Abstract
Introduction
The topics examined in this paper – Africa's neglected tropical diseases; HIV/AIDS, malaria and tuberculosis; the non-communicable diseases; mental diseases – extend the illustration of the range and diversity of the challenges that need to be addressed. Sources of past and likely future support for the intra- and international partnerships and coalitions that would be essential for meeting them have been reviewed. The importance of the roles of the publication information media – press, television and media – has been noted. The current and anticipated future roles of the World Health Organization (WHO), the Global Commission on the Social Determinants of Health have been presented. The potential for a future supporting role by the Commonwealth has been noted. The roles of the pharmaceutical industry and others; philanthropic organizations like the GAVI Alliance, the IMF, the World Bank, have been recognized. The paper ends with a review of the three papers that comprise the series and a proposed ‘Action for change’.
Africa's neglected tropical diseases
These include urinary and intestinal schistosomiasis, lymphatic filariasis, onchocerciasis, the soil-transmitted helminth infections (ascariasis, trichuriasis and hookworm infection), African trypanosomiasis, kala-azar, buruli ulcer and blinding trachoma. Up to 90% or more of the world's disease burden from these conditions is believed to occur in Africa. These diseases add significantly to the overall African disease burden. They are not only diseases of poverty; they make significant contributions to it.
We are in agreement with the increasing perception that these disorders are likely to affect as many as those affected by HIV/AIDS and rising rates of non-communicable diseases in Africa and that there is an adequate range of effective drugs and resources available to make their cost-effective control both feasible and practicable. 1
HIV/AIDS, malaria and tuberculosis
The Global Fund has been established specifically to cater for these disorders. The lethal partnership that has been formed between HIV/AIDS and tuberculosis, the increasing drug resistance of tuberculosis and malaria, and the ease with which they can be spread worldwide by international air travel have added new and threatening dimensions to the hazards that these disorders already present individually and collectively to global public health. It is their close linkage which makes it so desirable that their national and international surveillance be carried out simultaneously.
The linkage of HIV/AIDS and poverty to each other also make them inevitably part of the global fight against poverty; and the global HIV/AIDS programme has itself become part of the global fight against discrimination. It was Jonathan Mann, 2 Director of the WHO initial Global Programme on AIDS, who first put the spotlight on the human rights and societal issues against which the HIV/AIDS pandemic was unfolding – pointing out that they were highly specific within each society and yet fundamentally similar around the world.
This is why the fight against HIV/AIDS is not only one of money and medicine, but also a political struggle to extend human rights. Indeed, beyond HIV/AIDS, a new movement linking health and human rights has been catalyzed. This brings a new challenge and a new responsibility for public health – beyond its recognized duty ‘to ensure the conditions in which people can be healthy’. Elie Wiesel, Nobel Peace Laureate, has emphasized that ‘One cannot, one must not, approach public health without looking for its human rights component’. 3
The non-communicable disorders
The challenge presented to the global community by non-communicable disorders is one of its greatest health challenges. Formerly considered to be disorders especially associated with affluence, non-communicable disorders were of particular concern for developed countries. It is their now accelerating rates in developing countries, however, and among the poor in the developed, which has now brought them into special global focus.
One of the most important constraints against success to date, in developed and developing countries alike, in addressing the non-communicable disorders, has been the failure to act on the findings of past decades of research. Another has been failure to appreciate the wide range and complexity of the life conditions, lifestyle and lifestyle-related issues that need to be grappled with, concurrently, if effective strategies for their prevention and control are to be achieved. Their adverse lifestyle influences begin to play their roles long before the consequences to which they give rise – hypertension, coronary heart disease, diabetes, obesity stroke, the consequences of smoking and certain tumours – begin to manifest themselves. It is on these early influences that the preventive effort must be concentrated.
The WHO estimates that non-communicable disorders now account for 59% of the 56.5 million deaths that occur globally every year and almost half (45.9%) of the global burden of disease. 4 They are expected to become the main cause of death and disability in the world by 2020. 5 In 1998, of the total number of deaths attributable to non-communicable disorders, 77% occurred in developing countries and of the disease burden they represent 85% was borne by low- and middle-income countries. 6 They now kill more people worldwide than malaria, AIDS, tuberculosis and several other infectious diseases combined. 5 And, as far as morbidity is concerned, the adverse effects of non-communicable disorders on the quality of life of millions worldwide must also be beyond estimate or measurement.
