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The paper draws attention to issues and challenges pertaining to global health from an Asian perspective. It highlights threats to sustainable global health, scenarios and challenges in developing and Asia Pacific countries. These include water and sanitation, the avian influenza, non-communicable diseases, dengue and chikungunya, and natural hazards. It further recommends the entry points to resolve these issues and challenges. It reiterates further that health is critical for security, peace, human aspiration, social solidarity and stability, and it involves the person, governments and nations.
Key Words: global health, natural health hazard, health in developing countries
What are the threats to sustainable global health? Firstly, it would be poverty and inequality. There are social groups which seem to be in different poverty lines; the gender issues and also issues of rural versus the urban areas. Secondly, is the rising vulnerabilities and these include natural hazards, communicable and chronic diseases. Thirdly, it would be water and sanitation as access to safe water and proper sanitation is critical. Fourthly, it is uncontrollable urbanization. There is an increase of slums in mega metro cities and how it has impacted rural areas. Fifthly, it is the marginalization of the rural population due to rapid development. Sixth, it is the unsafe workplace and home condition due to exposure to poor hygiene and dangers at the work places, homes, and healthcare facilities. Last but not least will be financial investment, as with less money invested it will have profound impact in the delivery of better healthcare.
2. SCENARIOS IN DEVELOPING AND ASIA PACIFIC COUNTRIES
What is clearly evident are the constraints in the healthcare resources including migration of skilled workers in developing countries. There is a huge variation in the quality of healthcare among developing countries as different countries are at different developing stages and having limited technical capacity in human capital. Health financing system is not efficiently managed and there is limited coverage. There is a poorly developed health information systems in most of these countries. The Asia-Pacific region covers 48 countries and has 3.45 billion people which comprises 53% of the world population. Since there are so many countries, there are diverse development, diverse demographic, environmental, and economic backgrounds; and of course, there are differences and similarities in the public health practices .The projected global distribution of total death shows that communicable diseases, maternal and perinatal conditions and cardiovascular diseases predominate. It also shows that we have our fair share of cancers, diabetes, chronic respiratory diseases, other chronic diseases and injuries. . In the Asia-Pacific, the communicable diseases are now on the up rise. It contributes to 20% while the non-communicable diseases contribute to about 60% of all deaths. TB is making a comeback. There are 5 million new cases with 800,000 deaths. Similarly with Malaria which is now endemic in 20 countries. Cancer is a main contributor now causing 30% of all deaths. Maternal death and newborn death are also still persisting problems .
Some of the issues that we are facing and issues that we need to know and we need to understand have to be highlighted.
2.1 Water and Sanitation
In the Asia-Pacific, 18% of the population still lack drinking water. Two billion people lack proper sanitation. There are disparities persisting in social classes and of course within the countries related to issues of inadequate water supply. The water may be available but the quality is questionable mainly due to improper storage of water. Even if water can be stored, there are a list of waterborne diseases like dengue lurking in the background. 1.8 billion people die annually from inadequate drinking water and sanitation and 90 % of these are children. These are those under 5-year-old and they die from diarrheal diseases and 88% of the diarrheal diseases is due to inadequate water supply, sanitation, hygiene, and this happens mainly in the developing countries. Diarrhea and other infectious diseases such as worm infestation will affect nutritional status of children and this may contribute to the underdevelopment and the learning
2.2 Avian Influenza
If we were to look at the chronology of the evolution of this virus since 1918, it started changing and had been changing ever since. Presently, the viruses are of diverse strains and diverse infectivity. There have been deaths and it does not only affect Asia but the whole world as well. We would have thought it would infect the young, the very old, the debilitated and the immune deficient. However, the victims are healthy young people, very healthy middle-aged classes. Hence, this is a disease that transcends all the age groups. This is a disease that will infect anyone who is exposed and who may succumb to it. A lot of the stakeholders are getting involved. It is not only the Ministries of Health but also includes the private and public sectors. The obvious response was to implement screening and quarantining. There were travel restrictions, banning of public gatherings, school closures, public education information and promotion of personal hygiene. There was also disease surveillance and vaccination. We have never seen this kind of undertakings with other diseases. Of course, the big question mark was which intervention would be cost effective. Was it washing of hands, using of aerosols, having public campaigns or covering your nose when you sneezed was the most effective. Individuals and communities are now also involved. There is suddenly a phenomenon of social consciousness from gatherings and meetings. There was also this new ethic that when you cough, you have to close your mouth or you have to cover your nose. There was also the use of masks. Surely the young children do not like having their faces covered. There was also this new procedure of hand hygiene. There were issues connected to household ventilation, letting fresh air coming in, and using all kinds of filtration. There was issue with the vaccination. The question was whether it could be produced to meet the demand and whether it would be accessible by developing countries. How much was it going to cost? Can developing countries afford this? Is the vaccine safe enough? How efficacious is the vaccine? What is the financing mode? Can the public program implement it effectively? Evidently there is hope. However there are also these questions that come along with hope. It impacted all the health services in most of the countries. The financial impact was phenomenal. Just referring to the prediction of SARS, Hong Kong flu, and Spanish flu; the World Bank reckoned that the impact would be 0.7 to 4.8 of the global GDP and of course, there is 70% effect on productivity due to absenteeism and also efforts to avoid the infection.
