health

It can be argued that to have good health is far more important than being rich, being acclaimed as a sport or film superstar, enjoying a happy family life or having an interesting, exciting and well paid job. Health determines what you can achieve in life, where you can go, your state of mind and your ability to make your own decisions. Good health, then, is vital if people are to make the most of their lives.

The health of people in North America and Europe advanced immeasurably around 120 years ago with piped water coming on tap, improved sanitation and better nutritional levels. Complementing these advances were the increase in the number of doctors/nurses being trained, more advanced operations being performed and new discoveries in medicines, all of which helped push life expectancies ever higher. Then the gradual introduction of health insurance and/or free national health services ensured that health care was available to everyone from the cradle to the grave 24/7. And today, in the rich countries of the North, it seems, scientists continue to conquer new frontiers in medicine allowing surgeons to perform more intricate operations and doctors to prescribe new and better drugs for patients. Nurses, who are mostly caring, then look after patients until they are ready to go home or move in with family or into a residential care centre. Today, in rich countries, 10% of the workforce can be found in health and social care.

In stark contrast, in countries in the South, with little money available and few trained doctors and nurses, most governments struggle to provide even basic healthcare. Poor as these countries are, increased pressure falls on their health services due to the effects of people drinking dirty water and lack of hygiene. It is estimated that 60% of hospital beds in Africa are occupied by patients with water-borne diseases such as dysentery, diarrhoea, cholera and typhoid. Danger to health also lurks in the developing world through poor sanitation and the open sewers running down the streets in shanty towns.

It is in the South then where the fiercest battles against disease are waged daily. But here, the fight for better health is often undermined when doctors and nurses, once trained, opt to leave their homeland to seek better opportunities with higher pay overseas. This aggravates an already dreadful health situation found in many developing countries where sometimes only 1 in 3 people have access to hospitals and medical centres. And even for these 'lucky ones', drugs, if there are any, are too expensive. As a result, modern advances in medicines and treatments are beyond their reach leaving the door open for diseases of epidemic proportions like HIV/AIDS and malaria, and, more recently in West Africa, ebola to run rampant. Locally this often means the decimation of entire populations leaving children orphaned, industries depleted of skilled workers and average life expectancy spiralling downwards.

Just one story exemplifies the frailty of life in poor nations.

In a small town in Zambia, a mother brought her two children to the doctor - one was three years old, the other thirteen. Both were very sick. The doctor prescribed medicine for each of them. She thanked him and left. When he saw her again, some time later, he asked her how the children were and she told him that the younger one had died. She explained that, as she did not have enough money to pay for treatment for both children, with much pain, she decided to pay for the older child’s medicine. He got better quickly but the family had to watch, heartbroken, as the younger child died.

In the North a similar situation would provoke utter outrage leading to a government enquiry.... but in the South it is just an everyday occurrence.

One look at the comparable figures on health from countries in the North and South underlines this yawning gap in the provision of healthcare.

The '2018 Mo Ibrahim Forum Report: Public service in Africa' calculates that only three African countries; Libya, Mauritius and Tunisia, have at least one doctor per 1,000 people. And it is with such poor health infrastructure that countries in the South also have to confront pollution, the largest environmental threat to human health, responsible for 8.3m premature deaths, or 15% of all deaths globally. (Pollution kills three times as many people a year as Malaria, TB and HIV/AIDS combined.)

Exacerbated by climate change, according to Global Alliance on Health and Pollution (GAHP), the world faces serious risks from pollution. The top ten nations with the most pollution deaths include both the world's largest and wealthiest countries, and some of its poorer ones. However, deaths from pollution in relation to population size sees Chad, with 287 deaths per 100,000 people, top the world list. In second place is Central African Republic (251) followed by Noth Korea (202), Niger (192) and Madagascar (183). This outcome may come as a surprise to many people but the reason poor countries suffer so fundamentally from pollution is because of poor sanitation and contaminated indoor air.

