tag:theconversation.com,2011:/us/topics/low-and-middle-income-countries-64182/articleslow- and middle-income countries – The Conversation2019-08-18T08:17:30Ztag:theconversation.com,2011:article/1219512019-08-18T08:17:30Z2019-08-18T08:17:30ZGlobal health still mimics colonial ways: here’s how to break the pattern<figure><img src="https://images.theconversation.com/files/288159/original/file-20190815-136208-1183zr2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">High income country trainees and experts must learn to listen and be humble</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Imagine this scenario. A couple of newly minted Master of Public Health graduates from an African university, say in Rwanda, land in Washington DC for a 2-week visit. They visit a few hospitals, speak to a few health care workers and policymakers, read a few reports, and write up a nice assessment of the US health system with several recommendations on how to fix the issues they saw. They submit their manuscript to the American Journal of Public Health. </p>
<p>Can you imagine journal even sending it out for review? Even if the paper got published somewhere, would US health researchers take it seriously? (They should, I suppose. After all, the broken US health care system needs all the help it can get.)</p>
<p>Clearly, it’s an impossible scenario yet American graduates land in low-income countries to advise them on global health issues all the time. I met an African expert recently and she expressed her frustration about how American “kids” with little or no experience come all the time to “advise” her government on what to do about health.</p>
<p>American graduates aren’t the only ones accused of such <a href="https://www.globalhealthnow.org/2019-08/10-fixes-global-health-consulting-malpractice">global health consulting malpractice</a>. It happens with all high-income country folks. And it is not just naïve rookies stepping into advisory roles. The professionalised consulting industry, such as McKinsey or Bain, and NGOs such as PATH or CHAI, as well as and donor agencies send high-income country “experts” to low- and middle-income countries to offer “technical assistance” when they might know little about the countries they are advising or the problems they are trying to fix.</p>
<p>This problem of consulting malpractice is merely one facet of a larger issue of how global health, even today, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62379-X/fulltext">is still colonial</a> in many ways, and how high-income country experts and institutions are valued much more than expertise in low- and middle-income countries. Analyses of research studies’ authorship show that <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30497-7/fulltext">high-income country authors dominate and lead publications</a> even when the work is entirely focused on or done in low- and middle-income countries. </p>
<p>While <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30239-0/fulltext">parachute research</a> is increasingly being discouraged, there is little discussion about parachute global health consulting.</p>
<p>To be clear, I am not against consulting or technical assistance. Nor am I against high-income country trainees visiting low- and middle income countries for global health. They are mostly well-intentioned. Also, we do not want to discourage young people who want to do good. But I do believe things can be done better. </p>
<p>Based on a recent <a href="https://twitter.com/paimadhu/status/1159400898126331909?s=20">thread I posted on Twitter</a> and the dozens of responses, here are 10 crowd sourced ideas on how consulting can be improved.</p>
<h2>Ten ideas</h2>
<p><strong>1. Global health courses must discourage global health <a href="https://blogs.scientificamerican.com/observations/the-trouble-with-medical-voluntourism/">voluntourism</a></strong>, and guide trainees and graduates on what they must NOT do, when they go to low- and middle-income countries. <a href="https://t.co/B6pqCt1zA0?amp=1">How NOT to save the world</a> must be a critical, required component of all global health courses. The principle of <em>do not harm</em> must be reinforced in all training. The recent story of an <a href="https://www.npr.org/sections/goatsandsoda/2019/08/09/749005287/american-with-no-medical-training-ran-center-for-malnourished-ugandan-kids-105-d?utm_campaign=storyshare&utm_source=twitter.com&utm_medium=social">American woman with no medical training running a centre for malnourished Ugandan children</a> is an excellent case study in global health clinical malpractice.</p>
<p><strong>2. Those studying or working in global health</strong> must complete a course or book on the colonial history of tropical, international and global health. I recommend Randall Packard’s book, “<a href="https://jhupbooks.press.jhu.edu/title/history-global-health">A History of Global Health</a>.” For a more gut-wrenching account of colonialism, I suggest “<a href="https://www.amazon.com/King-Leopolds-Ghost-Heroism-Colonial/dp/0618001905">King Leopold’s Ghost: A Story of Greed, Terror and Heroism in Colonial Africa</a>.” </p>
<p><strong>3. Predeparture training by global health programmes</strong> must go beyond what vaccines to take and also include content on <a href="https://www.ncbi.nlm.nih.gov/pubmed/26630608">cross-cultural effectiveness and cultural humility, bidirectional participatory relationships, local capacity building, long-term sustainability</a>, and respect for local expertise and leadership. Training in <a href="https://m.youtube.com/watch?v=APdNxzsqnz4">privilege and allyship</a> is also critical. Above all, high income countries trainees and experts must learn to listen and be humble.</p>
<p><strong>4. Consultants must have lived and worked in low- and middle-income countries,</strong> preferably, in the same countries they will be advising. A 2-week trip to South Africa does not make anyone an “Africa expert.” As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872019/pdf/BLT.18.030418.pdf">Randall Packard</a> put it</p>
<blockquote>
<p>Everyone involved in global health decision-making should be required to work in the countries and see how things look from the ground level.</p>
</blockquote>
<p><strong>5. Consultants should be careful about going beyond</strong> their specific content or country expertise. It is perfectly fine to decline consulting invitations that are a poor match with skill sets or country-specific experience.</p>
<p><strong>6. Before technical assistance is offered ministries of health in low- and middle-income countries should be consulted</strong> on whether they need assistance, and what specific expertise and prior experience/background they need. If there are local experts who are suitable, they could be contracted to provide technical assistance instead of expensive consultants flown in from high-income countries.</p>
<p><strong>7. Strengthening global health capacity in the Global South</strong> and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30558-8/fulltext">expanding the cadre of national experts is key</a> for weaning low- and middle-income countries away from the current dependence on high-income countries experts. This is an opportunity for high income countries institutions to demonstrate <a href="https://link.springer.com/article/10.1007/s10734-019-00416-1">reciprocity</a>. Schools of public health and research institutions in high-income countries have an obligation to host, train and send back talented low- and middle-income countries researchers and experts. The NIH <a href="https://www.fic.nih.gov/Pages/Default.aspx">Fogarty International Center</a> could be a model for other High Income Countries. </p>
