Blog on global health in an open world on the occasion of the Niels Bohr jubilee 2014
Science
does not exist in vacuum and science does not have a life of its own. Science
has a history and has always been part of history. Science does not believe in
creationism. Or does it? Global health science seems to be wondering about in
its own echo chamber biting its own tail repeatedly trying to recreate itself
regardless of its own history and ignoring the real world context of global
health. It took 186 years from the discovery of the Smallpox vaccine to the
eradication of the disease; it took only 20 years from the onset of the global
HIV epidemic to create a global HIV disaster caused by ignorance, negligence,
political correctness, religious considerations and lobbying, epidemic stigma
and counterproductive politically governed control measures. Governments have
had to interpose themselves into controversies of sex, injected drugs, and
other taboos in public media. Even the WHO has had trouble confronting such
realities. The slow and inadequate international response to HIV/AIDS may have
accelerated the epidemic and made it more severe. And some have argued that over-emphasized
individual rights against public good, was not the best approach for Africa, as
Africa’s society is based on community/group understandings and is not as
individualistic as the European or North American societies. The timing of the
HIV/AIDS epidemic is also an ignored historic fact. In addition, combating AIDS
requires costly change in economies and national cultures. The concurrence of
the HIV epidemic with the collapse of the hospital care system in Africa
contributed to the disaster and later famines in southern Africa in 2001-2003
and the explosion in food prices in 2009 have sparked a second HIV epidemic –
this time among single mothers striving to pay newly imposed school fees and
user fees for simple health care [1, 2]. Some are waiting for the vaccine
“fix” or the wonder drug for HIV – but given the history of Smallpox it will
probably take 186 years from now if the world doesn’t open its mind both to
history and to reality. AIDS is not a fashionable subject anymore but the story
of HIV/AIDS is a lesson to global health decision makers. Rephrasing Elisabeth
Pisani: whores have wisdom, and we had better open our minds and face it [3].
But why
global health? Well, health has never been more clearly global than now. Social
media have reorganized our way of talking, discussing and interacting globally
by spreading happiness, hate speech, obesity and knowledge at the same time. Diseases
have never had respect for border control. Polio has suddenly re-emerged in
Syria, measles is popping up all over Europe, West Nile fever came from Uganda
to USA and is raging in Texas, Dengue and yellow fever threatens to spread to
new areas of Europe and the southern states of USA, patients with extremely
drug resistant TB have been travelling freely across Europe and the Atlantic
ocean within 8 hours, epidemics of diabetes are seen in China, India, Africa
and among the poor in Europe and the US and antibiotic resistance is caused by
the food industry and spread by humans and food. But looking at the causes
behind the current resurgence of polio in Israel, Britain, Eastern Europe and
Nigeria there are quite unique and independent global causes to this viral
proxy for chaos: The Israeli strain came from Egypt that got it from Pakistan,
in Nigeria it is caused by Muslim groups in the North that reject child
vaccinations, while Eastern Europe faces the consequences of a collapsing health
care system combined with a heavy migration load. But digging deeper into the
Nigerian Polio dilemma the
immunization crisis is best understood after considering developments in the
broader politico-religious contexts, both local and global. The controversy as
a whole should be understood against the background of the deepening interface
between health and politics. In that view the crisis is best seen as
originating from a lack of trust in social interaction between ordinary
citizens and the Nigerian state on the one hand, and between the same citizens
and international health agencies and pharmaceutical companies on the other.
The analysis of trust shows that it is a historically embedded crises and
illuminates the historical dynamics of relations among the identified actors –
not just Muslims rejecting immunization[4]. Some global threats spread by the means of
mosquitoes, parasites and viruses, others by transmitting genetic resistance
and yet others spread by behavior and living conditions. We have never been a more
connected globe, for better and for worse. We can learn from these tendencies
if we can see these disease outbreaks in context – as not so much isolated
risks we can ‘contain’ but as symptoms of an ever-changing, ever challenged,
system. The interesting point is that global health lessons have always been there – history can teach us how to tackle global
health – but our failure to take existing experience into account has made us
reinvent the global health wheel once a year.
