NCDs, UHC, and MDGs

Universal health coverage has received a great deal of attention in the past few decades, arguably due to the rise of non-communicable diseases. As Maher and Sridhar point out, NCDs are no longer limited to wealthy populations; they have infiltrated previously unaffected portions of society and are rooted in social determinants of health. The insidious nature of NCDs complicates the fight against them; the effects of NCDs are not immediately observable, and are thus easily left untreated. Furthermore, the fact that ailments such as diabetes, heart disease, and obesity are wreaking havoc on impoverished populations poses another issue: many of the plagued individuals do not have access, or cannot afford to buy access, to the health care necessary for treatment.

                Not surprisingly, there has been a call for universal health coverage to combat this issue. Unfortunately, there has been limited success in mobilizing policy-makers and donors to allocate time and resources to NCDs. Millennium Development Goals, in this vein, have been unsuccessful, and indicative of the first world powers from which they originate. As long as wealthy nations have control within global organizations such as the WHO and IMF, NCDs will continue to fall to the wayside. Wealthy countries have dealt with such afflictions for years- the only difference being that for the most part, citizens of such nations can more easily afford individual treatment.

                Additionally obfuscating the plight against health disparity, rising NCDs, and health inequality and inequity is the simple fact that policy-makers have failed to construct clear guidelines for action. UHC is especially emblematic of this; the term universal technically means that there is a legal obligation of the state to provide health care to all its citizens. However, this definition does little to clarify what standard of health care this entails, or under which conditions. It also ignores individuals not belonging to a state, such as refugees. The MDGs are responsible for this confusion- according to O’Connell et al, the MDGs focused too much on national aggregates of health disparities, and this emphasis masked inequality. All in all, the MDGs are an extension of the United Nation’s failures; smaller states are ignored, and larger entities are put on a pedestal. As long as countries such as the US and other western powers are symbolically in control of the UN and other trans-lateral bodies, NCDs will continue to spread at an infectious rate, and health disparities will follow in suit with the rising wealth discrepancies that are observable globally.

Non-Communicable Diseases and the MDG agenda

Non-communicable diseases, such as cancer, diabetes, cardiovascular disease and mental illness, are on the rise. Three out of five deaths worldwide are cause by non-communicable diseases, and yet only three percent of the global public health budget is being spent on assistance for low and middle-income countries. 

As a rule as the rates of infectious disease decrease, the rates of non-communicable diseases rise. This phenomenon is being observed all over the world, but particularly in nations with historically high burdens of infectious diseases. As we get better at treating diseases like lower respiratory infections and cholera rates for diseases such as cardiovascular disease and cancer have risen.

People are living longer and comparatively healthier lives, but with increased life expectancy come a higher risk for developing non-communicable diseases. There is an adage, at least in the biological sciences, which states that if you live long enough you will get cancer. It is the inevitable result of the years and years of the genetic replication that occurs in the body. But in reality most people develop cancers because of factors outside of age, most of which are self-imposed. This can be said of most non-communicable diseases, which are generally associated with lifestyle choices: factors like high-blood pressure and smoking are the leading risk factors for lost DALYs worldwide. These risk factors have become increasingly prevalent in poverty stricken nations: indeed there is a general consensus that Africa is facing a ‘smoking epidemic’ in the next 12 years.

And yet most people do not think of sub-Saharan Africa when they think of lung-cancer and heart disease. These are diseases of the rich and fat nations, and the notion that these diseases are on the rise in poverty stricken countries does not fit will with the images of theses regions that have been fed to us for so long. Unfortunately the prevalence of these diseases is rising at a staggering rate, not helped by the poverty, lack of strong health systems and legal or political will power to make a difference in the countries that are facing the rising tide of non-communicable diseases.

We most re-evaluate the way the non-communicable diseases are being perceived, and attempt to combat the rising risk these diseases pose to global health. With the upcoming evaluation and re-assessment of the millennium development goals, there should be a push towards preventing these diseases, as we will only see a continued rise in their rates over the next decade.

Acronyms to Save the World

As the reality of 2015, and the deadline for Millennium Development Goals (MDGs) gets closer and closer, it’s time for those proponents of global development to evaluate the changes seen under the MDG era and start thinking towards the future towards new goals and strategies.

The general consensus as far as the effectiveness of the MDGs is- and get ready for it to be vague- that we still have a lot of work to be done. Criticisms, of course, vary, and some critics looking towards 2015 are focused on the strategies used to meet goals for the purposes of improvement, while others scrutinize the goals themselves and how they could more accurately represent both universal and country-specific needs post-2015. Still another group chooses to discuss the relevance of having a program liked the MDGs, we’ll return to that later.

The MDGs are a broad set of goals cover an impressive range of social, economic, and biological initiatives that are necessary for lessening inequality and improving lives on a global scale. They require an incredible amount of work to be done on every organizational level imaginable, and incorporate a diverse cross-section of fields. Arguably though, the public health sector both affects and is affected by each of the goals, and it’s no coincidence that the public health community

As discourse progresses on the post-2015 agenda, what role will the global public health community play in setting the agenda?

