development.

Since 1982, every year the Food and Nutrition Board specifies a theme for the NNW and through its network of 43 Community Food and Nutrition Extension Units (CFNEUs) located in all the four regions of the country, coordinate with concerned department(s) of the State/Union Territory Governments, National Public Health Institutions, Non-Government Organizations, among others. CFNEUs organize State/Union Territory level workshops, orientation training of field personnel/partners/functionaries, awareness generation camps, and community meetings during the NNW on a specified theme. Further, CFNEUs organize workshops, lectures, film and slide shows, exhibitions in collaboration with the concerned Departments of the State Governments, Educational institutions and Voluntary organizations. For instance, with respect to educational programmes, CFNEUs focus on various vital aspects of public health nutrition, including the importance of immunization, breastfeeding, principles of proper sanitation and hygiene, nutrient conservation during cooking, among others.

Although these aforementioned public health initiatives are laudable and have undeniably resulted in considerable decline in malnutrition numbers in India, there is much more to do and rather equally important to undo in the upcoming years. Thus, I am sorry to disappoint my blog reader that looking at the current state of affairs regarding public health nutrition in India, there is not much to celebrate, but that is a topic of discussion for another day and another blog(s)! I say (or rather write) that because malnutrition is an inter-generational and multidimensional phenomenon. The vicious cycle of malnutrition leads to health crisis and is no less than an epidemic. There is no straightforward solution to address this grave public health concern. For that reason, it is important to understand that malnutrition can manifest in multiple ways, the pathways to prevention involves but must not be limited to only nutrition-specific interventions such as adequate maternal and child nutrition; optimal breastfeeding practices; intake of nutritious foods for early childhood development, etc. Public health interventions must encompass a nutrition-sensitive approach, ensure a healthy environment including access to basic primary health services, opportunities for physical activity (now that India is facing a double burden of malnutrition), among others.

To put things in perspective, last year on July 24th, three sisters in a household with low socioeconomic status in the capital city Delhi – Mansi, Shikha, and Parul aged eight, four and two years, respectively, made headlines across India because they succumbed to severe acute malnutrition. The ‘real’ cause of death was certainly not only lack of proper nutrition but also pathetic living conditions and other socioeconomic factors!

Also Read: Three Delhi sisters died of ‘severe malnutrition’, say doctors

Over the past couple decades, India has shown exemplary economic performance. Since 1991, there has been a tremendous progress in India’s Gross Domestic Product, but it is also true that she still remains a country where 195 million people (i.e. approximately five times Canada’s population) are undernourished. The Global Hunger Index 2018 ranks India at 103 out of 119 countries (well below many poorer countries in sub-Saharan Africa) on the basis of three key indicators – the prevalence of wasting and stunting in children under the age of 5; child mortality rate under the age of 5; and the proportion of undernourished in the country’s population.

In essence, just like various other international, national, regional, and local news reports, Government/non-Government agency reports, United Nations reports, policy think tanks’ white papers, etc. sources of information, the Global Hunger Index echoes the fact that India is suffering from a serious problem of hunger and malnutrition.

Mobile Phone Incentives for Childhood Immunizations in Rural India

WHAT’S KNOWN ON THIS SUBJECT: In previous studies, researchers have established the role of mobile phone messaging in improving health outcomes. However, there are few studies in which researchers have evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunization coverage.

WHAT THIS STUDY ADDS: A biometric-linked, cloud-based immunization record platform was used for positive identification and tamper-proof delivery of automated compliance-linked incentives. We demonstrate that incentives are an important intervention for improving the timeliness and coverage of childhood immunizations in a resource-poor setting.

STUDY OBJECTIVES: Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations.

STUDY METHODOLOGY: Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression.

STUDY RESULTS: Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%–69.2%), 40.1% (IQR: 30.8%–69.2%), and 50.0% (IQR: 30.8%–76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations.

CONCLUSIONS: Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings.