To
understand global health and the potentials for solutions to world health
problems we need to understand the basics of health, health care and decision
making in global health. We also need to understand that major players in
global health, such as social determinants of health, are not taken serious. But
social determinants of health are like a 600 pound gorilla in the room: it
fills out the global health space and it keeps staring at us while we can’t
figure out how and when it is going to attack us. An open mind is useful in
global health where global cognitive short cuts, convenient moral codes, shifting
fashions in politics, vague national security arguments and a million religious
minority interests so far have taken over where common sense, scientific facts
and principles of equity were in fact initially in command. Global health
discussions were open minded and innovative in the years up to the Millenium
Development Goals for 2015 and retained an innovative momentum up to 2008 when
the Global Forum for Health died out. The scene was taken over by large
independent donors, The World Bank and large international NGOs and cross disciplinarity,
equity, innovation and research based interventions vanished from the scene.
The analysis of the abolishment of one of the top 5 killers in low income
countries, user fees, is a painful but necessary example of admitting that
history can help us improve future global health intervention if we test what
we want to do before we introduce it on a global scale [5].
The
diversity and scope of global health is rapidly expanding. From evolving
individualized personalized medicine based on genetics over epigenetics
claiming that a grandmothers birth weight determines the grand children's birth
weight, to an epidemic of female obesity in exploding cities of low income
countries and to deadly epidemics of measles because there is no funding for
that particular vaccine or polio epidemics because religious groups and
minorities in Africa, Asia and Europe, for different reasons, refuse to have
their children vaccinated.
Increased concern
about global health has focused attention on governance questions, and calls
for new governance architecture for global health have appeared. Global health diplomacy is a
relatively new field in global health. Health has emerged as an important
foreign policy issue but has at the same time de-masked that health was
previously deliberately separated from foreign policy – instead health was seen
as something between charity and an international moral necessity. Global
health threats have forced foreign policy makers to re-think how they see
national security threats. Nowhere is this more visible than in the
relationship between public health and national security. Whether discussing
biological terrorism, HIV/AIDS or
pandemic influenza, foreign policy makers and public health experts have
increasingly outlined certain health threats as security challenges. Without
question, the major powers of the international system have driven this process
with their national interests in mind, which worries many of those involved in
protecting and promoting health [6]. Some governments have taken
determined steps to incorporate health as a foreign policy tool. But maybe it’s
the opposite that is happening as Illona Kickbusch noted in 2007: foreign
policy is now being driven substantially by health to protect national
security, free trade and economic advancement [7]. The world of global health
diplomacy is quite dynamic at the moment, with new partners setting trends
while traditional actors are re-configuring their views and practices [8]. A whole range of middle income
countries recently emerged from a low income situation and they have, with
individual backgrounds and different goals, entered the global health scene.
Some of these countries have very recent experiences in receiving foreign aid
and now find themselves on the other side of the table. Some of these countries
(Such as Mexico, Brazil or South Korea) challenge the good old boys around the
table disrupting their “old school” thinking. Furthermore each of the newcomers
have developed their own “middle power” focuses on global health, often filling
some of the huge gaps that the old donor countries have left in global health.
Global health management faces a new
problem, by Fidler called “open-source anarchy.” The forces of open-source
anarchy means that States, NGOs and large donors resist global power structure reforms
that would limit their freedom of action. Gates foundation for example scores very poor on the aid
transparency index 2013 [9]. In this context, what is emerging is not
governance architecture but a normative “source code” that States,
international organizations, and non-State actors apply in addressing global
health problems. The source code’s application reveals deficiencies in national
public health governance capabilities, deficiencies that are difficult to
address in conditions of open-source anarchy. Governance initiatives on global
health are therefore disclosed as weak, powerless and vulnerable [10]. The
Unwillingly
we have introduced inequity in global health because one of the key elements is
to work for equal global access to new research and technologies. By doing this
instead of focusing on what is really needed we have forced low income
countries without resources for scientific evaluation to expand the topics they
have to deal with instead of assisting in solving the topics they are already
struggling with.
