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Responding to Global Health Challenges:Releasing Capacity for Sustainable Solutions

8 September 2007 at 13:10 | 4293 views

UBC Centre for International Health
March 17, 2007

From Theory to Practice

Edited Keynote Address
By Dr. Godwin O. Eni
International Health Consultant
Formerly, Division Chair & Director, Graduate Program in Health Services Planning & Administration
Department of Health Care & Epidemiology, Faculty of Medicine
University of British Columbia

Introduction
Resource investment in global health has been considerable. The majority of developed nations,
especially those in the Western hemisphere, have agencies that provide resource support for
health, education and social service programs in developing countries. Given the amount of
resources expended over the years to achieve health improvements in developing countries, one
might expect significant gains in the health status of recipient populations. Unfortunately, this is
not the case. Rather, many developing countries, in South-East Asia and especially in Africa,
have continued to experience static or declining health status, some of which mirror the same
challenges they faced several decades ago.

The challenge is not located in the lack of willingness to help poor and impoverished populations
to achieve better health outcomes. It is not due to the lack of scientific breakthrough or altruism
given the number of agencies involved in international health programs and the amount of
resources donated to study and to respond to global health challenges. Over time, an impressive
body of knowledge has been accumulated through research to inform governments, donor
agencies and front-line workers about the challenges of global health and what to do about them.
Perhaps we need to do things a little differently to achieve greater progress in some areas of our
involvement. Perhaps we need to shift certain gears from theory to theory and practice especially
in areas with the best chance for success.

A few years ago, at the GOSA conference on global health, held at the First Nations Long House
at this University, I called attention for a need to understand the context in which health services
are provided in developing countries, the plurality of medical systems, the socio-cultural context
of health care, and an expanded view of health care systems based on the work of Arthur

Klienman1 - a psychiatrist and anthropologist - whose work in Asia has helped to illuminate our
understanding of non-western environments. Klienman defines the health care system as
“everything a given society does to address the health needs of its citizens” - from self care to
other forms of care under plural medical systems. Based on this notion about three decades ago,
the late Dr. Adeoye Lambo, a Nigerian psychiatrist and former Deputy Director of the World
Health Organization, introduced the slogan “health for all by the year 2000” which was adapted
in 1990 as a resolution by WHO.2
It is now 2007 and the world has yet to attain this promise. Rather, human populations in many
parts of the world have continued to experience new and different challenges to their health. What
are these challenges and how can the world do things differently?

In our discussion, I hope to highlight some existing and emerging challenges to global health, in
part, based on my experiences in 19 countries in Africa and South-East Asia. Some of the issues
have been with us for so long that we may have taken them for granted or minimized their
relative importance. Other issues seem to emerge incrementally to mediate our effort to achieve
effective and sustainable community health programs in far away places. More importantly, we
will consider an alternative perspective which may contradict some assumptions of professional
training and socialization.

Current Situation
It is important to recognize that in the past 150 years, medical science has achieved significant
breakthroughs and discoveries via research. The discoveries led to great improvements in public
health. Many of the achievements are self-evident especially those that contribute to saving lives
such as the discovery of new vaccines, alternate ways to deliver community services, and
innovative surgical interventions to name a few. Although high mortality rates are declining
overall in all regions of the world, nevertheless, two regions, Asia and especially Africa, have
continued to experience lower life expectancy rates and high, unacceptable mortality rates.

There are wide global differences in average life expectances at birth. The global spread ranges
from 34.0 years in Sierra Leone to 81.9 years in Japan. These differences also seem to mirror
differences in other health status indicators between developed and developing nations. For
example, the developed countries of Canada and Germany have much higher Life Expectancy and Healthy Life Expectancy [HALE] at birth for male and female than the Sub-Saharan
countries of Coté d’Ivoire, Ghana, Malawi and Burkina Faso.