<p><strong>8. There is no reason why good training and capacity development</strong>cannot happen in low- and middle-income countries. Building top-notch schools and institutions in these countries and developing world-class expertise within them is key. A few recent examples include the <a href="https://phfi.org/">Public Health Foundation of India</a>, <a href="http://sph.bracu.ac.bd/">BRAC School of Public Health</a> in Bangladesh, the <a href="https://ughe.org/">University of Global Health Equity</a> in Rwanda, and the <a href="https://www.ahri.org/">Africa Health Research Institute</a> in South Africa. The <a href="https://www.scientificamerican.com/article/a-cdc-for-africa/">Africa CDC</a>, <a href="https://gh.bmj.com/content/3/2/e000712">Nigeria CDC</a>, and <a href="http://www.aslm.org/">African Society for Laboratory Medicine</a> are examples of technical agencies. Initiatives such as the <a href="https://www.ev4gh.net/">Emerging Voices in Global Health</a> have empowered researchers from the Global South by providing skills training and facilitating their participation in global health events.</p>
<p><strong>9. The ultimate solution is to challenge the current architecture</strong> of global health and work towards “<a href="https://www.healthsystemsglobal.org/blog/341/The-C-Word-Tackling-the-enduring-legacy-of-colonialism-in-global-health.html">decolonising global health</a>”. This includes answering uncomfortable questions. </p>
<p>Why are global health institutions, donors, and power structures invariably based in high-income countries or controlled by their experts? Why is the flow of funding, people and knowledge unidirectional (North to South)? What colonial practices have led to the heavy dependence of lower-middle income countries on aid and technical assistance from their former colonisers? Why are major decisions in global health made in Geneva, Davos, New York or Seattle when those who deal with the real issues and have solutions are not at the table (or <a href="https://blogs.bmj.com/bmj/2019/07/30/ulrick-sidney-visas-for-global-health-events-too-many-are-losing-their-seat-at-the-table/">struggle to get visas</a>, even when invited)? And why are <a href="https://naturemicrobiologycommunity.nature.com/channels/304-on-the-road/posts/40361-tb-conferences-we-must-do-better">global health meetings held in high income countries</a> when the real problems and expertise are elsewhere?</p>
<p><strong>10. The entire global health consulting industry</strong> needs a serious re-think. As <a href="https://www.theatlantic.com/international/archive/2012/03/the-white-savior-industrial-complex/254843/">Teju Cole</a> wrote:</p>
<blockquote>
<p>If we are going to interfere in the lives of others, a little due diligence is a minimum requirement.</p>
</blockquote>
<p>In the end, when strong global health leadership emerges from low- and middle-income countries, the role of external consultants will need to evolve. High Income country experts will have to <a href="https://academic.oup.com/inthealth/article/10/2/63/4924746">see themselves as enablers</a> and <em><a href="https://harvardmagazine.com/2011/05/paul-farmer-accompaniment-as-policy">accompagnateurs</a></em>, not “fixers.” </p>
<p><em>This is an edited version of an article that was originally published in <a href="https://www.globalhealthnow.org/2019-08/10-fixes-global-health-consulting-malpractice">Global Health NOW</a>.</em></p><img src="https://counter.theconversation.com/content/121951/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Madhukar Pai served as a commissioner on the Lancet Commission on Tuberculosis. He receives funding support from the Canada Research Chairs program, the Bill & Melinda Gates Foundation, Stop TB Partnership, and FIND, Geneva. He has no financial or industry related conflicts.</span></em></p>High-income country experts and institutions are valued more than expertise in low- and middle-income countries.Madhukar Pai, Director of Global Health & Professor, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1143402019-04-09T13:24:38Z2019-04-09T13:24:38ZWorkers in Tanzania’s noisy factories are at risk of hearing damage<figure><img src="https://images.theconversation.com/files/268129/original/file-20190408-2905-qms01u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Manufacturing sites are high noise working areas.</span> <span class="attribution"><span class="source"> Israel Paul Nyarubeli</span></span></figcaption></figure><p>Excessive exposure to noise can cause permanent hearing loss. It’s estimated that a <a href="https://www.who.int/health-topics/news-room/fact-sheets/detail/deafness-and-hearing-loss">third</a> of disabling hearing problems in the world are caused by excessive exposure to noise among adults who are older than 65. Some noise workplaces include mining, manufacturing, agriculture and construction sites.</p>
<p>The number of people with hearing loss in the world has <a href="https://www.who.int/news-room/fact-sheets/detail/deafness-and-hearing-loss">increased</a> over the past two decades, from <a href="https://www.ncbi.nlm.nih.gov/pubmed/12689363">120 million</a> people in 1995 to 466 million in 2018. Estimates of hearing loss caused by working in noisy environments are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4007124/">higher</a> in low- and middle-income countries including sub-Saharan Africa than high-income countries. This may be due to ongoing economic investments in industrialisation as well as inadequate public health policies, lack of industrial regulation and limited resources spent on preventive measures. </p>
<p>Despite <a href="https://www.ncbi.nlm.nih.gov/pubmed/28685503">efforts</a> such as engineering and administrative controls, and mandating the use of hearing protection devices at workplaces by governments and health and research organisations, this problem isn’t going away.</p>
<p>People who work in really noisy places such as construction sites, military sites, mines and factories are particularly at an increased risk of hearing damage or loss.</p>
<p>We conducted a <a href="https://academic.oup.com/annweh/article/62/9/1109/5064905">study</a> looking at workers in high noise environments in Tanzania. We wanted to determine if these workers knew the effect of working in noisy environments and if they had access to noise protection devices. We found that most of the workers didn’t have any protection against potential hearing loss and didn’t know that the negative effects of working in a noisy environment were irreversible. This sort of <a href="https://apps.who.int/iris/bitstream/handle/10665/177884/WHO_NMH_NVI_15.2_eng.pdf">damage</a> affects the inner part of the human ear and can’t be effectively treated with existing technology. </p>
<p>Hearing loss like this is preventable. Measures to control or reduce workplace noise exposure are critical to protect the health and safety of these workers. </p>
<h2>What we found</h2>
<p>We surveyed workers in large steel manufacturing factories in Dar es Salaam, Tanzania. We asked if they knew that exposure to high noise levels might cause hearing problems. Only 45% of participants did. And only 33% understood that this damage was permanent. </p>
<p>We were shocked to find that workers in iron and steel factories were exposed to an average noise level of 92 decibels. This level is higher than the <a href="http://www.tbs.go.tz/index.php/standards/">national regulatory limit</a> for noise exposure at work, which is 85 decibels. This is similar to standing next to an operating jackhammer without hearing protection or standing next to a landing aircraft without protection for your ears. </p>
<p>Additionally, 86% of the factory workers we studied had never been provided with nor used hearing protection devices. This was unexpected in such large and well-organised factories.</p>
<p>We believe the situation is probably the same in factories in other low and middle income countries. It’s also likely to be worse in small and unorganised workplaces in many other countries in the world, among them places like <a href="https://www.ncbi.nlm.nih.gov/pubmed/19672017">India</a>.</p>
<h2>Tackling the problem</h2>