One of the main purposes of this section of this paper is to show that non-communicable disorders is not an inevitable burden on the world's population, but one about which something positive can be done; that address to it goes beyond doctors; that there is need for intersectoral advocacy and support, for lifestyle interventions and other risk factor control strategies for wide intersectoral, interprofessional and interdisciplinary collaboration and support; for the implementation of new strategies – for reforms of the education of doctors, nurses and other health professionals, for reforms of school education for health and for more supportive partnership roles for the public education media, for greater attention to psychosomatic determinants of them than have been considered essential in the past. The chief merit of the lifestyle and living and working conditions intervention approach is that it shifts the health paradigm from predominant treatment of disease, to prevention, to promoting health and wellbeing.
The international medical community has recognized the latter as among its most critical challenges for the foreseeable future. In introducing the Global Consensus for Social Accountability of Medical Schools 130 organizations and individuals from around the world with responsibility for health education, professional regulation and policy-making stated that ‘just as the beginning of the 20th century presented medical schools with unprecedented challenges to become more scientific, the 21st century presents medical schools with a different set of challenges: improving quality, equity, relevance and effectiveness in healthcare delivery; reducing the mismatch with societal priorities; redefining roles and providing evidence of impact on people's health status’. This was the introduction to a charter which sets out the 10 strategic directions for medical schools to become socially accountable. It is thought to be as important a charted landmark for medical education worldwide as the Flexner report was 100 years ago.
The global epidemic of obesity, itself a risk factor for several other serious health problems, has been reviewed in recent WHO 7 and PAHO 8 reports. In countries as diverse as the Czech Republic, Finland, Germany, Kuwait and Jamaica, at least half the population is overweight and one in five obese. Rates in excess of 50% are found in some island countries of the Western Pacific, over 75% in urban Samoa. High and rising rates have also been reported for Barbados and other islands in the Caribbean. 9–13
And the fact that obesity is associated with diabetes, hypertension, stroke, and other non-communicable disorders has been well demonstrated. 14,15 And important as are national food policies for providing community members with healthy food and dietary choices, responsibility for them cannot be left solely to individual countries or choices – least of all the poor ones, where the need is greatest and the resources essential for solutions are likely least available. This is an issue that, like the Framework Convention for Tobacco Control, calls for the highest level of regional or international decision-making.
There are also certain aspects and examples of non-communicable disorders that call for special attention and also call for special modifications of current preventive and control methods. High on the list has been the recent simultaneous explosive occurrence in many countries of obesity, diabetes and cardiovascular disorders. There are also associations and NCD-linked occurrences which deserve special mention – the accelerated and aggressive marketing of cigarettes in undeveloped countries that have characterized the strategies of the tobacco industry in retreat, the malnutrition to which tobacco usage may be associated when too high a proportion of household income in developing countries is so disposed; high levels of tobacco usage and alcohol intake occur in countries like Russia.
This paper draws on the conclusions and the recommendations of the International Consultation on a Strategy for the Prevention and Control of Non-communicable Disorders held in Barbados in April 2005 16 (one of us, KS, was Chairman). They called for international action on non-communicable disorders in developing countries; for international prioritization of population health; they assigned roles to all sectors of government, all community groups and for all individual members of society. The Caribbean have recently made significant progress in this direction by the creation in 2011 of the Healthy Caribbean Coalition, 17 a network established to combat chronic diseases in the Caribbean.
The September 2011 United Nations Summit on the non-communicable diseases gave the prestige of its name to a global call for action on these disorders and provided opportunities for the setting of national and global targets for their prevention and control. We agree that ‘this summit must be the beginning of genuine whole-of-government action to address these diseases and their coordination at national and international level’. 18
Mental disorders
The mental disorders of black and Afro- Caribbean people, in Britain in particular and in the developing world in general, have been neglected for too long. The 2005 Count me in Census in Britain has found that black African and Caribbean people are three times more likely to be admitted to hospital, up to 44% more likely to be detained under the Mental Health Act and twice as likely to enter mental health services via the criminal justice system as the general population.
A recent WHO report shows that mental health problems account for nearly one-third of the chronic disability affecting the world's population and now comprise five of the top 10 causes of disability. 19 More than 450 million people around the world have mental, neurological or behavioural problems, yet the vast majority lack protection and appropriate treatment. Mental health legislation is missing or outdated in 64% of countries and 30% lack a budget for mental health.
Patel's comprehensive account of mental disorders in the developing world is not only depressing it is an affront to the international community. It is time that action was taken. 20
Review and prospects for collaborative initiatives and funding support
The several issues that call for action against poverty and the diverse modalities of the action that are called for should provide a range of invaluable tools against health inequalities – information and motivation to enable developing country governments and national institutions to recognize and counter them; to collaborate with each other; to make relevant policy decisions in addressing poverty and its related issues; to effectively engage with and influence the decisions and policies of international organizations; to specifically address diseases that are consequences of poverty and those that contribute to it; to place a special focus on population growth, animal husbandry and other critical issues – particularly in poorer countries where their effects would be mostly felt; in effect, to address the causes of poverty itself, to contribute to the achievement of the MDGs.
