Category Archives: Prevention

The challenges of tobacco control

The WHO FCTC (Framework Convention on Tobacco Control) has been trying to regulate tobacco production the world over by restricting the use of land available for tobacco farming. The reasoning behind this is  two-fold: first tobacco has been singled out as the greatest preventable cause of death. Second the use of scarce farmland, especially in food deficient areas around the world, has been said to contribute to food shortage and hunger.

As expected, the convention has drawn the ire of tobacco farmers, the tobacco industry and their interest groups. Focal interest groups have amassed a war-chest to put up a fight. The FCTC isn’t any far behind; it has painted tobacco use as the greatest evil plaguing public health today.

What makes this battle interesting to watch is that both the sides have a valid point to the argument. The farmers point out, nothing gives them as much of a return from the land as tobacco. That is a valid argument, though not entirely so. Tobacco farming is very high up indeed in the value chain but projects elsewhere have  shown that it is indeed possible to derive as much returns from the land by means of farming other suitable cash crops.

Tobacco related illnesses are known to cause almost 100 billions dollars of healthcare costs in the US alone every year. Such costs have to been borne by pooled resources, either through the government or through private insurance. So it is no surprise that people will look to curb such costs for the sake of the greater common good.

The FCTC isn’t the first blow anti-tobacco campaigners have managed to land at the tobacco industry. Tobacco tariffs are already stiff in many parts of the world. A few months ago the Australian government passed a legislation to enforce uniform (read visually unattractive) labeling on tobacco products, a move that has been upheld by the Australian High Court. Similar attempts are underway in many part of the world.

And some people are even talking about disallowing cigarette smoking without a license.

Legislating tough tobacco laws may however be the easy part. The exorbitantly high cigarette tax in New York has proliferated an entire industry trafficking cigarettes along I-95, from Virginia where such taxes are almost non existent to New York where such taxes are the highest. Gangsters that used to engage in gun and narcotic trade earlier now engage in the much easier and lucrative tobacco trade. This not only defeats the public health purpose of such legislation, but also causes loss of much needed revenues (illegal tobacco trade costs as much as 10 billion dollars in lost revenues in the US).

Our attempt at enforcing a strict ban on drugs holds valuable lessons. While enforcement has been very heavy in the US, drugs of abuse are still very easily available undercover and usage is alarmingly high in the general population. What this has essentially done is drive the whole trade underground. In the meantime, strict enforcement of drug control related rules has resulted in the largest prison population in the world in the US (25% of the entire global prison population). Incarceration on the other hand leads to its own irreversible social rot in the affected. Furthermore, underground drug trade in the US has fueled and fanned a drug Mafiosi in Mexico that has been declared almost impossible to wipe out even after the loss of tens of thousands of people in drug related violence and billions of dollars spent in the fight.

Tobacco certainly is one of the greatest preventable public health threats; tobacco use in no way should be encouraged or facilitated or condoned. However trying to force tobacco use to one dark corner using all our might may prove to  be another social disaster the with hitherto unfathomed consequences, the way our battle with drug enforcement has been.

Educating  and subtly modulating behaviour against tobacco use will likely give us the best results; trying to ham-handedly force people out of tobacco may ultimately backfire. After all, humans are a creature defined by free will; they certainly appreciate better health but also appreciate the the right to exercise their free will at least equally so.

Do vaccines work?

Big news is made about whether vaccination works. See here and here.  (The links are posted not out of endorsement, but to point out to the reader what they may run into). Often times the uproar has a hint of the sinister, fuelled by ulterior motives; however there is  also a lot of misinformation floating around and a significant amount of genuine concern that is fuelled by such misinformation.

Death rates for many infectious diseases have fallen  through out the world. Vaccines have had a great part to play in reducing such deaths. Conspiracy theorists posit that that vaccinations were there at the right place at the right time; that they happened to superimpose themselves upon situations where death rates were already falling, that they are part of a grand conspiracy of the medical-industrial complex unto mankind.