<p>Our research shows that many factory workers are exposed to hazardous noise levels and aren’t provided with hearing protection gear. </p>
<p>This situation calls for government and industry to promote and implement control measures in workplaces with high noise levels such as factories and construction sites. </p>
<p>Industry must provide workers with hearing protection devices. Government needs to ensure that operational safety guidelines are followed. And workers must learn about the dangers of noise exposure and received training on measure they can take to protect themselves. </p>
<p>This is important because deafness has biological, physical and psychological and economic <a href="https://www.who.int/health-topics/news-room/fact-sheets/detail/deafness-and-hearing-loss">effects</a> on individuals, families and societies. With the right protection and care, hearing loss in the workplace can be avoided.</p><img src="https://counter.theconversation.com/content/114340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work is part of the PhD project ‘occupational noise exposure and hearing loss among factory workers in Tanzania’ led by Professors Bente E. Moen and Magne Bråtveit from Univesity of Bergen, Norway with close collaboration with Dr. Alexander M. Tungu (co supervisor) from Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania. The project was financially supported by the Norwegian State Educational Loan Fund (Lånekassen) and equipment provided by the Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED). </span></em></p>Measures to control or reduce workplace noise exposure are critical to reducing hearing loss in workers.Israel Paul Nyarubeli, PhD candidate, University of BergenLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1136822019-03-21T13:05:32Z2019-03-21T13:05:32ZWhat African countries can do about ensuring safer surgery<figure><img src="https://images.theconversation.com/files/264581/original/file-20190319-60964-1543tdv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tools like the WHO checklist can lead to better surgical outcomes in countries with limited resources.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The World Health Organisation (WHO) has come up with plans and tools to help countries ensure safer surgery in their hospitals and clinics. These include the <a href="https://www.who.int/patientsafety/safesurgery/checklist/en/">surgical safety checklist</a> and <a href="https://www.who.int/patientsafety/implementation/checklists/childbirth/en/">safe childbirth checklist</a>.</p>
<p>But implementation is still poor in most African countries.</p>
<p>A recent <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X.pdf">report</a> in The Lancet medical journal suggests that at least 4·2 million people worldwide die within 30 days of surgery each year. Half of these deaths occur in low- and middle-income countries. This number of postoperative deaths accounts for <a href="https://www.ncbi.nlm.nih.gov/pubmed/28919116?dopt=Abstract">7·7%</a> of all deaths globally, making it the third greatest <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)33139-8/fulltext#fig1">contributor to deaths</a>, after heart disease and stroke.</p>
<p>This might in fact be an underestimate as little is known about the quality of surgery globally. This is because robust reports of postoperative death rates are available for only <a href="http://docs.wixstatic.com/ugd/346076_c853bd6c09d34ed6bca4b9b622d69de3.pdf">29 countries</a>. </p>
<p>Surgery and anaesthesia have long been neglected in global health given the need to focus on communicable diseases. However, the 2016 World Health Assembly emphasised universal care for all, including strengthening of surgery and anaesthesia. Only <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(14)70349-3/fulltext">12%</a> of the specialist surgical workforce practice in Africa and Asia, where a third of the world’s population lives.</p>
<p>This inequality and the lack of access to safe surgical interventions in low and middle-income countries lead to unacceptably high rates of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173895/">morbidity and mortality</a>. </p>
<p>During our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4982013/">research</a> in East Africa we set out to determine the knowledge of anaesthetists and their attitudes towards the use of the WHO checklist for surgical patients in national referral hospitals. We found that only a quarter of the anaesthetists we interviewed at the main teaching and referral hospitals used the WHO’s Safe Surgical Checklist. Results from our research in Uganda paint a similarly dismal picture.</p>
<p>In separate research to access the pre and post operative care for mothers giving birth in Uganda, we <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173895/">also found</a> that only 34% of the 64 hospitals we surveyed used the WHO safe surgical checklist. This study covered 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals in Uganda. </p>
<p>Our results point to the need to implement essential tools like the WHO checklists. This is because they have been shown to lead to better surgical outcomes; and would possibly have more impact in countries facing challenges such as shortages of surgical specialists, drugs and equipment.</p>
<h2>What we found</h2>
<p>We conducted a survey from February 2013 to March 2014 in the main referral hospitals in hospitals in Uganda, Kenya, Tanzania, Rwanda and Burundi. During the survey we interviewed 85 anaesthetists working in the obstetric theatres in these national referral hospitals. We asked questions to determine their knowledge of the WHO Safe Surgical Checklist, and its availability and use at the various hospitals.</p>
<p>We found that only 25% of the anaesthetists regularly used the WHO safe surgical checklist. None of the anaesthetists in Mulago Hospital (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available. </p>
<p>In Muhimbili Hospital in Tanzania only 65% of anaesthetists used the checklist. Only 19% in Kenyatta Hospital in Kenya and 36% in Centre Hospitalier Universitaire de Kigali in Rwanda used it.</p>
<p>None of the hospitals had anyone responsible for ensuring that the surgical checklist is available in each theatre, or checking that all members of the surgical team implement it. </p>
<p>Muhimbili Hospital in Tanzania had a locally designed pre-anaesthesia checklist for caesarean sections, which included machine, drugs and airway equipment checks. But 57% of the anaesthetists reported that it was not generally available for use.</p>
<h2>What needs to be done</h2>
<p>It’s necessary to make the WHO’s surgical checklist available, to train the surgical team on its importance and to identify local anaesthetists to champion its implementation in East Africa and other resource limited countries. </p>
<p>The ministries of health in the participating countries need to issue directives for the implementation of the WHO checklist in all hospitals that conduct surgery in order to improve surgical outcomes.</p><img src="https://counter.theconversation.com/content/113682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, The World Bank, Government of Uganda</span></em></p>Research found that only a quarter of anaesthetists working in main referral hospitals in East Africa used the WHO safe surgical checklist.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1111022019-02-21T14:17:27Z2019-02-21T14:17:27ZCancer drug pricing gets in the way of treatment in developing countries<figure><img src="https://images.theconversation.com/files/257024/original/file-20190204-193226-1kwfkjq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to affordable medical treatment can save lives.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Most cancers can now be detected early. This hasn’t always been the case. The first big breakthrough came 80 years ago when the <a href="https://www.mayoclinic.org/tests-procedures/pap-smear/about/pac-20394841">pap smear</a> was introduced. Ten years later the <a href="https://www.pinkdrive.co.za/breast-health-info/mammograms/">mammogram</a> was created and then nearly half a century ago the <a href="https://www.mayoclinic.org/tests-procedures/fecal-occult-blood-test/about/pac-20394112">fecal occult blood test</a> was developed. </p>