Source: Seth R, Akinboyo I, Chhabra A, et al. Mobile Phone Incentives for Childhood Immunizations in Rural India. Pediatrics. 2018;141(4):e20173455

The online version of this article, along with further information and resources, is located on the World Wide Web at:

http://pediatrics.aappublications.org/content/early/2018/03/12/peds.2017-3455

Cervical Cancer – Inclusion of HPV Vaccine in India’s Universal Immunization Programme

In the United States, the month of January was ‘Cervical Cancer Awareness Month’. Efforts are made all over U.S. to raise awareness about this fatal disease. In the States, the disease affects approximately 13,000 American women each year. In comparison, approximately 366 million Indian women above the age of 15 years are at risk of developing cervical cancer. (Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3385284/)

Cervical cancer or cancer of the uterine cervix is the second most common cancer among women in India. Approximately 12.3 million new cervix cancer cases are diagnosed, killing approximately 70,000 women every year in the country, more than any other causes of maternal mortality. It is a highly preventable and treatable cancer, but only if people take the necessary steps to get screened and vaccinated. Yet, the Ministry of Health and Family Welfare – Government of India, has taken an in-principle call against the introduction of the cervical cancer vaccine in the public health programme (Universal Immunization Programme). This decision was taken adhering to recommendations from an organization affiliated to the Rashtriya Swayamsevak Sangh (RSS) called Swadeshi Jagran Manch (SJM). As per reports, SJM wrote a letter to the Prime Minister’s Office (PMO). The RSS affiliate organization seems to be of the opinion that cervical cancer is not a serious issue and “scarce resources” should be used for “more worthwhile” health initiatives.

The letter was duly acknowledged by the PMO and accordingly sent to the ministry for consideration. A sub-committee of National Technical Advisory Group on Immunization (NTAGI) was earlier constituted to look into the matter of introduction of HPV vaccine in India. While NTAGI is yet to give a decision, highly placed sources have revealed that SJM’s recommendation is being adhered to, and regardless of what NTAGI decides, the vaccine will not be included in UIP scheme, reported national daily – The Indian Express.

It is imperative for India to introduce the cervical cancer vaccine. In nearly all cases, the cervical cancer can be attributable to Human papillomavirus (HPV) infection. The HPV is a sexually transmitted infection (STI) and is preventable by HPV vaccine. The HPV vaccination can help prevent up to 90 percent of cervical cancer cases and deaths. The American Cancer Society recommends HPV vaccination for girls and boys beginning at ages 11 or 12 when it’s most effective. The HPV vaccine provides protection from the virus that can cause seven different types of cancer in men and women, including the two most prevalent types of cervical cancers. Cervical cancer forms slowly. Normal cells change to pre-cancerous ones that, over time, may grow into cervical cancer. For most women, pre-cancerous changes go away without any treatment.  But, if these pre-cancerous cells are identified and treated, almost all true cervical cancers could be prevented.

The World Health Organization has recommended the inclusion of the HPV vaccine among routine mandatory vaccinations. Dr. Soumya Swaminathan, Deputy Director General (programmes) of the World Health Organization has said that India is a fit case for introduction of the HPV vaccine.

Further, there is enough support regarding the safety of the vaccine. The National Technical Advisory Group on Immunization (NTAGI) had earlier recommended HPV vaccination in India to prevent cervical cancer. A paper published by National Health Portal of India also stated, “Cervical cancer can be prevented by vaccinating all young females against the HPVs….” (Source: https://www.nhp.gov.in/disease/reproductive-system/female-gynaecological-diseases-/cervical-cancer). Furthermore, a pilot of the Punjab government in two districts, that is, Bhatinda and Mansa districts for administering HPV vaccine to young girls have shown encouraging results. This was done last year and was very successful. The Punjab Government is now thinking of scaling up this initiative. Post Graduate Institute of Medical Education and Research (PGIMER), Punjab, which has been commissioned to do a cost effectiveness study of the vaccine for Punjab, points out the cost of the vaccination will be roughly USD14 per girl, if the government rolls it out through a mass programme.