To examine if there is a logical basis for such a point of view, let us take a historical look at the data that is available. We will look at two disease patterns: polio, and measles and how they have been affected by the introduction of vaccines.

Lets start off with disease and death trends for measles.

US Measles death rates

Approximately between 1915 and 1955, case fatality rates for measles dropped by around 100 times in the US and the UK. Measles vaccines were introduced in 1963 in the US and 1968 in the UK.

Opponents of vaccines often latch onto these numbers to discredit vaccination against measles: that measles was already on the wane when vaccines were introduced; and that the vaccine simply laid claim to gains of some other strategy that had worked to reduce death rates.

But here is the rub: measles vaccines have never really claimed to reduce case fatality rates (c.f. total deaths); however what the vaccine has indeed shown to do is that it reduces the number of cases in the first place. Lets take a look at this graph.

US Measles Incidence

Between 1958 to 1962, the United States had an average of 503,282 cases and 432 deaths from measles. Further more, in large city areas, before the introduction of the vaccine, epidemic outbreaks occurred every 2-5 years.

In the US the last epidemic was in 1989-1991. In the last 60 years there has been a 4000 fold decrease in measles deaths. Since 1997 fewer than 150 cases have been reported per year.

In 2000 measles was declared eliminated (meaning there is no endemic transmission) in the US. The majority of the cases in the US since then have either been importations from other areas, or have been in children that have not been immunised.

Which brings us to the earlier part in the discussion, that we stepped aside from: why was there such a drop of 100 fold in measles deaths from the around 1910-1960?

There do not seem to be clear answers here. The trend falls in line with overall falling death rates, but the drop was far more acute to be explained by that alone. Improved nutrition, sanitation, antibiotics (remember it’s usually the secondary infections that kill in measles), the use of high flow oxygen in pneumonia, the introduction of Vitamin A may have had individual roles to play, but none of these factors explain the drop in the entirety.

The less than 3  deaths that we have had from measles in the US for the past 11 years is probably due to a host of factors in association with vaccination; but it it no hyperbole to conclude that high prevalence of vaccination had the single most important role in eliminating measles as a public health threat in the US and much of the Americas.

What’s TB’s problem anyway

You’ve got to give it to the global health community to come up with atrocious goals and targets every once in a while. You might as well have been tempted to discount it for unwarranted grandiosity propelled by their own sense of hubris, had it not been for their penchant for achieving them.

The Stop TB partnership’s attempt to half  TB prevalence by 2015 (base levels at 1990) and  eliminate TB from the face of planet by the year 2050 is one such goal.

To those of us who have been down in the trenches with TB, such an attempt is nothing short of heresy. The problems with controlling TB are manifold. The tools of the trade are ancient. Sputum microscopy, the only available diagnostic tool in much of the world, has limited efficacy and is more than a hundred years old. Isoniazid, the mainstay of treatment everywhere is 60 years old. (See a brief timeline of TB here.) In much of the world the only “recent” innovation in the fight against TB was the implementation of DOTS- which to be sure, has been credited with a lot of success in halting or reversing the tide of  TB in some parts of the world. 

However, the partnership is well aware of the resource and knowledge  gap for the task at hand. Here (table, right) is an estimate of funding requirements up until 2015.

In order to accelerate and prioritize research, the partnership in conjunction with the with the Stop TB Department at the WHO, has come up with the TB Research Movement. Working groups operating across the continuum of  fundamental research to drug and diagnostics to implementation have come up with priority areas for research and knowledge creation to plug existing gaps. Estimates show around 9.8 billion dollars in research are required within 2015, the greatest requirements are for the development of novel therapeutics;  on a relative scale however, research in diagnostics has the largest funding shortfall (graph, below).

Implementation of such an initiative is expected cost around 37 billion dollars until 2015.