<p>Advances in diagnosis have made a huge difference. When cancer is detected at an <a href="https://www.who.int/news-room/detail/03-02-2017-early-cancer-diagnosis-saves-lives-cuts-treatment-costs">early stage</a> – and when coupled with appropriate treatment – the chance of survival beyond five years is dramatically higher. Early diagnosis can also reduce the cost of treatment. </p>
<p>Despite this, millions of cancer cases are found late. This results in expensive and complex treatment options, diminished quality of life, and avoidable deaths. </p>
<p>The <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">global cancer burden</a> is estimated to have risen to 18.1 million new cases and 9.6 million deaths in 2018 up from 12.7 million new cases and 7.6 million deaths in <a href="http://governance.iarc.fr/SC/SC50/Biennial%20Report%202012-2013.pdf">2008</a>. One in 5 men and one in 6 women <a href="https://www.uicc.org/new-global-cancer-data-globocan-2018">worldwide</a> develop cancer during their lifetime, and one in 8 men and one in 11 women die from the disease. </p>
<p>Unless greater effort is placed into altering the course of the disease, this number is expected to rise to close to 30 million <a href="https://gco.iarc.fr/tomorrow/home">new cases</a> by 2040. </p>
<p>More than <a href="https://www.who.int/news-room/fact-sheets/detail/cancer">70%</a> of the world’s total new annual cases occur in Africa, Asia, and Central and South America. These regions account for more than 60% of the world’s cancer deaths. Yet treatment for cancer is not widely available in these regions. Health systems are often not equipped to deal with detection and treatment of cancers. Prevention and early detection programmes are often weak or non-existent. </p>
<p>This situation is exacerbated by the <a href="https://www.healthpolicy-watch.org/cancer-drugs-unaffordable-for-millions-treatment-costs-exceed-other-diseases-who-reports/">high cost</a> of treatment and, in particular, the high cost of newer cancer medication. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834140/pdf/mdx521.pdf">Cancer medication pricing</a> has increasingly become a global issue creating access challenges in low-and middle-income countries. Death rates from cancer in wealthy countries are <a href="http://cebp.aacrjournals.org/content/cebp/early/2015/12/10/1055-9965.EPI-15-0578.full.pdf">declining slightly</a> because of early diagnosis and the availability of treatment.</p>
<p>But this isn’t the case in low- and middle-income countries. For example, over 80% of children diagnosed with cancer in high-income countries will be <a href="https://www.who.int/news-room/fact-sheets/detail/cancer-in-children">cured</a>. In low and middle-income countries the rate is as low as 10%. </p>
<h2>Massive disparities</h2>
<p>Only <a href="https://academic.oup.com/annonc/article/21/4/680/156750">5%</a> of global resources for cancer are spent in the developing world. Yet these countries account for almost <a href="https://www.sciencedirect.com/science/article/pii/S014067361061152X?via%3Dihub">80%</a> of disability-adjusted years of life lost to cancer globally. And developing countries, governments and individuals struggle to pay for products that are priced at several times the level of their per capita GDP. Buyers are at the mercy of a single provider, often the patent holder of the product, particularly where the product has no competitors. </p>
<p>In 2018 the <a href="http://apps.who.int/medicinedocs/en/m/abstract/Js21758en/">World Health Organisation</a> found that pricing of cancer drugs was disproportionately higher than other types of pharmaceuticals and therapies.</p>
<p>Nor is it just a question of price. Efficacy comes into the picture too. In 2017, estimated global expenditure on medicines for cancer and related supportive care amounted to <a href="https://www.iqvia.com/institute/reports/global-oncology-trends-2018">US$ 133 billion</a>. Despite these huge costs, a systematic evaluation of 68 cancer medicines approved by the European Medicines Agency in 2009–2013 showed that only <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5627352/">35%</a> had established evidence of prolonged survival at the time of approval. Similarly, only 10% of the 68 medicines had evidence of improvement in the quality of life at the time of approval.</p>
<p>In addition, some medicines may present higher risk of toxicities to patients, with <a href="https://apps.who.int/iris/handle/10665/272962">evidence</a> of high rates of deaths related to treatment (toxic deaths) and high chances of patients discontinuing treatment due to intolerance. </p>
<h2>Some answers</h2>
<p>We often hear that efforts to expand cancer care aren’t affordable and will divert resources from higher priorities. A similar view was once held about HIV/AIDS. Yet we have seen remarkable success expanding access to services. Many lessons can be learnt from this experience. For example, generic drug competition in the HIV market has been essential in bringing the price of antiretroviral medicines down dramatically. </p>
<p>Developing countries should be encouraging the use of generic and biosimilar cancer medicines with a view to enhancing competition. This will certainly drive down cancer drug prices. <a href="http://ascopubs.org/doi/10.1200/JGO.2016.008607">For example</a>, in Norway, an infliximab biosimilar was discounted by nearly 70% and now represents more than 50% of drug sales. Similarly, in India and Peru, a rituximab biosimilar was introduced at a 50% lower price compared to the originator, illustrating the value they bring into oncology care.</p>
<p>In addition, governments must ensure that the application of patent law and rights for market exclusivity are not over compensating innovators and becoming barriers to access. Such activism has been found resonance in many countries as has been the case in <a href="https://www.fixthepatentlaws.org/wp-content/uploads/2016/09/MSF-FTPL-report-FINAL-VERSION.pdf">South Africa</a>.</p>
<p>These approaches are important to create platforms for engagement and the political momentum to strengthen health care for cancer patients at national level and take action globally to provide guidance for treatment and care, share knowledge about treatment cost and provide a legal framework to ensure treatment is available. </p>
<p>The cost of new drug development as an explanation for the high prices of new medicines is doubtful. Yet when it comes to health care and certainly in the case of potentially fatal diseases such as cancer, people are willing to bear a heavy burden even if the health benefits in reality turn out to be limited.</p>
<p>What’s important is that biomedical and technological advancements don’t introduce greater disparities and inequities when it comes to access to care and outcomes. The watch word must be affordability, not profitability.</p><img src="https://counter.theconversation.com/content/111102/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vikash Sewram does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The global cancer burden especially in developing countries is exacerbated by the high cost of treatment.Vikash Sewram, Director of the African Cancer Institute, Faculty of Medicine and Health Sciences , Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1104562019-02-05T13:44:18Z2019-02-05T13:44:18ZWeighing up the costs of treating ‘lifestyle’ diseases in South Africa<figure><img src="https://images.theconversation.com/files/256102/original/file-20190129-108364-17vwexn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Salty and fatty foods are driving up obesity.