The organizational and administrative strategies envisaged in this paper, the new national and international interprofessional and intersectoral coalitions, the research initiatives will be costly. There are good prospects for support for them. In recent years there has been a substantial and welcome upsurge in funding for strategies and scientific initiatives for the protection and promotion of national and international health from governmental, intergovernmental, charitable and private sources – the IMF, the World Bank, private and government institutions, the Global Fund, the Wellcome Trust, the Bill and Melinda Gates Foundation, the GAVI Alliance.
Our perception has been that the donor stage in the international funding field has been uncoordinated and crowded; that donor priorities often take precedence over national ones; that the support given for special vertical programmes often resulted in the weakening of the country's general ones. However there are not only good prospects of support from international and international and governmental institutions but for favourable revisions in their policies and practices. The recent support given for our point of view, for incorporating the concept of ownership into health assistance, holds out prospects for change. 21
The International Health Partnership, which was launched in London in 2007, had a comparable objective. The purpose was to bring together donor and recipient countries with a wide range of health-related IGOs and NGOs, whose objective would be to make health-related aid work better in poorer countries by ‘focusing on improving health systems as a whole rather than on individual diseases or issues; bringing about better coordination of effort among donors; developing and supporting the health plans of recipient countries’. The soil of the international health donor community seems prepared for and receptive of the ideas proposed in this paper and the preceding papers in this series. 22,23
Another of the hoped-for outcomes of this paper would be the recognition by the international health funding community that national and international interdisciplinary consultation and action have the capacity to contribute to the solution of national or international health problems – and particularly among groups which, although they might be essential stakeholders, might not normally have opportunities to come together to discuss, promote and collaborate in such action.
The range of likely issues, stakeholders and participants in the consultation/action processes has been set out in the text. Participants in such consultative/action processes, would be from academia, industry, professional associations and government sectors – e.g. agronomy, anthropology, animal husbandry, engineering education, health, nutrition, sociology, economy, the environment, law and the institutions and bodies, like those listed below which, for reasons stated, are also likely to have definitive planning and/or implementation roles:
The WHO: would clearly have important supportive and participatory roles. A recent House of Lords Select Committee on Intergovernmental Organizations has specifically recommended that, ‘given appropriate strengthening of its management arrangements WHO's remit and resources should be developed in order to encourage and support collaboration and
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rationalization among the many actors on the international health stage’. The WHO-based Global Commission on the Social Determinants of Health, which already has the remit for a promotional, coordinating and monitoring role in several aspects of the work envisaged in this paper, might also be strengthened to enable WHO to facilitate this expanded cross-cutting global role. WHO's remit for the governance and direction of world health is currently heavily constrained by the brakes imposed on it by its dependence on the health consensus of its member countries; The Commonwealth, its associated institutions and professional associations: The Commonwealth with its long tradition of international collaboration among its member countries – and its established mechanisms for achieving it – can provide greater scope for such global cooperation than any other community. Its potential for advancing enlightened ends has inevitably a global reach. It has in place the organization to enable it to garner the views of governments representing more than two billion people; The academies of the world, like the Royal Society in Britain and other institutions for scientific support: A March 2010 Royal Society Policy Document recommends a better alignment of science and innovation with global challenges and the putting of science and innovation at the heart of a strategy for long-term economic growth. It is in this context that the global academies could play a promotional and supportive role for this proposal; Non-governmental organizations like WINDREF (The Windward Islands Research and Education Foundation): Located as it is in the Caribbean and committed, (in association with the Caribbean Chronic Diseases Research Consultation) to research and action on the non-communicable diseases, WINDREF might make a useful contribution to this category of research. The September 2010 UN Summit on the MDGs had stressed that ‘the challenges of meeting the goals are most severe in the least developed countries, particularly in some small land-locked and island developing countries’; The Pharmaceutical industry has contributed to the fight against poverty and health inequalities by (a) research towards solving major health problems and (b) policy in making available inexpensive drugs to the poor who would otherwise not have been able to afford them – particularly to sufferers from HIV/AIDS; Philanthropic organizations, like the Bill and Melinda Gates Foundation, the Wellcome Trust, the GAVI Alliance, the IMF, the World Bank.
Review of the series
This series of papers has demonstrated how wide and diverse is the range of issues that need to be tackled if the objective set out in their title is to be realized.
The first deals with a number of health administrative measures which we consider that each country should consider for introduction: arrangements that facilitate greater intersectoral, interprofessional, all-of-government, all-of-country involvement in health decision-making than has been customary in the past: a sharper focus on poverty, on socially-stratified health inequalities; on health as a global public good; on the roles of the international funding agencies – the IMF and the World Bank; on past or likely future rewards from health partnerships between the UK and other developed countries and the developing ones.