The agenda that has been laid out for research has been impressive. TB, despite the close to 2 million deaths that it causes annually, had up until recently been in the back burners of  innovation. The doubt however is if the funding shortfall can be overcome.

Health systems worldwide are already reeling under bitter  economic realities. The US and EU, which have traditionally marshaled resources, are finding it difficult to honor their prior commitments, let alone commit to new ones. The global fund, which has been the go-to funding mechanism for the three major killer communicable diseases, has already withheld its Round 11 of funds in view of the current economic climate, and replaced that with a transitional funding mechanism until 2014.

Hopes have been laid on some other sources of funding, most notably the BRIC (Brazil, Russia, India, China) nations where economic growth has been rapid. These countries incidentally, are also home to some of the largest epidemics of TB in the world.

This isn’t the first time the global health community has set its aims high depite seemingly insurmountable odds. Ten years ago. when the first drafts of the plans to fight the  HIV epidemic where being laid, it appeared as if HIV would wallop entire mankind. With incessant effort and ingenuity, we have been able to turn that tide for the first time. With similar efforts, and a modicum of luck,  we should be able to go even futher with TB, given a lot of  the operational framework for TB program implementation is present in most places, at least  in some form or the other.

The obesity epidemic

Of late there has been a flurry of publication about obesity, both in the scientific as well as the popular press. Either way you look at it, with 34% obesity rates and overweight rates at around 68% in the United States, the numbers aren’t pretty.

What this epidemic of over-nutrition is leading us into though, is outright ugly.

First the problem was seen to be one of the rich world.  In developing countries, obesity had always been thought to  be a disease of the urban affluent; in developed countries the opposite was held to be true. However, as recent research shows, both points of view are crumbling over their own weight.

In low and middle income countries, it still is a disease of the wealthy, especially wealthy middle aged women, but it is now percolating down to the poor people are well.

In rich countries the problem was thought to be largely concentrated among the urban poor, where lack of proper food choices and inappropriate personal choices were said to drive the epidemic; however when 68% of the people are considered to be overweight, the problem is not only in the urban ghettos, but is also right in the middle of the affluent suburbia. In the developed countries no one in really immune any more, and there aren’t just a few easy explanations of poor choices and poverty to explain the epidemic.

The drivers of this epidemic are far more complicated than was previously believed. A four part series on obesity in the Lancet, offers an incisive analysis of the causes and consequences of the obesity epidemic.

Which brings us to the second part of the problem: the consequences. As such obesity has already overrun tobacco as the greatest modifiable threat to public health in many parts of the world. A case in point: tobacco is an addiction in close to a billion people in the world and will contribute to their death in some way or the other in at least one half of them.

As the global burden of morbidity and mortality, shifts from communicable to non-communicable causes, obesity alone can cause already unsustainable health care costs to sky rocket. If current trends continue, in the US and the UK alone, 65 million additional people could be obese by the year 2030, leading to more than 5 million additional cases of diabetes. A roughly  equal number  of additional heart diseases and half a million cancers are also predicted. Year on year additional health expenses in the US alone are expected to be around 50 billion dollars.

A sad truth is despite universal head scratching, we have not really been able to implement strategies to fight off obesity at a population scale. Strategies have been suggested, however conflicting interest groups make it close to impossible to implement strategies that could lead to the reversal of such an epidemic. Furthermore, to complicate matters, we don’t have a single mass scale field-tested  epidemiological intervention that we can pull from and emulate elsewhere that we can use to fight off obesity.

Our gains in health care over the next several decade will largely depend upon how well we are able to mount population level interventions against risk factors such as  obesity. Ingenious research, adept interventions,  forceful advocacy and implementation of population scale strategies will be required to make any dent in the epidemic of obesity.

Shadows of the silent epidemics

As the UN calls for a global summit on non-communicable diseases (NCDs) here in New York, more than half of the people that die this year in Nepal will die from conditions that our health system never even really bothered to care about.