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Economic growth, accompanied by a fall in infectious diseases over the past two decades, has changed the profile of the biggest <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32279-7/fulltext">threats</a> to the health of people living in low and middle-income countries.</p>
<p>At the turn of the century, the greatest threats were posed by <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31891-9/fulltext">infectious diseases</a> like diarrhoea, pneumonia, tuberculosis, and HIV. Today, the biggest threats are posed by so-called <a href="https://theconversation.com/lifestyle-diseases-could-scupper-africas-rising-life-expectancy-107220">“diseases of lifestyle”</a>. These include diabetes (high blood sugar), hypertension (high blood pressure), and hypercholesterolaemia (high cholesterol), which have been slowly and quietly rising around the world. </p>
<p>While diabetes, hypertension and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778427/">hypercholesterolaemia</a> often don’t cause symptoms, they have debilitating and deathly consequences which can include heart attacks, angina, heart failure, amputation, stroke, kidney disease, and blindness. These are now the most common causes of death and disability in many low and middle-income countries. But unlike many infectious diseases, there’s no course of antibiotics to treat them.</p>
<p>Obesity and lack of activity contribute to the rise of diabetes, hypertension, and hypercholesterolaemia. These are driven, in turn, by lifestyle changes, often biased towards foods that are convenient (sugary and fatty) and jobs that require less physical activity.</p>
<p>Strong policies are desperately needed to alter the environment to promote physical activity and prevent obesity. But there’s also a need to treat people who already have diabetes, hypertension, and hypercholesterolaemia– which are largely without symptoms – to try to prevent their consequences.</p>
<p>Unfortunately, <a href="https://theconversation.com/why-its-so-difficult-to-tackle-diabetes-in-sub-saharan-africa-81339">access to care</a> for people with these conditions is poor in many low and middle-income countries. South Africa is no exception. In our <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30450-9/fulltext">research</a> we set out to establish who suffers from these conditions, who has access to care and what the consequences would be if the access to care didn’t change. We also wanted to establish what the cost savings would be for the South African government if access to care improved.</p>
<p>After analysing our findings in relation to these questions, we concluded that South Africa should invest in care for treating diabetes, hypertension, and hypercholesterolaemia. This will, in the long run, save the country a lot of money.</p>
<h2>Managing risks versus treating the diseases</h2>
<p>As far as deathly and debilitating consequences are concerned, we found that poorer black men were at high risk and they had the worst access to care. </p>
<p>Overall, only 50.4% of people in the study community with hypertension were treated to acceptable levels. Just under 9% were treated adequately for diabetes and less than 1% for high cholesterol. </p>
<p>We estimated that if access to care continued at current levels, premature deaths due to cardiovascular conditions would be around 40 per 1000 people annually. Although HIV still causes the greatest percentage of premature deaths in South Africa, diabetes, stroke, and heart attacks are all in the top 10 causes, with diabetes rapidly rising through the ranks. More of these deaths would occur among those who are poor, black and male. There is also substantial risk for blindness and kidney disease. </p>
<p>We further estimated that the cost of treating all of these deathly and disabling consequences of diabetes, hypertension, and hypercholesterolaemia would be $34.2 billion a year. That’s roughly 10% of South Africa’s GDP in 2017.</p>
<p>We also found that if access to care for diabetes, hypertension, and hypercholesterolaemia was improved to levels seen in the UK or Germany, deaths and disability would be reduced. The benefits would also be seen among people who currently lack access to care, such as poor, black men. </p>
<p>If people are sceptical of South Africa’s ability to achieve access to care at the same level as the UK or Germany, it may be reassuring to note that <a href="https://elpais.com/elpais/2017/02/10/inenglish/1486729823_171276.html">Cuba</a> has managed to achieve these levels of access to care.</p>
<p>In addition to determining the costs of treating consequences of diabetes, hypertension, and hypercholesterolaemia, we calculated what it would cost to treat these conditions by improving access to care and implementing locally appropriate guidelines. We used two guidelines for our estimates: the World Health Organisation’s (WHO) <a href="https://www.who.int/nmh/publications/essential_ncd_interventions_lr_settings.pdf">Package of Non-Communicable Disease Interventions</a>, and the locally developed <a href="https://www.idealclinic.org.za/docs/guidelines/PC%20101%20Guideline%20v2_%202013%2014.pdf">South Africa Primary Care 101 Guidelines</a>. </p>
<p>We found that it was cheaper to improve access to – and treat these conditions – using either guideline than to stick with current levels of access and care and suffer the consequent diseases. In fact, implementing the WHO guidelines would save around US$125,000 per 1000 people and US$185,000 with South Africa’s guidelines. The local guidelines are more cost effective. They are also more equitable, with better improvements in treatment and reduction of risk in black people, men, and those who are poorer.</p>
<h2>What needs to be done</h2>
<p>Even though we have shown that rolling out the guidelines would save costs in the longer term, there still needs to be substantial investment in building programmes for treatment in the short term. And there needs to be monitoring and evaluation to ensure the guidelines are correctly implemented.</p>
<p>The balance is tipped in favour of widescale implementation of the guidelines because they are likely to lead to the well-being of individual patients. This would include reductions in death and disability, and improved equity, quality of life and accompanying cost savings.</p><img src="https://counter.theconversation.com/content/110456/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine Ina Davies receives funding from The Wellcome Trust. </span></em></p><p class="fine-print"><em><span>Ryan G Wagner does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>At the turn of the century, the greatest threats were posed by infectious diseases today, the biggest threats are posed by lifestyle diseases.Justine Ina Davies, Professor of Global Health, Institute for Applied Research, University of BirminghamRyan G Wagner, Research Fellow, MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1106302019-01-31T11:22:09Z2019-01-31T11:22:09ZWhy screen time for babies, children and adolescents needs to be limited<figure><img src="https://images.theconversation.com/files/256316/original/file-20190130-108367-xkkbx4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Less recreational screen time is better for children. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There is increasing concern about the amount of time children and adolescents are spending in recreational screen time. There’s also increasing <a href="https://www.bbc.co.uk/news/health-46749232">controversy</a> over whether or not screen time is actually harmful. </p>