The second examines the special responsibilities of individual governments for arriving at effective intra- and international collaborations, the main tool for the meeting of which is its control of: (a) the sectors and levers of government; (b) national policies and enactments; and (c) many infrastructural developments. It also examined two major issues that commonly contribute to poverty and health inequalities in many areas and populations of the world – uncontrolled population growth and neglect of agriculture and livestock development.
The third examines a range of diseases and challenges as examples of widely-differing issues of major national and international health importance that also specifically call for wide national or international consensus seeking and planning. It examines the likely contribution to the reduction of health inequalities by initiatives for the elimination of Africa's neglected tropical diseases. It considers issues relating to the special categories of diseases for which the Global Fund has been created (HIV/AIDS, malaris and tuberculosis), the non-communicable diseases (the topic for the United Nations most recent high level discussion on health, September 2011) and mental diseases. It also discussed prospects for the achievement of the MDGs and for the development of effective north–south collaborative initiatives and for achieving philanthropic support for them, which are considered to be favourable.
Action for change
The search for an improved quality of life and the relevance of health to that search is important not only for poor countries, but for the affluent ones as well. What these papers have not adequately stressed, however, is how essential health is for human wellbeing – as a prerequisite for meeting one of the major global challenges, arguably the greatest of all, the attainment of human happiness. Few countries have adequately prioritized health in these terms. We hope that the action we propose in this series might make a major contribution, might usher in a new era in global societal expectations, in which the experience of or contribution to health/human happiness becomes a credible prime national and international societal expectation.
In this context the contribution that industry, business corporations, the pharmaceutical and other industries, scientists have made to human happiness, health and development have made to human development deserves greater recognition than they commonly receive. Recognition must also be made of the enormous contributions of institutions like the WHO, the IMF, Partners in Health, the Global Health Council and a number of other global health-supporting institutions and which we expect will continue. But additional contributions are still called for – agendas of support across a broad international spectrum of agendas, countries and issues. And central to these agendas must be factors that have the greatest influence on the social development of members of societies, to the development of societies.
International health needs trusteeship, stewardship, more than ever – individuals, groups and institutions committed to the maximization of the benefits that the investment of their skills, commitment and resources can realize for it. We envisage groups of activists in undertaking the roles of self-elected ‘trustees’ meeting with each other and with other activist groups in support of initiatives of assistance in which their support would be most beneficial.
And since they have to confront so many challenges simultaneously these trustees and shareholders will need arrangements for dealing with global health issues in a proactive, comprehensive and systematic way. An associated objective will be to provide models for approaching other aspects of global interdependence: for fostering dialogue, promoting understanding of how different people, institutions, countries and regions might deal with each other: more effectively confront challenges they collectively face.
Of the several challenges discussed in this series one of the most important is likely to be the identification, coordination and integration of the roles of the several stakeholders in health in all countries – Heads of government themselves to lay community members, health professionals, other professionals and community service organizations, educational institutions, business corporations and all sectors and levels of government: in sum, the entire society. And here the roles of the public information media – press, radio and television – are critical. Arrangements for facilitating and sustaining their participation and collaboration in initiatives for achieving public advocacy for and participation in the several inter-acting issues and actions that relate to health would be essential.
We hope, indeed, anticipate, that international health might witness the emergence of something completely new – a unique global alliance of countries, individuals, philanthropists, professional associations, scientists and a wide range of stakeholders towards action for realizing the goal set out in the title of these papers. We aim to provide the motivation for governments, policymakers, professional organizations, educational institutions to formulate completely new, or revise existing, policies and programmes for supportive action towards this goal; to address the reality behind the abstraction of global poverty and disease.
Policies and programmes for dealing with both infectious and non-infectious disease manifestations of health inequalities will overlap with those designed to confront the poverty and social disenfranchisement of which they are manifestations. It is the joint national and international planning and simultaneous implementation of strategies and coherent programmes for dealing together with this mosaic of factors and needs that will constitute both the global challenge and motivation for this activity.
Initiating actions
Initiating actions towards this global goal might be the achieving of the widest possible distribution of these proposals among governments and likely key stakeholders and the establishment of a steering committee on methods for promoting and sustaining global advocacy for and action on them.
DECLARATIONS
Competing interests
None declared
Funding
None
Ethical approval
Not applicable
Guarantor
KS
Contributorship
Both authors contributed equally
Acknowledgements
The authors are grateful to the following colleagues for their discussions of aspects of this paper and for advice in its preparation: Charles Engel, Cedric Hassall, Michael Marmot, Calum Macpherson, Sonny Ramphal, former Commonwealth Secretary General Bishnodat Persaud, former Commonwealth Economic Advisor Lord Rea