Furthermore
a range of the interventions that high income countries, often for selfish
reasons, have imposed on LIC have had serious long term repercussions. User
fees, immunization campaigns with no - or harmful effects, decentralization,
withdrawing funding for health care and replacing it with administrative
funding all have had unexpected and disrupting long term effects[11]. Now international donors have
drawn the carpet under many health programs by suddenly defining circumcision
of men or HPV vaccination of girls as the new large scale interventions
together while at the same time only 40 % of HIV positives in LIC cities are on
anti-retroviral therapy for their HIV infection (nobody wants data from
non-urban areas) and condoms are never to be found in the right place at the
right time, even though the condom was invented in 1564 over 400 years ago [12]. The narrow and exclusive focus on
investments in Primary Health Care in LIC from 1980 has left complete health
care systems without functional referral levels above health centers because of
a chronically underfinanced hence collapsed hospital sector and has left the
bill to be paid by the poorest patients in most need of public hospital care [13]. So now the international community
is forced to invest in hospitals that essentially aren’t really functional hospitals
anymore– but we, the high income countries – actually created that problem ourselves
[14]. An often ignored historic fact is
that the HIV epidemic spread most rapidly in the 1990s when Africa suffered an
economic decline, when the health care services were falling apart (partly due
to Structural Adjustment Programs of the World Bank) and when attention by
health officials was on other health priorities such as Unicef’s Extended
Program of Immunization (EPI).
During the
past decade, the explosion in global health activities by governments,
international institutions, multinational corporations and nongovernmental
organizations is extraordinary and shows the conversion of health as a national
and global political struggle [15]. Commentators have, however, begun
to warn of the adverse implications of so many players engaging in so many
health efforts in so many parts of the world. All this activity is producing
what can be called two tragedies of the global health commons. This dynamic is
producing a global health version of the "tragedy of the commons" as
actors' rational, self-interested calculations generate over-exploitation of
the global health commons[16]. Critical parts of the global
health commons, particularly developing and least-developed countries, cannot
adequately support the ongoing proliferation of activities, which tend to
fragment already fragile local and national capacities for public health and
health care.
But the
global health commons experiences as well the tragedy of under-exploitation.
Critical health issues such as women's health, the global spread of non-communicable
diseases and the building of broad-based local and national public health
capacities, receive insufficient attention and suffer from the fragmentation of
public health and health-care systems caused by proliferating yet uncoordinated
public and private health initiatives. In fact WHO in a report from 2013 WHO
highlighted violence against women as a ‘global health problem of epidemic
proportions’ – yet no global measures to control the epidemic were launched.
Examples of other unsolved controversies and disputes in global health are:
·
Falsified,
Substandard and Counterfeit Medicines: Public health or intellectual property
rights issues? Counterfeit, falsified and substandard medicines pose a
considerable threat to health security. They can fail to cure, promote
antimicrobial resistance or cause injury and death. The threat posed by such
medicines is growing, particularly in poorer countries with weak regulatory
mechanisms and poorly monitored distribution networks. Poor patients in
developing countries, who usually have to procure medicines with their own
resources, are particularly vulnerable.
·
Corruption
in health care is a serious threat to health governance, undermining quality
and availability of services, especially for the poor. Although no country is
immune, citizens in poorer countries are more likely to experience corruption
when they interact with public officials, and the effects of corruption on
their health and welfare are exacerbated.
·
With
more than a billion smokers worldwide, tobacco is mankind’s most widespread
serious health hazard, and among its most contagious. It is therefore quite
naturally that the tobacco industry is often compared to an infectious disease
vector. The tobacco industries manipulate scientific evidence on the risks of
tobacco and undermine research findings
·
Controversies
in migration and international health. There are over 12 million undocumented
migrants in the world. Their right to human rights is challenged and their
access to health care has been hampered by failure to accept their existence
while at the same time countries depend on their labour.