<p>Since 2016, we (researchers who’ve contributed to the development of the <a href="http://www.csep.ca/view.asp?x=696">24-hour movement guidelines for children and adolescents</a>) have led a number of wide-ranging <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4849-8">reviews </a> of the scientific evidence on the <a href="http://www.nrcresearchpress.com/doi/pdf/10.1139/apnm-2015-0630">impact</a> of screen time from infancy to early adulthood. We examined whether or not the amount of recreational (spare time, non-educational) digital screen use influences health. These included risks such as obesity, reduced sleep, low physical fitness, anxiety and depression. We also looked at the impact of recreational screen time on social and emotional as well as cognitive and language development, well-being and educational attainment. </p>
<p>These reviews demonstrated that high levels of screen time, now typical among children, are associated with potential harm. And they showed clearly that less recreational screen time is better for avoiding obesity, and for promoting sleep, physical fitness, and cognitive, social and emotional development.</p>
<p>Over the past three years the evidence reviews generated authoritative guidelines nationally in <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/npra-0-5yrs-brochure">Australia</a>, <a href="https://csepguidelines.ca/early-years-0-4/">Canada</a>, <a href="https://theconversation.com/heres-how-much-kids-need-to-move-play-and-sleep-in-their-early-years-107024">South Africa</a>, the UK and internationally. </p>
<p>We were all involved in the development of global guidelines for zero to four year-olds for the <a href="https://www.who.int/end-childhood-obesity/news/public-consultation-2017/en/">World Health Organisation</a> (WHO). These guidelines all recommended that recreational screen time should be limited in infancy, childhood and adolescence. </p>
<h2>limiting screen time</h2>
<p>Guidelines from Canada, Australia, and South Africa recommend that recreational screen time should be avoided in the under two’s, limited to one hour per day in two to four year-olds, and to two hours per day in five to 17 year-olds. </p>
<p>Based on our collective experience in developing these guidelines it’s clear that these limits on recreational screen time are needed for a number of reasons.</p>
<p>First, the evidence suggests strongly that limits are required. The recommendations to limit screen time were based on a rigorous, <a href="http://www.nrcresearchpress.com/toc/apnm/41/6+%28Suppl.+3%29">widely-accepted</a>, and <a href="https://bmcpublichealth.biomedcentral.com/articles/supplements/volume-17-supplement-5">evidence-based</a> approach. This included systematic reviews, critical appraisals of the evidence, national and international consultation and review, and transparent reporting.</p>
<p>Second, less recreational screen time is clearly better. There is evidence in support of the specific time limits recommended and our wide consultation with stakeholder individuals and organisations – including parents and families – suggests that they find time limits helpful.</p>
<p>Third, our recommendations that recreational screen time should be limited are consistent with other recent and thorough reviews of the evidence conducted by authoritative bodies such as the <a href="https://www.who.int/end-childhood-obesity/publications/echo-report/en/">WHO</a> and the <a href="https://www.wcrf.org/dietandcancer/summary-third-expert-report">World Cancer Research Fund</a>. These reviews highlighted the important role of recreational screen time in the development of obesity, many cancers and myopia. </p>
<p>Our specific recommendations are also consistent with those made by the <a href="https://healthychildren.org/English/family-life/Media/Pages/Where-We-Stand-TV-Viewing-Time.aspx">American Academy of Pediatrics</a> and the <a href="https://www.cps.ca/en/documents/position/screen-time-and-young-children">Canadian Paediatric Society</a>.</p>
<p>Taking a laissez-faire approach to screen time would be to ignore the wider context. This is that modern childhoods are characterised by low physical activity, excessive sitting and time indoors. Children and adolescents also suffer from poor motor skills, high levels of myopia, increased risk of type 2 diabetes and hypertension. </p>
<p>And as new forms of screen time emerge, a precautionary approach is required – some limits on recreational screen time would be prudent until it is clear that there are negligible harms.</p>
<h2>Still time to act</h2>
<p>Some <a href="https://www.rcpch.ac.uk/resources/health-impacts-screen-time-guide-clinicians-parents">argue</a> that the “genie is out of the bottle” in relation to screen time. But this is defeatist. The same arguments could have been made in relation to control of tobacco and alcohol and sugar. But it is now accepted that unlimited exposure to these substances isn’t compatible with public health. And constraints are accepted as essential. </p>
<p>In addition, in many parts of the world the genie may not yet be out of the bottle. In many low- and middle-income countries exposure to recreational screen time may still be relatively low among children.</p>
<p>There is also scope to prevent excessive screen time in babies and young children, acting before adverse, or at least sub-optimal, lifestyle habits become established later in childhood or adolescence.</p>
<p>Screen time harms can be indirect as well as direct – recreational screen time increases with age and as it does it displaces more beneficial forms of sedentary behaviours such as reading. Screen time also displaces physically active play, and sleep.</p>
<p>Recreational screen time may seem to be an inevitable part of modern life. But even from infancy and early childhood, we should all be concerned about the potential for harms – at least until new, robust evidence demonstrates no harm. The most prudent approach would be cautious, attempting to follow recent evidence-based guidance that recreational screen time should be restricted.</p><img src="https://counter.theconversation.com/content/110630/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John receives funding from The Scottish Government Chief Scientist Office, WHO, Hannah Foundation, Cunningham Trust, and Inspiring Scotland.</span></em></p><p class="fine-print"><em><span>Anthony (Tony) Okely receives funding from the Australian Government Department of Health, National Health & Medical Research Council of Australia, and NSW Department of Health</span></em></p><p class="fine-print"><em><span>Catherine Draper receives funding from the British Academy for the Humanities and Social Sciences. She has an honorary affiliation with the Division of Exercise Science at the University of Cape Town</span></em></p><p class="fine-print"><em><span>Mark S. Tremblay receives funding from the Public Health Agency of Canada, the Canadian Institutes of Health Research, the Conference Board of Canada, the University of Alberta, the Canadian Society for Exercise Physiology and in kind from ParticipACTION. </span></em></p>Global experts warn that excessive screen time increases the risk of obesity, low physical fitness, anxiety and depression.John J Reilly, Professor of Physical Activity and Public Health Science, University of Strathclyde Anthony Okely, Professor of Physical Development, University of WollongongCatherine Draper, Senior Researcher, University of the WitwatersrandMark S Tremblay, Professor of Pediatrics in the Faculty of Medicine, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1098332019-01-22T13:56:50Z2019-01-22T13:56:50ZInjuries from burns in Kenya affect mostly children and happen in homes<figure><img src="https://images.theconversation.com/files/254485/original/file-20190118-100279-e0pbvo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many children got burn injuries because of poor housing.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>An estimated 180,000 people die every year <a href="https://www.who.int/news-room/fact-sheets/detail/burns">worldwide</a> as a result of burns and survivors often suffer terribly. Burn injuries are particularly common in low- and middle-income countries. </p>