What are the lessons learnt? Firstly, the pandemic posed huge public health challenges to the world with tremendous social and economic impacts. Secondly, we have seen systematic and unsystematic responses to curb the pandemic. What are the interactions between the various stakeholders? In fact, the more intellectual they are, the more they add to the confusion and the chaos. The public health intervention remained the most important issue. Chronic diseases management is an important element in the prevention of death in the pandemic. Though secondary prevention through vaccination is thought to be effective, it may not be afforded by developing countries. The cost-effective measures like simple washing of hands, simple covering of mouth and the face should be given priority in the mitigation efforts. Education is also important.
2.3 Non Communicable Diseases
Daar et al (2007) highlighted the grand challenges and what we need to do with these diseases. The non-communicable diseases would include diseases of the lifestyle; tobacco control, injuries, violence, mental and neurological illnesses, substance abuse and thalassemia. The chronic NCDs had become a leading cause of death, morbidity and disability in this region. Cardiovascular disease, cancer, chronic lung diseases and diabetes have emerged as major public health problem. Mental health and associated disorders affect a great number of people. Now that we are living longer, certain genetic diseases are beginning to be increasingly recognized such as Parkinson’s and Alzheimer’s. The burden of chronic diseases in the developing countries are likely to increase if we do not put in measures to curb that .The grand challenges in the NCDs include firstly to raise public awareness. This includes political priority and commitment by governments to promote healthy lifestyle through effective education and public engagement. Economic legal environmental policies need to be enhanced. There is a need to study and address the impact of government spending and taxation on health. Development and implementation of local, national and international policies need to be in place. Regulatory restraints to discourage the consumption of alcohol, tobacco and unhealthy food should be in place. A study to assess and address the impact of poor health on economic output and productivity should also be conducted. Risk factors need to be looked at firstly through universally deploying proven measures to reduce for example, tobacco use. Secondly is to increase the availability of the consumption of healthy food. We should promote lifelong physical activity, to exercise every day and regularly and to inculcate better understanding of environmental and cultural factors that affect behavior. Goal D is to engage businesses and communities to be involved as a key partner in promoting health and preventing diseases. Goal E would be to mitigate the health impacts of poverty and urbanization and to study how to address this issue. This should link with the Build Environment organization and also the CNCDs. Goal F would be to disorientate the health system, allocate resources within the health system based on burden of diseases, to conduct more health professional training and encourage practice towards prevention .
2.4 Dengue and Chikungunya
These are diseases of the poor and almost 2.5 billion people are at risk of acquiring dengue. The occurrence of chikungunya has been increasing since 2004 and this is now endemic in 23 countries. Dengue covers the whole world and in fact America is not even safe from dengue anymore.