Only two doses of the vaccine administered at a 6 to 12 month interval are enough to protect girls under the age of 15 years. Cervical cancer can be prevented by vaccinating all young females against the HPVs and by screening and treating pre-cancerous lesions in women. In addition, if cervical cancer is detected early and treated in earlier stages it can be cured.

Thus, it is surprising that the Union Health Ministry has decided to exclude the HPV vaccine from Universal Immunization Programme (UIP). Do organizations like RSS and SJM have technical and clinical expertise to hold an opinion which, if taken seriously, has the potential to adversely affect the health of approximately 366 million Indian women? Should the Government adhere to recommendations of credible organizations like NTAGI, WHO and CDC, among others or those of SJM?

Having said that, it is worth mentioning that the utility of HPV vaccine is highly controversial and not free from debate. There are concerns regarding morality (the vaccines were administered to poor tribal girls in Andhra Pradesh and Gujarat as part of a pilot study, and a Parliamentary Committee found that this process was fraught with unethical practices and violations of the children’s rights) and safety (side effects, however without any scientific evidence). Further, there is backlash from religious and conservative bodies not only in India but also in the U.S. as well.

However, the way forward is not to scrap cervical cancer vaccine, but to deliberate about the ways to prevent cervical cancer. The Government needs to make regular cervical screening available for the mass of girls and women in the country. Further, extensive research should be done to understand the implications of the HPV vaccine.

To conclude, the government should check the ‘disease incidence’ which is very high for cervical cancer in India. Evidently, the alternate to HPV vaccine is not effective (both in terms of cost and benefit) and the vaccination seems to be the way forward. It is critical that we take this issue on a priority basis and not get swayed by misogynist, orthodox, hyper-masculine patriarchal mindsets and organizations dictating norms on women’s health. Such attempts put women’s health on last priority!

As a public health professional and an advocate for women’s health, I have started a petition requesting the Prime Minister of India, Union Minister of Health & Family Welfare, Union Minister of Women & Child Development and other decision makers of our country to include HPV vaccine in the UIP programme of India on an urgent basis and help save our country’s women from this vaccine preventable cancer.

PS: Before you finish reading this article and get on with your life, please do not forget to SIGN THE PETITION and help save women from cervical cancer!

‘Mission Indradhanush’ – A shot in the arm for India’s Universal Immunization Programme

It is not common that India comes in for commending mention when health indices are in question. Mission Indradhanush(MI), a Central government initiative launched three years back in December 2014 with an aim to achieve full immunization, has managed to get its share of attention and international adulation. This is including a reference in a 2017 report of the Johns Hopkins Bloomberg School of Public Health.

Mission Indradhanush was designed as a booster vaccination programme in 200-odd under-served districts with low immunization coverage, to ensure that all children under the age of two and pregnant women are fully immunized against seven life-threatening diseases — tuberculosis, poliomyelitis, hepatitis B, diphtheria, pertussis, tetanus and measles.

The word ‘Indradhanush’ was chosen to represent the seven vaccines that are currently included in the Universal Immunization Programme against these seven diseases — the number has since risen to 12 with the inclusion of vaccines against measles, mumps and rubella (MMR), rotavirus, Haemophilus influenzae type B, pneumococcus and polio. In a select few states and districts, vaccines are also provided against Japanese Encephalitis.

The importance the government is attaching to the programme was clear when last year in October 2017, during the run-up to the Gujarat Assembly polls, Prime Minister Narendra Modi launched the upgraded version of the MI project — the Intensified Mission Indradhanush that aims to reach the last ‘unreached’ child. For the intensified MI, 1,743 districts and 17 cities were identified, aiming to reach ‘full immunization’ by December 2018. According to the National Family Health Survey 4, the vaccination coverage in the country is a mere 65 per cent.

In the three phases of the Intensified MI so far (usually held between the 7th and 14th of each month), health workers have covered approximately 4.5 million ‘unreached’ children — those who have never been vaccinated — and have fully vaccinated approximately 1.2 million children. They have also reached approximately 1 million pregnant women. The four phases of Mission Indradhanush, until July 2017, had reached approximately 26 million children and around 6.8 million pregnant women in 528 districts across the country.