This is the essential question, and a movement is growing to make Universal Healthcare (UHC) the common standby.

Within that discussion, it has become clear that there is no dearth of precedents for UHC as a global policy. In descriptions of basic human rights employed in a legal sense in many state documents as well as international definitions (see: The U.N. Charter and the Declaration of Universal Human Rights or their citations in many U.N. resolutions and satellite organizations) adequate health and sanitation and access to healthcare services and sanitary resources fall well within the tent of accepted tenants.

However, one issue follows, and that is not whether or not UHC falls within the boundaries of human rights, but rather the question of what falls within the boundaries of UHC.

Global criticism of UHC points out that if the goals of UHC are to improve all around equity of access to healthcare services, there are plenty of precedents for governance and regulatory actions parading under the banner of UHC that fall short of those goals. A common occurrence is UHC models that raise universal quality but fail to address gaps in access among different groups, or models that preserve inequality by relying heavily on the private sector to provide resources and services.

In many circles there is a call for leadership in developing more specific expectations for UHC programs and a tighter framework that aligns goals with methods. Returning to the question of whether or not the MDGs were appropriate, efficient, and successful when it came to making positive strides towards global development, I’m not sure. However, I feel confident that as an internationally recognized program with the strong backing of the U.N., the MDGs have an incredible potential for setting the development, and therefore the global public health, agenda for the post-2015 era. Efforts to set a positive agenda would be best served trying to find a more efficient structure for realizing the MDGs.

Political Committment Issues, Polio, and the Measles Initiative

For the most part, political commitment is a counterintuitive term; the majority of government-backed or state-supported endeavors appear to be fraught with inconsistency and lack of funding. In the health sector, the consequences of this manifest in either failure or incomplete results, which typically high-light the stratified populations of people who receive different forms of intervention and health care due to socioeconomic factors.

                In this way, the Measles Initiative is unique; despite its large-scale character, it was able to bypass the shortcomings of public services and inadequate infrastructure in certain countries. This is due to the MI’s complex coordination and planning, especially in regard to awareness campaigns. Learning from previous failures in the 1970s, the kick start of the Measles Initiative in 2001 made strategic outreach a core focus in its roll-out. The visibility of the endeavor-which was achieved by aggressive campaigning and case-based surveillance- made it impossible to ignore. By beginning initial efforts in stable governments and regions, it was able to achieve a reputation of success that would later make it impossible for insecure governments to ignore.

                This is interesting for many reasons; in global health, there seems to be a theme of grand-scale intervention that inevitably leads to failure. Superficially, it appears that lack of funding, cooperation, and technical deficiencies are the villains responsible for wreaking havoc on theoretically sound plans of intervention. For instance, the Polio Eradication Initiative has been successful across the Americas and Europe, yet the disease remains endemic in countries such as Pakistan. Many health officials point to Pakistan’s crumpled infrastructure as a scapegoat, but perhaps it is more helpful to search for reasons as to why the public health systems in certain governments are so dysfunctional. Clearly, lack of funding reflects a lack of support, but what are the reasons behind governmental resistance, and why do certain campaigns win over the hearts of dictators while others do not?

                The book Chasing Polio in Pakistan by Svea Closser begs this very question, and surmises that the Polio Eradication Initiative is failing in Pakistan due to issues of political commitment. Pakistan fails to comply with WHO and UN requests not only because it feels that the PEI is an extension of Western imperialism, but also because it simply does not regard Polio as a top-priority issue. In Pakistan’s agenda, health problems are already of low-importance, and so they are largely shuffled to the bottom of the government’s to-do list. Assuming that this is correct, what then makes an issue a priority?

In many western nations, priority is divided amongst different sectors and government levels. Political commitment is not necessarily a government promise- it is merely associated with a larger force, but implemented by a division of the system that is entirely dedicated to that cause or mission. Thus, the relation of the PEI and the MI is found in each one’s varying levels of political commitment and strategic approach. The PEI began as a top-down measure; the WHO and UN delivered demands, and countries with the capabilities and resources followed dutifully. This is also the case for the MI, but success has been somewhat more attainable due to the Initiative’s early emphasis on reaching out to strong nations in positions to carry out large health interventions. Health endeavors are inherently political, and like anything else in politics, the reputation of a health program is the ultimate determinate of whether or not it will succeed. By starting with wealthy and capable countries, MI was able to convince the most skeptical of leaders and governments that eradication was possible, whereas the PEI went straight to the most affected countries, which were the least-equipped to deal with the issue.

                Ultimately, failure of public health interventions is in its most literal sense a result of inadequate funding, support, and commitment. Symbolically, however, failure is due to an oversight in recognition on the part of these health initiatives. The PEI did not take into account the political environment of the countries where Polio is endemic; the MI-while not perfect- did notice the correlation between measles and political instability. This acknowledgement allowed MI to strategically plan its roll-out, and success has been much more prevalent as a result.