Then there are the world's other major killer diseases:

MALARIA is a life threatening parasitic disease transmitted by mosquitos which is endemic in more than 100 countries. It is the world's oldest disease and today half the world's population is still at risk from malaria. In 2018 it was estimated that there were 220m cases worldwide resulting in 435,000 deaths, 350.000 of which were children. However, the good news is that mortality rates for malaria have dropped by 60% globally since 2000 although in the last three years there seems to have been a levelling off. One of the reasons for this is that the mosquito and the malaria parasite are developing resistance to the interventions used to fight them.

92% of the malaria cases occur in Africa mostly among young children resulting in malaria being responsible for 1 in 3 hospital admissions there. A child in Africa has, on average, between 1.5 and 5.5 episodes of malarial fever every year. In Africa malaria kills a child every 2 minutes and is the leading cause of under-5 mortality there. Countries with the most cases of malaria in sub-Saharan Africa are Burkina Faso, Cameroon, DRC, Ghana, Mali, Mozambique, Niger, Nigeria, Tanzania and Uganda. (Contrastingly, in May 2019, Algeria was declared malaria-free by WHO and joins Lesotho, Mauritius and Seychelles in a small list of African countries where malaria has been conquered.)

Vector control is the main way to prevent and reduce malaria transmission. Two forms of vector control are effective in a wide range of circumstances: insecticide-treated mosquito nets (ITNs) and indoor residual spraying. Over the last 15 years, there has been a major increase in coverage of ITNs in sub-Saharan Africa. By 2017, half of the population had access to an ITN, compared to less than 2% in 2000. In 2017 120 million people globally were protected by indoor residual spraying, including 50 million in Africa. About 6% of the population at risk of malaria in Africa live in households protected by indoor residual spraying.

After years of research, the first ever malaria vaccine has just been developed by GlaxoSmithKline. Here trials have indicated a halving of malaria cases in young children and a reduction of about a quarter in cases of infants. And now European drugs regulators have recommended it should be licensed so the company will now start roll out the vaccine selling it at just a fraction over cost price with the promise to invest any profits into further tropical disease research. But more recently the jury seems still to be out here because of low efficacy. However, a combination of bednets and insecticide spraying should help to keep reducing dramatically the number of malaria cases as long as funding can be guaranteed. Malaria makes people feverish and unable to work and many of those who survive an attack can suffer from brain damage. In economic terms it is estimated that malaria costs Africa $12bn (£9bn) or 1.3% GNI annually in lost productivity. This tragic disease has been responsible for more deaths throughout history than any other but now it may at last start to be brought under control.

Just recently, in June 2019, the fight against malaria was given a further boost after scientists, in a trial in Burkina Faso, made a genetically modified fungus containing spider venom and discovered that it wiped out disease-carrying mosquitos within days.

TUBERCULOSIS (TB) is a contagious disease and like the common cold it spreads through the air. It is a disease of poverty affecting mostly young adults in their most productive years. The vast majority of deaths are in the developing world where only 1 in 4 sufferers from the disease has access to effective medical treatment. The latest figures from WHO show that the number of people falling ill with TB in 2018 was estimated at 10 million with 1.5 million dying from the disease including 250,000 with HIV. This is down from a peak of 1.8 million in 2003. It is estimated by WHO that effective diagnosis and treatment of TB saved an estimated 58 million lives between 2000 and 2018. Left untreated each TB sufferer will infect on average 10 -15 people each year. TB drugs have been around for more than 3 decades and cost as little as $10 (£7.50) for a 6 - 8 month course of treatment. However, even at this price, many sufferers in the developing world cannot afford drugs and without treatment 70% of them will die. Ending the TB epidemic by 2030 is among the health targets of the newly adopted UN Sustainable Development Goals.