·
Food
companies have contributed to the development of a food system that now
provides adequate and safe food to billions of people worldwide. However
nutrition crises related to over- and under- nutrition and exploding food
prices remain common and urbanization is closely related to changes in eating
patterns and physical activity.
·
Uncontrolled
and rapid urbanization creates breeding grounds for poverty, diseases of
poverty, break down of public administration, lack of schools and sanitation,
human insecurity and rapid increases in non-communicable diseases. This was not
a development that started yesterday but decision makers have failed to
monitor, accept and act on the epidemic of urbanization.
·
Humanitarian
Action- Security and Military intervention: Humanitarian interventions are
increasingly politicized and militarized. The deteriorated security situation
for humanitarian workers in many crisis zones, as well as the political
discussions about terrorism and counter terrorism strategies developed after
9/11 (the Global War on Terror), have led to increasing militarization of many
humanitarian fields. Militarization of aid as well as counter-terrorist
interventions backed with humanitarian activities in order to win the “hearts
and minds” of the population has contributed to blurring the lines between
combatants and non-combatants. These developments have had considerable impact
on the ability of humanitarian organizations to genuinely provide aid to
populations in dire need, within a strictly humanitarian assistance framework.
In addition, aid recipients’ perception of humanitarian actors has been
affected.
·
Single
disease funding. General Health System Management in the Context of PEPFAR and
the Global Fund Overview: Alignment/coordination of resource flows to maintain
efficiency and support for PHC services. Major investments being made through
international grant making mechanisms such as PEPFAR, PMI, GFATM, GAVI that, in
some circumstances, can create distortions and coordination problems in
managing human and material resource flows to assure broad access to an
integrated package of health services. If half of a financial resource flow for
health in a country is focused on HIV/AIDS, how can the policy leaders assure
that the whole health system is re-inforced. Plenty of global health experts
think that fighting a single disease is inefficient. It doesn’t build the
capacity of the health system as a whole, and it can distort the entire health
sector. Health care providers and services are pulled into the area where there
is money. If all your doctors are treating tuberculosis, who takes care of the
children with pneumonia?
So to
re-invent global health we have to re-analyze and learn from global history:
|
OBSERVATION
|
CONSEQUENCES and IMPLICATIONS
|
|
Getting history
right
|
|
|
Global health
interventions are never really tested yet introduced at global level with
unexpected and uncontrolled health effects
|
The following is
examples of interventions with geographically limited or no evidence before
introduction: decentralization and privatization of health care, user fees,
childhood immunizations, male circumcision, Vertical ARV programs and their
vulnerable funding structure
|
|
Governments,
ministries, organizations have no memory and don’t collect experience
systematically
|
The very
organization that introduced and forced user fees to be introduced in LIC was
the organization to take credit for “saving” LIC from the effects of user fees
by introducing a new program to replace it: “Universal health coverage”. This
program still hasn’t demonstrated that I can increase equity while user fees
have now become a “right” for health workers and way of supplementing their
often missing salary payments
|
|
Diseases and health
problems lose their international X-factor regardless of importance. Some
interventions are just too boring and simple
|
Diseases like
diarrhea and measles their solutions (soap and immunization) are tedious and
have been around for so long that politicians think they are almost
eradicated. Traffic accidents, among the top 5 causes of death worldwide has no
sex appeal and no attraction in terms of a solution.
|
|
Global health does
not exist in a vacuum
|
It was not science
alone that discouraged smoking by providing evidence for the risk of lung
cancer. It took over 7,000 studies, all showing the same association, and 20
years of time, before decision makers in health dared to say in public that
smoking causes cancer.
|
|
Getting the picture
right
|
|
|
Issues of wealthy
NGOs, ethics, gender, religion, national security and environmental issues
are heard through established institutions, boards and lobby organizations.
But issues regarding
equity and transparent and sensible agendas for research have no voice. Research
priorities and how to secure that good research is implemented into practice
has no interest organization behind it any longer.
|
The global health
agenda is biased towards the agendas of wealthy and powerful organizations
that do not necessarily feel obliged to follow needs of recipient countries
or to listen to scientific evidence. They are not part of a global policy
process but define their own goals and means.