Chikungunya is distributed all over, especially so in Asia and in the Sub-Saharan Africa. A review showed that the resultant burden was likely to increase under changing environmental conditions. While serious efforts are being made to control these diseases, the current potential solution such as vaccination has yet proven to be effective or even available. The social resources needed for vector control are significant in terms of human resources to manage and sustain community-based program. The determinants of dengue and chikungunya could be physical, environmental, demographic, socioeconomic, and there are other determinants like perceptions of the diseases. A way of trying to mitigate this problem is to build vulnerability maps. This would identify the hotspots, resource, policy development, spending priorities, targeted interventions, sustained planning, provide valuable information on priority areas and identify the most vulnerable populations of the target.
2.5 Natural Hazards
Natural hazards impact health and health systems. The tsunami that hit Indonesia, Thailand, and Malaysia in 2007 and some of the islands resulted in injuries, deaths, infections as well as long-term social psycho-emotional problems including malnutrition. There were more than 300,000 deaths in 8 countries. The injuries related to tsunami are different kinds of injuries. It impacted the health services where some of the clinics were destroyed, manpower affected by those killed and there were people displaced all over the world. In Indonesia and Thailand, most of the clinics were destroyed. In Aceh, 700 health workers died. The financial estimates by the World Bank goes into millions. Floods are a normal occurrence in countries like Bangladesh and forest fires are impacting some countries. The Asia Pacific has still a substantial forest reserves and burning of this forest would cause pulmonary diseases.
3. ENTRY POINTS
The recommended entry point for poverty and inequality includes a basic hygiene education, access to high quality healthcare service, affordable pharmaceuticals and medical services, and better health protection. For the rising vulnerability, there must be enhanced outreach and vaccination programs. Acute prevention measures must be provided such as vector control. Information exchange must be fostered. Effective surveillance must be included. Mitigation measures must be enhanced. In the area of strengthening the knowledge and awareness, cost-effective and comprehensive health must be achieved through formal and informal education. Applied research must also be strengthened. This is where the universities will play an important role in developing the hygiene and public health policies. Public health can be further strengthened through e-media and information technologies. For water and sanitation, there must be efforts to provide safe water and secure investment in proper appropriate sanitation system. For urban and rural health, there must be policies and good governance included to improve the healthcare system. While providing access is one, fostering of health delivery system is the other. Efforts must be made to provide preconditions of establishing public health systems, training of health workers and of course to do a holistic epidemiological characterization and monitoring of the public health in urban and also in rural areas.
For societal and structural health awareness, there is a need to strengthen public organization to make sure that adequate hygiene, nutrition, and health is for all the public. Steps must be made to establish mechanism of enhancing health competence. This may be done through the school, the workplace and also the communities to facilitate action to urge sectors responsible to achieve safe and decent workplaces, to promote awareness and individual capacities for health maintenance including physical, mental, emotional and spiritual well being. In terms of investment, it must be transparent, accountable and be effective. There should be a design how investment can be in place. There must be an insurance scheme for provision of the health services, design and implementation of health insurance and more importantly, support of public-private partnership projects is greatly welcomed. With regards to the global GDP, 44.5 trillion is spent on health spending. However it is interesting to note that Africa and developing countries which contribute to 90% of the illness burden of the world is only spending 11% of the global spending on health.
The underlining message is that good health is good wealth as health is the bedrock to all facets of life, economic prosperity and it fosters better investment opportunities and improves productivity of human resources. Good health is good governance. Health fosters good governance. A healthy workforce, safe homes and working conditions, social health protection and access to water and sanitation are noble objectives.
Good health fosters stable cities, rural areas, and also societies. Good health is good for security and peace building. Health has become a basic human right. It is the basic human aspiration irrespective of the religious affiliation or cultural background. Providing sufficient health services is not only the expression of social solidarity, but also the foundation of social stability and the basis of sustainable development including assurance of human security worldwide. Last but not least, health is everyone’s business; it is everybody’s, it is the government’s and it is the country’s.
- World Health Organisation (WHO)., 2008. Health in Asia and the Pacific
- World Health Organisation (WHO)., 2004. Global Burden of Disease, Update of (2008)
- Abdallah Daar et al., 2007. Grand Challenges in Global Health, Nature, 450 (22), 494-496