HIV/AIDS - Since being discovered in 1981, it is estimated AIDS has infected 74.9m people killing 32m and in sub-Saharan Africa it has become a pandemic comparable to the Black Death in Europe in the 14th century. The United Nations Aids Agency has recently revised down the number of people suffering from AIDS around the world from a previously estimated 39.5m to 37.9m. The number of new infections is also down to an estimated 1.7m in 2018 from 3.2m in 1997. Of this latest total of 37.9m sufferers, 26.3m of them live in sub-Saharan Africa where an estimated 660,000 people died from the disease in 2018 out of a world wide total of 770,000. However, in sub-Saharan Africa, the number of AIDS-related deaths in 2018 was 55% lower than in 2005. There AIDS still results in more deaths than any other infectious disease and is depriving some of the poorest countries of their most economically productive workforce. For example, at its height, in countries like Botswana, Zambia and Zimbabwe there were large numbers of teachers with AIDS who were dying faster than they could be replaced. South Africa still has the largest number of people (7.7m) living with AIDS whilst Eswatini has the highest rate of HIV infection in the world with 27.3% of the population infected, just ahead of Lesotho with 25%. However, thanks to organisations like the Global Fund, about 60% of all those needing treatment are now receiving it. And according to the World Health Organisation (WHO) the world is poised to end the AIDS epidemic by 2030 - provided it can accelerate the pace of progress achieved globally over the past 12 years. But here it will depend not only in maintaining current annual funding of US$22bn (£16.5bn) but increasing this figure to US$30bn (£22.5bn) by 2020. A way to go then but already much has been achieved - and in 2015 the Millennium Development Goal that called for the halting and reversing the spread of HIV on a global basis was met.

Almost everywhere you look in sub-Saharan Africa AIDS has wreaked a terrible toll resulting in 1 in 10 children being orphaned and left to be looked after by grandparents - if they were still alive. Otherwise the eldest child has had to become the breadwinner sacrificing his/her own future to bring up brothers and sisters many of whom will themselves have AIDS. And as orphans these children will undoubtedly have a high risk of malnutrition, suffer from the stress of seeing their parents die and probably never see a school classroom.

Most countries in sub-Saharan Africa have been slow to address the problem of AIDS mainly because of the lack of finance, government commitment and a fragmented health service. But a notable exception to this rule has been Uganda whose government was quick to move into action and as a result the infection rate there has now fallen from 30% in 1990 to just 6%.

When it came to tackling prevention the Ugandan government used a combination a massive advertising through the media trying to alert youngsters of the dangers of unprotected sex and by the use of posters. The ABC approach - Abstain, Be faithful and use a Condom - was the favoured method. At the same time health services in poor countries are also starting to screen blood before transfusion so that patients do not become infected in that way.

In 2002, the UN launched the Global Fund to Fight AIDS, TB and Malaria. Supported by OECD countries and international charities including the Bill and Melinda Gates Foundation, the Global Fund has become one of the most powerful tools in the fight against AIDS, TB and malaria. As at 30 June, 2018 the Fund has financed more than 1,050 programmes in 150 countries saving an estimated 32 million lives and turned the tide against these terrible diseases: new HIV infections have been cut by 20%, malaria deaths in Africa are down by one third and TB deaths worldwide have fallen by more than 40%. In raw figures, in 2018, the Global Fund was providing HIV treatment for more than 18.9 million people, up from 5.3 million in 2013; 5.3 million people were being treated for TB and the Fund distributed 131 million bednets to prevent malaria. (Studies have found that if a person living with HIV is receiving anti retroviral therapy the risk of transmitting the virus to their sexual partner is reduced by up to 96%.) The battle against these diseases then is slowly starting to be won thanks mainly to the Global Fund and the huge reduction in the cost of AIDS drugs where annual treatment costs are down from US$20,000 15 years ago to as little as US$200 today.

Governments in developed countries should also use this opportune moment to go further in helping poor countries in the South combat disease. At present only 10% of global health research addresses 90% of global disease problems as there is little incentive for pharmaceutical companies to fund development into finding a cure for diseases found mainly in the third world as people there would not be able to afford the drugs. Governments in rich countries, then, should offer to fund research into not just AIDS but all tropical diseases like malaria, dengue fever, ebola etc. on the basis of richly rewarding success - and paying nothing for failure. This should fuel massive research and when success comes it would dramatically change the health landscape in the developing world. Now that would not only be globalisation at its best, it would be one of the best investments ever made on the globe. [On average, the time taken to develop a new drug from scratch takes 14 years and costs an estimated US$1.2bn (£0.9bn)].