Health sub-centre at Village Ghasera, Haryana and Mission Indradhanush drive in the village

Mission Indradhanush (MI) immunization drive underway in Ghasera

According to the government’s Integrated Childhood and Immunization Survey, the first two phases of Mission Indradhanush led to a 6.7 per cent annual increase in immunization coverage as compared to the 1 per cent increase in the past. At those rates, the country would take a quarter of a century to reach the target of 90 per cent coverage.

MI happened with no additional resources from the Centre. When it was first mooted, states raised the demand for extra vaccines but Dr. Pradeep Halder, often hailed as the brainchild of the immunization programme, argued that since vaccines are procured with the entire birth cohort in mind, those meant for children who are not covered “should be somewhere in the system”. About 10 per cent could be presumed wasted, but the rest the states would have to fish out. They did that and out of this experience was born ‘eVIN’.

eVIN (Electronic Vaccine Intelligence Network) is an indigenously developed technology system in India that digitizes vaccine stocks and monitors the temperature of the cold chain through a smart phone application. The innovative eVIN is presently being implemented across twelve states in India. eVIN aims to support the Government of India’s Universal Immunization Programme by providing real-time information on vaccine stocks and flows, and storage temperatures across all cold chain points in these states. The technological innovation is already being implemented by the United Nations Development Programme (UNDP) and has been categorized as a global best practice. Teams from Philippines, Indonesia, Bangladesh and Thailand are now preparing to roll it out in their own countries.

Future Challenges & Opportunities –

The picture is not all that rosy. Health officials have reasons to worry. There is fear that MI is taking the emphasis away from the routine immunisation (RI) project. While MI is only meant to supplement RI, some states have started reporting consolidated figures for RI and MI that not only takes away from a realistic assessment of MI but also raises fears of the booster shot replacing the primary. There are concerns that because of the emphasis on MI and now Intensified MI, states will push resources into this and the routine immunization programme will suffer.

The first 2 phases of MI had led to an increase in immunization coverage by approximately 7 percent. Micro-planning needs to be strengthened so that all children and pregnant women, especially those in far-flung areas and high-risk habitations are covered. The biggest challenge is the deadline India has set for herself, that is, of bringing down the target date (for 90% immunization coverage) from 2020 to December 2018. This means that the Intensified MI would have to reach out to the populations in the most remote locations in a limited timeframe. However, it is easier said than done. A major barrier in achieving this target is the deeply ingrained cultural issues and religious beliefs and general lack of formal health communication at the ground level (village households).

[Also Read: Health in India’s villages – Challenges in Ghasera]

MI is a strategy to strengthen RI. MI must lead to capacity building of frontline health manpower for providing quality immunization services. Massive campaigns have been carried out for MI which has led to an increased awareness on immunization and encouraged inclusiveness. Most importantly, MI in areas which were previously left out of RI has led to these areas being integrated into RI micro-plans and taking immunization services closer to the people than ever before. An integrated RI plus MI (and now Intensified MI) has provided much needed impetus to the national immunization programme.

Is achieving 100 % target possible for India?

Achieving 100 percent immunization coverage requires persistent and sustained efforts because new cohorts of children who have to be immunized are added continuously. There is always a high probability that small proportion of children may not be covered despite best possible efforts due to reasons like migration (for work), among other factors. Hence, there can never be a target date for achieving 100 percent coverage. The aim should probably be to attain and sustain the immunization coverage across the country at 90-95 percent levels.

Conclusion

Vaccination is one of the surest methods of ensuring healthy children and eventually a healthy nation. As per the direction of the Prime Minister of India, the goal of Intensified Mission Indradhanush is to increase the immunization coverage to 90 percent by the end of this year. This can be achieved only when we reach out to those ‘unreached’ children who are left out of routine immunization sessions.

A public health programme, let alone child immunization programme, even globally, has never targeted such a large population in such diverse geographies. The only way ahead is to focus on the most backward districts or the so called ‘aspirational states’. What is significant is India does not need money to push these things forward but unwavering focus and meticulous planning and implementation.