Decisions regarding
child health are made on what funders want to fund, not what really works or
what is needed. Polio immunization is a donor darling while measles
immunization, treatment of diarrhea and pneumonia is not.
Individual or
minority human health security is not defended.
Research in health
disparities interventions tends to be oriented towards the individual and how
social determinants and behavioral factors affect the individual. In fact
this has spilled over into intervention research where a recent review of 30
years of health disparities research found that 90.5 % of all research has
been focused on patient interventions or interventions aimed at the patient’s
community. Only 9 % of research was aimed at changing the organization of the
health care sector to a more equity based focus or at increasing equity
competencies among health care professionals [17].
Favouritism in
health care, unofficial user fees, fake drugs and corruption, educational
disparity in care are poverty boosters that reinforce the effects of being
poor [5, 18, 19]. The clinical outcome of
tuberculosis treatment depends on social determinants via lower quality of
care [20].
|
|
The blind spots in
global health
|
|
|
Some diseases and
their interventions suffer from “donor fatigue” in spite of their continuing
deadly effects on child survival.
“Cooperative
countries” get more funding – other countries are termed “fragile states”.
Innovation is
increasingly being interpreted as “technological fixes”.
Problems that are
not easily solved are not subject to global health interest. Some problems
are simply regarded as too big for global health – or realistically beyond
the reach of global control.
|
What is funded
changes on a yearly basis with new policies, new governments and new
fashions. Recipient countries are defenseless – if they don’t comply they
don’t get funding or risk depending on compassion, charity or funding for national
security reasons instead of for health problems.
Research funding has
shifted from competence development of health workers to ehealth and mhealth
technology. Technology doesn’t solve the problems in lacking skills and
increasing inequity.
If migrants around
the world lived in the same country they would be the 5th largest
country in the world, yet the fact that migrant populations are vulnerable
populations has not led to a global health focus on this immense challenge.
Traffic injuries are
a result of an activity that is regarded as the ultimate individual freedom,
hence a right that ranks above global public health.
Being born female is
dangerous to your health and is more dangerous than being a soldier at war [21].
International
tourism has exploded leaving international health authorities with their
hands tied. Not only does it lead to import of tropical diseases to high
income countries it also poses a health threat to communities in low income
countries through tourist importing news diseases to rural areas[22].
|
|
Getting the
proportions right
|
|
|
Reality check: The
global health reality is drawn by media, decision makers and donors but does
not always match what researchers and the most vulnerable population groups
see.
|
Social media shows
social networks we couldn’t see before: happiness, overweight, smoking and
risk behavior spreads in ways we would never have imagined and further in
networks than expected.
Loneliness is just
as dangerous as smoking 30 cigarettes a day.
Children in LIC
continue to die from simple preventable and treatable infectious diseases.
91 % of worldwide
traffic deaths occur in LIC and constitute the most prevalent cause of death
in ages 15-29 years. Half of them are pedestrians and bicyclers.
100 mio people
globally fall into extreme irreversible poverty because of illness related
expenses imposed on them by doctors and the health care system.
|
|
Getting the counting
right
|
|
|
It is not a human
right to be counted or to be counted right. It is not a right to have access
to research results or that they are put into practice
|
Population groups
with low literacy, low numeracy or health literacy are routinely excluded
from investigations and research. Hence, they are neither made part of the
challenge or the solution to the challenge.
Though interventions
tend to be most effective among the poorest and with less school education
most interventions tend to be based on less poor and more educated.
Poor population
groups have no voice in global health and are targeted by interventions aimed
at groups that have very little benefit from them.
|
|
Understanding the mechanics
of social determinants
|
|
|
We have virtually no
understanding of-, or research in, the mechanisms by which social
determinants and school education affects health and disease.
|
Recent research has
demonstrated that poverty does bad things to your brain: you are less
competent in decision making and combining information because the brain is
occupied with worries and distress that occupies cognitive resources.