<p>It’s estimated that burns are the cause of 20% of all trauma seen at Kenyatta National Hospital, one of two national referral hospitals in Kenya. We did a <a href="https://www.sciencedirect.com/science/article/pii/S0305417917306113">study</a> on patients admitted with burns to the hospital to determine the demographic pattern and risk factors for the injuries. </p>
<p>Our findings confirm other <a href="https://www.researchgate.net/publication/313034987_A_systematic_review_of_burn_injuries_in_low-_and_middle-income_countries_Epidemiology_in_the_WHO-defined_African_Region">research</a> which shows that in sub-Saharan Africa injuries from burns occur mainly in homes and children are most affected.</p>
<p>We found that burns were most common among children under five years. And the main causes of burn injuries in adults were; fire or flames, contact with hot objects, high voltage electricity and chemicals.</p>
<p>Based on our findings we identified areas of intervention for burn injury prevention strategies. In our recommendations we suggest that a number of risk factors should be addressed in burn injury prevention programmes for Kenya. The main factors we identified were low levels of education, use of kerosene for cooking and lack of knowledge of burn injury prevention and fire safety. </p>
<p>People with lower levels of education end up in jobs with less pay and are therefore more likely to live in informal settlements. Use of kerosene for cooking or lighting sometimes results in stove or lamp explosions if adulterated fuel is used, or appliances are handled poorly. Lack of knowledge of fire safety and burn injury prevention can also result in burn injuries.</p>
<h2>What we found</h2>
<p>Many children sustain hot fluid spillage or emersion burns at home mainly as a result of poor housing, overcrowding and inadequate supervision by caregivers. Some sustain injuries after touching electricity wires while playing on balconies of buildings constructed in close proximity to high voltage electricity lines.</p>
<p>Burn injuries in adults occur in homes, mostly after clothes catch fire or when a flammable substance spills and catches fire or results in an explosion. These happen in homes during cooking, lighting or extinguishing fires, during functions after spirit or gel burners catch fire or when houses catch fire. People have also sustained bad burn injuries or died in schools, factories and motor vehicle fires. </p>
<p>Slum or shack fires have been reported frequently and have resulted in many injuries and fatalities. In these cases the <a href="https://citizen.co.za/news/south-africa/1968651/shack-fires-devastate-cape-town-and-gauteng/">cause</a> of the tragedies is usually carelessness, lack of knowledge, overcrowding and poverty.</p>
<p>Explosions related to fuel tankers, leaking oil pipelines or petrol stations have also been a cause of many burn deaths and burn injuries in <a href="https://www.youtube.com/watch?v=vpZaIHcPCfc">Ghana</a>, <a href="https://www.nation.co.ke/news/Established-Cause-of-Sinai-fire-tragedy-/1056-1368976-tsks1nz/index.html">Kenya</a> and <a href="https://www.bbc.com/news/world-africa-18814738">Nigeria</a>. In 2016, about <a href="https://www.standardmedia.co.ke/article/2000226481/mayhem-on-the-road-as-dozens-caught-up-in-naivasha-fire-tragedy">40</a> people died and scores were injured after a lorry carrying petroleum products rammed into a line of motor vehicles near Naivasha in Kenya. </p>
<h2>Prevention</h2>
<p>Burn injuries are a global public health problem. Fortunately, they are preventable. This has been demonstrated by the considerable progress made by high income countries in their burn injury prevention strategies. There are documented burn injury prevention <a href="http://apps.who.int/iris/bitstream/handle/10665/97938/9789241501187_eng.pdf?sequence=">success stories</a> from several countries such as Australia, Canada, New Zealand and United Kingdom. </p>
<p>Low- and middle-income countries tend to focus on treatment with little or no funding allocated to injury prevention and research. But treating burn injuries is expensive which is why policies and legislation need to be developed to reduce them. </p>
<p>Our study shows that prevention strategies should include concerted public health campaigns. These must comprise of driving awareness, through the media, of the need for burn injury prevention. The American Burn Association has an annual <a href="http://ameriburn.org/prevention/burn-awareness-week/">burns awareness week</a> and in South Africa, fire safety campaigns are often <a href="https://www.youtube.com/watch?v=xnkIjkZY-4w">reported</a> on in the media. </p>
<p>In addition, policies and laws targeting specific risk factors should be developed and enforced. For example, building and electrical codes in the US have <a href="http://apps.who.int/iris/bitstream/handle/10665/97938/9789241501187_eng.pdf?sequence=1">resulted</a> in fewer electrical burn injuries in homes. Kenya should make it illegal for buildings to be constructed close to high voltage electricity lines.</p><img src="https://counter.theconversation.com/content/109833/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Kimani Wanjeri does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Research found that burns were most common among children under five years.Joseph Kimani Wanjeri, Lecturer - Department of surgery Speciality: Plastic & Reconstructive Surgery, University of NairobiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082052019-01-15T15:12:52Z2019-01-15T15:12:52ZSand flea disease is neglected: what needs to be done<figure><img src="https://images.theconversation.com/files/250639/original/file-20181214-185234-1rpjdq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People can suffer terrible consequences from being bitten by sand fleas. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>Tungiasis (sand flea disease) is a parasitic inflammatory skin condition caused by the female fleas Tunga penetrans (most prevalent) and less commonly Tunga trimamillata <a href="https://www.ncbi.nlm.nih.gov/pubmed/19712148">species</a>. The condition is also known by <a href="https://www.who.int/lymphatic_filariasis/epidemiology/tungiasis/en/">names</a> such as sand flea, jigger, chigger, nigua, kuti, bicho-do-pé, puce-chique, and pique infestation. Tungiasis occurs mainly in low- and middle-income <a href="https://www.ncbi.nlm.nih.gov/pubmed/23949241">countries</a> and has been classified as a neglected tropical disease by the <a href="https://www.who.int/neglected_diseases/diseases/en/">World Health Organisation</a> (WHO). It’s one of the most widespread parasitic skin diseases <a href="https://www.ncbi.nlm.nih.gov/pubmed/11348517">in</a> sub-Saharan Africa, Latin America and the Caribbean. Ina Skosana asked a group of public health researchers to explain.</em></p>
<hr>
<p><strong>What is tungiasis?</strong></p>
<p>Tungiasis is identified by clinical examination of lesions caused by fleas burrowing into the skin, often on the toes, soles of the feet or hands. Each infected child can harbour up to hundreds of parasites – usually on their <a href="https://www.ncbi.nlm.nih.gov/pubmed/17472674">feet and hands</a>. It typically <a href="https://www.ncbi.nlm.nih.gov/pubmed/12768415">presents</a> as single or multiple itching red-brownish spots in the early stage. The mature stage of the disease presents as a white or yellow patch with a central black dot. And it presents as a black crust surrounded by necrotic tissue in the late stage when the flea is dead. </p>
<p>Tungiasis is characterised by itching, pain, and inflammation. Left <a href="https://www.ncbi.nlm.nih.gov/pubmed/12100437">untreated</a>, the inflammation and secondary bacterial infections can have devastating effects. It can lead to deformation and loss of nails, disfigurement of the feet, death of surrounding tissue, tetanus, gangrene, sepsis and <a href="https://www.ncbi.nlm.nih.gov/pubmed/22941398">even auto-amputation in extreme cases</a>.</p>