Finally it would help third world nations enormously in developing their own health services if OECD countries refused to poach doctors and nurses trained there. In a recent 'Lancet' investigation in Africa it was found that:-

- 23,000 doctors and nurses leave Africa every year. Only 50 of the 600 doctors trained in Zambia in the last few years are still in that country and there are more Ethiopian doctors in the US than there are in Ethiopia

- out of every 4 nurses who complete their training in Malawi: 1 migrates, 1 takes a better paid job in another sector, 1 dies of AIDS and only 1 remains in nursing in the country.

These are ludicrous health statistics on medical personnel from the world's most blighted continent and represent an appalling loss of talent to those impoverished countries.

Rich countries, then, should not only stop encouraging doctors and nurses trained in Africa from coming to work over here they should move to reverse the process altogether by offering to train doctors and nurses from the developing world on the understanding they return to their own countries. Then even more progress can be made towards the ideal of one day decent medical services being made available to everyone in every country in Africa.

A report 'corruption in healthcare' produced by Transparency International in March 2019 found that 'corruption has a devastating impact on health systems and is responsible for the deaths of around 140,000 children every year holding back the fight against some of the world's deadliest diseases. While WHO estimates that an extra US$370bn per year would be enough to give everyone on the planet access to healthcare, experts warn that over US$500bn in health resources are lost annually to corruption.' The report documents how 'widespread bribe-taking, theft of medical supplies, absenteeism and other abuses prevent patients from getting the care they need, fuel antimicrobial resistance, and contribute to the spread of HIV/AIDS.'

Then there is EBOLA which was discovered in 1976 when there were 2 deadly outbreaks of the disease. One was in a village near Ebola in the Democratic Republic of Congo (DRC) and hence its name. Ebola is a virus that initially causes sudden fever, intense weakness, muscle pain and a sore throat. It then progresses to vomiting, diarrhoea and both internal and external bleeding. People are infected when they have direct contact through broken skin, or the mouth and nose, with the blood, vomit, faeces or bodily fluids of someone with the disease. Patients tend to die from dehydration and multiple organ failure.

The latest occurrence of Ebola was in three provinces of the DRC - in July 2018 - and was immediately declared a 'public health emergency of international concern' by the World Health Organisation. This outbreak was the second largest on record and has so far infected more than 3,400 people leaving more than 2,200 dead. 15 million people live in the three affected provinces. The worst ever outbreak occurred in west Africa killing more than 11,000 people between 2014-16.

There is a vaccine that is considered to be 99% effective but it is in short supply. Merck, the US pharmaceutical company, says that there is only 1.5 million doses of the vaccine available but is working hard to produce more. A trial of 2 new drugs also show encouraging signs with 90% of the patients who received them responding positively.

(Amazingly, according to WHO, life expectancy in Africa has risen from 40 years in 1960, 50 years in 1990 to 60 years in 2016 due to more child vaccinations, malaria control and better HIV treatment.)

[UK - In a report published in January 2016 it was disclosed that there are more than 4 million diabetics in Britain and that 2 out of 3 adults weigh too much. The UK spends £6bn per annum on the medical costs of obesity and a further £10bn on dealing with diabetes. UK ministers are currently considering taxing sugary drinks as an effective way to discourage unhealthy diets. But the British government should consider going further by encouraging people to exercise more. It is ludicrous, for example, that the average car journey in the UK is only 8 miles with 25% of these being of less than 1 mile.]

[UK - bed-blocking in hospitals. It is regrettable that elderly patients who have finished their treatment cannot be discharged because they are unable to look after themselves at home. No parent would ever leave a child in hospital and no children should ever leave a parent in hospital either. Most parents spend 24/7 endless hours, particularly in the first few years, looking after and entertaining each and every child and, in return, children surely have an obligation to their parents to do the same when they get old and infirm and cannot look after themselves. There is also no doubt that old people would survive and thrive much better in the family home environment. And, after all, that is how family life spun out all through history.]

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