The Measles (& Rubella) Initiative

In recent years, the field of global health has moved away from disease-specific approaches, like the Measles initiative, as health system approaches are favored.  At the same time, U.S. measles cases are on the rise even in our 92Y neighborhood where a health system is long established and fairly accessible.  Weak health systems prevent measles from being eradicated, so health system strengthening is a crucial long-term goal.  But without organizations with targeted short-term goals, regression in public health outcomes is possible, as evidenced by the reappearance of measles in the U.S.

In a Google search for the Measles Initiative’s website, I was surprised to discover that since the Global Health Delivery’s 2011 Case Study on the Measles Initiative, the organization broadened its name, and mission, to the Measles & Rubella Initiative.  The organization partners with countries to immunize and monitor outbreaks through planning, monitoring, and implementing campaigns.  In its 13-year mission, the M&R Initiative reduced measles deaths by 74% from 2000-2007 and by 78% from 2000-2012.  There are still 122,000 measles deaths annually, and the disease accounts for 4% of all child mortalities.

There is still a gap between today’s 78% reduction and the proposed 90% reduction, or even eradication hoped for by 2010.  There are many challenges associated with eliminating Measles: there is no cure, it is highly contagious, and immunity often requires two vaccinations.  The slow progress achieved by the M&R Initiative is not insignificant in light of these challenges.  The widening of the organization to encompass Rubella appears to be an effort to maintain its crucial role in mitigating these specific diseases, while addressing the larger health care issue of ensuring regular vaccination. 

Cure-alls are a myth

The global response to control the HIV/AIDS epidemic put global health on the map. The global science community, especially in wealthier countries with major research capabilities, tackled the virus head on and new antiretroviral medications were patented by the 1990s and 2000s. The world could rest easy knowing that AIDS cocktails could be distributed to the masses to control the HIV/AIDS epidemic at $10,000-15,000 per patient per year.

The problems with this outcome are numerous, including education, access, and focus. A family of medications has caused a number of problems that go beyond the epidemic itself and bleed into many facets of society.

One of the biggest problems lies in education and distribution knowledge about the HIV virus and what spreads it. The view that HIV is a “gay disease,” that there is a connection between the virus and the queer community continues to this day. Uganda, infamous for its legislation against homosexuality, has closed a US-funded HIV project. The government has cited that the Walter Reed Project “trains youths in homosexuality.” The demonization of certain groups in connection to spreading the disease remains a huge problem around the world, including in nations that seem to have a more “lenient” view. Is all the attention placed on developing new drugs taking away from educational initiatives so people can understand the semantics of the disease?

Intellectual property rights have caused a monopoly by pharmaceutical companies over the secret “recipes” of HIV/AIDS medications. Do private companies have the right to keep the rights to their medications? Medical treatments for HIV/AIDS are subsidized by wealthier countries, where many of these medications originate. The cost is so prohibitive for some medications that generics from countries like India are becoming more and more popular, adding up to $93 billion in trade in the United States alone.

The focus on treating HIV/AIDS is also distracting from other problems that many people in a country face. With the rise of global health, a large percent of donations go specifically to HIV/AIDS treatment. How much money goes to preventive measures, like safe sex education and prophylactics? Is money going to training medical professionals or building more infrastructure?

Medications are an integral part to treating HIV/AIDS, but I also wonder what we’re losing by focusing too heavily on the physical treatment rather than risk factors that affect the spread.

The Wider Implications of Epidemics

Obviously, the first thing that comes to mind when you hear the word "epidemic" is illness.  Hundreds of people sick, many dead, more joining them every day.  But it is also important to keep in mind the wider implications of an epidemic.

When there is an epidemic, particularly one that is proving to be virulent, people stop going out.  No one wants to come into contact with more people than is strictly necessary for survival.  Think about all the people you come into contact to on a daily basis.  A rough estimate of my number from today is 40, and that is just the people I actually saw and interacted with.  We should also consider everyone who touches the self check out unit I used, everyone who sits in the Metro North seat I sneezed on, or touches the bathroom door handle, or sits in the seat I sat in at the Red Hook Diner this morning.  That is a significant number of people and they are all now likely to find themselves waking up in three days with a sore throat and unreasonably itchy nose, all because I traveled from Bard to New York this weekend.  When you really think about how easy it would be for you to come into contact with the carrier of a deadly disease, it becomes easy to see why epidemics have a massive negative drag on economies.

Particularly for countries that depend on tourism for large segments of their economies, epidemics can be crippling.  If no one travels to your country you cannot make money from a tourism sector.  So to do the economies that feed those tourism industries suffer.  If no one is going out to fancy dinners in southern asia, there is going to be a sharp decline in the amount of fish sold from Australia.  this dip in sales then impacts the australian economy, and the effect continues to trickle down.  The interconnected nature of our globalized world means what happens in one country is not confined to its borders, whether that thing be illness or economic stress.

This potential for suffering makes countries that discover epidemics less likely to tell anyone else about them for fear of losing out on foreign economic support, and domestic spending lost to fear of contact with other people.  This is a real problem for the global health community, particularly if they want to build a robust health infrastructure with failsafes to prevent a global pandemic.  We are all going to have to trust each other more, and be willing to support those who are suffering from illness so they will feel safe warning us that the illness exists in the first place.