Poor people are not
just sick because they are poor but because they are 5 times more likely to
live in unhealthy and deprived areas. They are five times more likely to be
subjected to unofficial fees before treatment. Because of inherent
differences in interaction, poor people are sick because health care has less
effect among the poorest patients than among less poor.
School education
makes patients walk longer for help, makes them ask more questions,
compliance is increased and they recover more quickly.
|
Solutions & recommendations
A problem
cannot be solved by the same mindset that created it. We therefore need to
establish an international body that independently can defend existing sound
pro-poor health interventions and be given mandate to reject new interventions
until they have provided an evidence base.
The
international agency should:
·
Record,
and promote use of, evidence and experience in global health including
historical observations
·
Monitor
and promote research into practice and protect simple good interventions from
shifting fashions in global health
·
Protect
the most vulnerable population groups from random unpredictable effects of
moods, morals and money
·
Evaluate
and comment on equity issues in existing or new global health interventions
·
Work
under the idea that: Ideas don’t have rights – people do.
Furthermore
it is recommended that:
·
Research
should focus on mechanics of social determinants and school education
·
Investments
in education to improve empowerment and health behaviour
·
Investment
in poverty reduction to improve health decision making among the poorest and
protect against iatrogenic poverty
·
Research
on research: how to get the best and most interesting research questions funded
and how results are best translated into policy and practice
Conclusions
Global
health should be studied the same way we study peacekeeping, global governance
and defense management. Pandemic flu won the First World War – there were too
many unplanned casualties following the attack from an unexpected enemy for
which no sides of the war had effective defense mechanisms. Health has always
been a part of “high politics” – but while the flu didn’t get much attention
for its role in the First World War, HIV, SARS and the recent flu pandemics
have wiped away any doubts about the importance of global health in shaping
foreign policy, international relations and human security. International
relations have been invaded by a range of health subjects that previously were
blind spots: globalization, human rights, social determinants, social media, migration
and international law. Women live lives more dangerous than soldiers at war
just because they give birth, every year 200 million people end in extreme
poverty because of catastrophic health expenditure for their illness, every day
4,500 children die from simple and preventable diseases such as diarrhea while
sanitation still receives less than 0,5 % of what is spent on aid in low income
countries. All of these deaths and suffering are the result of local and
international political decisions. Decisions made contrary to what history has
learnt us and contrary to what science tells us. Most people will agree that
health is a human right is vital to good politics and human security, yet
States have consistently refused or ignored to include health on the list of
basic rights. An open world has been created by globalization and social media,
but politicians and large international donors need to open their minds to the history
and science of global health. The 186 years from Smallpox immunization was
discovered until the disease was eradicated, is a lesson in global health:
science, as health, does not exist in a vacuum and depends deeply on brave
sensible politics based on facts and historical evidence. Today we can control
a car driving around on Mars and drones can deliver ordered books directly to
you within an hour – why is it then that hand washing, sanitation,
maternal-child health and respect for history and scientific evidence is so
difficult? Maybe we have complicated matters by allowing global health to be defined
and governed by a chaotic group of private donors, large funds and NGOs without
regard to what human beings really need to be able to live a normal healthy
life. Most states, even when committed to health as a foreign policy goal,
still make decisions primarily on the basis of the ‘high politics’ of national
security and economic material interests. Development, human rights and
ethical/moral arguments for global health support, the traditional ‘low politics’
of foreign policy, are present in dialogue but do not appear to control
practice. While political drive for health as a foreign policy goal persists,
the framing of this goal remains a disputed issue. Narrow minds in an open
world are what prevent global health from releasing its full potential among
the poorest populations of the world. Homer Simpson shows us just how
embarrassing our narrow minds are: “How
come you guys can go to the moon but you can't make my shoes smell good?” Maybe
it is not so difficult after all if we start with the smelly feet problems instead
of looking for a fix behind the moon? Condoms were invented in 1564 but still
fail to be in the right place at the right time. Global health in an open world
requires an open mind….and brave sensible politicians dealing with earthly
matters.
References