<p>Direct person-to-person transmission of tungiasis is not possible. This is because the parasite must go through off-host phases of its life cycle in the soil before infecting another human. The female parasite starts the cycle by burrowing into the host skin and feeding on host blood. This allows it to increase dramatically in size. It then expels eggs to the ground. The eggs develop in the environment, larvae hatch, develop into pupae, and finally the fleas emerge and find a host. The cycle ends with <a href="https://www.ncbi.nlm.nih.gov/pubmed/12756541">natural death</a> of the female embedded parasite within the skin.</p>
<p><strong>Who gets tungiasis?</strong></p>
<p>Tungiasis affects both humans and animals. In <a href="https://www.ncbi.nlm.nih.gov/pubmed/25390058">endemic areas</a>, children between the ages of 5 and 14 are usually most heavily affected. Prevalence rates can be as high as 97% in children, compared to 60% in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/22941398">general population</a> in highly endemic resource-poor communities in South America and in sub-Saharan Africa. It’s also one of the most common conditions of travellers returning from <a href="https://www.ncbi.nlm.nih.gov/pubmed/17995532">endemic areas</a>.</p>
<p>Tungiasis has long been neglected by both the scientific community and health care providers. As a result, accurate estimates on the global burden of the disease are <a href="https://www.ncbi.nlm.nih.gov/pubmed/15368123">limited</a>. The WHO estimates that 20 million people are at risk of developing tungiasis in South America. In 2014, an estimated <a href="about%204%%20of%20the%20total%20population">1.4 million Kenyans</a> suffered from the condition and 10 million were at risk. There were 265 deaths due to the disease in 2011 in Kenya, according to a local <a href="http://www.jigger-ahadi.org/index.html">non-governmental organisation</a>. Considering many cases remain unreported, it’s highly likely that the number of deaths is much higher. </p>
<p>In Uganda, tungiasis affected <a href="http://www.health.go.ug/docs/Press%20statement%20on%20NTDs.pdf">2.4 million people</a> and six million others were at risk in 2012. </p>
<p>A 2015 <a href="https://www.ijsrit.com/uploaded_all_files/2582587130_q12.pdf">Kenyan study</a>, involving 20 primary schools, showed that about 65% of students with severe tungiasis had difficulty walking.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/29309411">Another study</a> in Kenya showed that tungiasis had a moderate to very large impact on the quality of life of the majority (78%) of affected children. This is attributed to difficulty in walking, sleep disturbance and concentration difficulties in class.</p>
<p><strong>How can it be treated?</strong></p>
<p>There’s no approved standard drug therapy for tungiasis. In fact, the most common current treatment is surgical removal of the embedded fleas with a sterile needle and disinfection of the residual skin. But in resource-poor communities this practice is frequently performed unhygienically. This almost inevitably leads to additional bacterial infections and more inflammation. It can also lead to the transmission of viruses like HIV, Hepatitis B and Hepatitis C. </p>
<p>A range of parasiticides and chemical agents have been explored for treating tungiasis. But there’s little data to support their safety and effectiveness.</p>
<p>Recently concluded small clinical studies in <a href="https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003058">Kenya</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5345134/">Uganda</a> showed considerable benefits, with limitations. A topical treatment using dimeticone (NYDA®; a synthetic silicon oil with varying viscosity) showed 78% efficacy in Kenya and 95% in Uganda. It works by suffocating the embedded parasite – otherwise it’s not lethal to the parasite, its eggs or secondary bacterial pathogens, and is unlikely to offer sustainable, long-term treatment outcomes. </p>
<p>Locally known repellents from natural resources (neem, coconut oils, castor oil, palm oil and Aloe Vera) have also been explored. Some countries, such as Kenya, have even included them in local government guidelines. </p>
<p>While researchers have been investigating new treatments, none has shown clear promise as a practically viable and clinically-proven therapeutic solution. </p>
<p>More importantly, it’s almost impossible to eliminate tungiasis in endemic areas without improving people’s living conditions. Nonetheless, greater focus should be given to developing new formulations or re-purposing currently available topical antimicrobial candidates with combined parasiticidal, ovicidal, antibacterial and anti-inflammatory activities, to address this truly neglected yet important clinical condition.</p><img src="https://counter.theconversation.com/content/108205/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Tungiasis, a disease caused by fleas, is neglected and needs action in sub-Saharan Africa.Solomon Abrha Bezabh, Lecturer, College of Health Sciences, Mekelle UniversityGregory Peterson, Professor of Pharmacy, University of TasmaniaJackson Thomas, Assistant Professor/Senior Lecturer in Pharmacy, University of CanberraJorg Heukelbach, ProfessorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082062019-01-02T09:11:52Z2019-01-02T09:11:52ZWhy improving access to surgery in childbirth makes economic sense<figure><img src="https://images.theconversation.com/files/251276/original/file-20181218-27758-j579lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women waiting to see a doctor at a hospital in Uganda. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal mortality remains high around the world, with more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext">303,000</a> women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa. </p>
<p>A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About <a href="http://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1">15%</a> of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.</p>
<p>One potentially devastating complication in childbirth is <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">obstetric fistula</a>. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">50 000 to 100 000 women </a>in sub-Saharan Africa develop fistula every year. </p>
<p>If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.</p>
<p>While conducting <a href="https://www.ncbi.nlm.nih.gov/pubmed/27918334">research</a> in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.</p>
<p>In my more <a href="https://academic.oup.com/heapol/article/33/9/999/5106382">recent research</a> I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost. </p>
<p>Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.</p>
<p>Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings. </p>
<h2>What we found</h2>
<p>Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region. </p>
<p>We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system. </p>
<p>We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.</p>
<p>We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51. </p>
<h2>What is needed</h2>
<p>Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries. </p>
<p>But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas. </p>
<p>Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula. </p>
<p>While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.06.011">as 99%</a>. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes. </p>
<p>All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.</p><img src="https://counter.theconversation.com/content/108206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.</span></em></p>If women don’t have access to quality emergency surgery, they can develop dibilitating complications such as fistula.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.