Non-communicable diseases like cancer, diabetes, respiratory diseases, heart diseases and mental diseases now account or an overwhelming majority of deaths in Nepal, even in people too young to die; leading to huge loss of life and economic productivity.

What were once thought were “diseases of affluence”, have now sucked the well-being of poorer nations like ours into a tailspin, and all the while NCDs have been under swept the carpet.

It has now been recognised that such “diseases of affluence” have now been disproportionately concentrated in poor and middle income countries. While health systems in richer countries are poised to handle such epidemics- or at least they have the systems in place and a tacit understanding about where the problems lie, we fail on both accounts. First we have not been able to acknowledge the kind of toll these diseases have been exacting, second we don’t have health systems capable of facing off such diseases.

The disheartening irony is,  for something that is causing majority of annual deaths, it’s hardly even mentioned in the  government’s annual health report- the department of health services’ flagship annual publication. Tucked away in one far away corner of the report is a graph that shows 80% of the reported illnesses in the year was with non-communicable diseases. After that there is a deafening silence.

Reference is made about immunisation, health education, reproductive health and control of infectious diseases, the kind of fodder that has been the staple of our health sector initiatives and their resulting annual publications. Vertical programs have been enacted across the whole health system to tackle disease conditions funded by global organisations with deep pockets. It feels like the health system has been amnesic all along about other half of its own body- the un-funded, un-cool half called NCDs.

The government’s only strategy against something that is killing 3 out of 5 people in the country is it intends to carry out some “nutritional interventions” to take care of heart diseases. As an added bonus it is throwing in some health education. And all that education amounts to is some money spent on flyers that will eventually be racked up in a dark dusty almirah in health posts village after mountain village.

There seems to be a ready resignation that it is okay to die with a chronic disease.While a young woman dying of an infection for example feels us with a just moral outrage, it is blatant hypocrisy to not demonstrate the same against something like a COPD or a heart attack when that death could entirely have been prevented in the first place.

Non-communicable diseases will kill more than 40,000 people in Nepal this year, more than combined due to all infections and reproductive health issues put together.

Evidence from the developed world has shown, much can be done to halt and revert the tide of such epidemics.

And it’s not that we need a pile of resources before we can start to tackle such conditions. There is enough we can do with out a slush-fund of money; all we need to do is drive ourselves out of our inertia. Like at least recognise that we have a problem first.

A few easy policy initiatives can take us a long way in battling NCDs. We already have one of the highest smoking and alcohol abuse rates anywhere. When all else in our economy seems to be failing the liquor industry is pegged at around Rs 10 billion and growing at 20% annually, and tobacco industry is fledgling. Add to that cigarettes are available to kids, we have one of the highest female smoking rates in the world and alcohol is more readily available than clean water, we have a potent recipe for a violent disaster.

Evidence shows strict regulation of alcohol and tobacco use can greatly impact incidence of NCDs in the future. Strict control of consumption coupled with excise taxing of these industries can significantly alter the epidemiological landscape of such diseases. None of this requires donor money to start with. Further more excise from the liquor and tobacco industry can form a significant source for our health system funding strategy. The cancer hospital at Bharatpur is a case in point. And we should ensure that good dietary habits, which have been our saving grace thus far, don’t go to the doldrums like they have in the inner city ghettos of rich nations.

It is not clear what sort of strategies the global UN meet at New York can come up with to battle these menaces. The last time such global UN event was held for health ten years ago, resulted in the creation of the Global Fund to Fight AIDS TB and Malaria (GFATM), a revolutionary funding mechanism and a paradigm shift in way we handle these three killer diseases. What good will the UN meet come up with this time over is any body’s guess; all we can do is pray that they don’t come up with a set of better funded vertical programs that address a few issues and then splinter whatever remains of the health system to rot in dereliction. Because to handle these beastly epidemics of NCDs, we will need a cost-effective, viable and robustly functioning health system above anything else.

This article first appeared in The Republica 9.21.11