The same indicators for South Eastern Countries, for example India and Sri Lanka are somewhere
between those of Europe and Sub-Saharan Africa. Countries with low Life Expectancies
experience high rates of infectious disease, often intensified by malnutrition, environmental
hazards, and scarce health care. They also experience the highest birth rates, as perhaps, surviving
adults strive to compensate for losses due to infant mortality.

(b) Infant Mortality
It seems the gap in some health status indicators of developed and developing regions of the
world have widened over time regardless of great strides in research, program development and
service delivery. From 1980 to 2005, the infant mortality rates in Africa and Asia declined by
21.2% and 37.1% respectively. Although Europe and North America have already achieved low
mortality rates 25 years ago, nevertheless, the rate of decline in infant mortality rates in North
America and Europe, 36.4% and 50.0% respectively were higher than the rate for African
countries over the same time frame.
Closer to home, the infant mortality rates for 2004 in Burkina Faso, Coté d’Ivoire, and Malawi
were 97.0, 118.0 and 109.0 per 1,000 live births compared to 5.0 per 1,000 live births in Canada.

In 2003 HIV/AIDS killed 47, 000 and 84,000 people in Coté d’Ivoire and Malawi respectively
compared to 1, 500 people in Canada.

Global inequity in the treatment of HIV/AIDS is reflected in the percentage of cases in Canada
and African countries that have access to one particular form of treatment. In 2003, 30,000 people
died of HIV/AIDS in Ghana. However, the percentage of people with advanced HIV infection in
Ghana who received antiretroviral (ARV) combination therapy in 2005 was 7%. During the same
period, 1,500 people died of HIV/AIDS in Canada out of which over 75% of infected people
received antiretroviral combination therapy.

The picture is a little different in South East Asia as many countries in the region have much
lower prevalence rates for HIV/AIDS than Sub-Saharan African countries.

It seems therefore that much resource effort would be required to address the health challenges of
Sub-Saharan Africa than would be required to address the same challenges in South-East Asia.

The leading causes of death in developing and developed countries are different except in four
categories, ischemic heart disease, cerebrovasclar disease, lower respiratory infections, and
tuberculosis. In the developed world, the three major killers are non-communicable
diseases - ischemic heart disease, cerebrovascular disease and chronic obstructive pulmonary
disease. The three leading causes of death in developing countries are HIV/AIDS, Respiratory
Infections, and Ischemic Heart Disease. However, the three leading causes of death in Africa are
communicable diseases, HIV/AIDS, Acute Lower Respiratory Infections, and Malaria.

It follows therefore that programs designed to address associated challenges should be
different for Sub-Saharan Africa because of disparity in the leading causes of death. It
follows therefore that different clinical and institutional approaches would be required as
responses , on the one hand, to Ischemic Heart Disease, Cerebrovascular Disease and
Chronic Obstructive Pulmonary, and on the other hand, to infectious diseases such as
Malaria, Acute Lower Respiratory Infection and HIV/AIDS. Programs and services should
therefore take into consideration, the geography, customs, practices and social contexts of the region in order to achieve better outcomes. The long held idea of duplicating Western approaches in Sub-Saharan Africa which are designed for a different disease category has
proven ineffective. Although donor agencies and NGOs are aware of the need to structure
and implement public health programs in accordance with community needs and
participation, yet, this principle is usually not effected in practice because of the demands of
evaluation criteria imposed by donor agencies. Rather than count numbers as the only
outcome measure, one may suggest also measuring the degree of involvement and
community participation in program design and implementation.

(d) Current Challenges
Saving lives and enabling people to acquire the capacity to save themselves, live longer and
contribute to society, seem to constitute the key global challenges to public health in the face
of considerable disease burden and high death rates in Sub-Saharan Africa, and economic
disparity among wealthy and poor nations..


Communicable diseases account for over three in five deaths in Africa. Data from the World
Health Organization indicate that in 2001communicable diseases, nutritional deficiencies,
and maternal and prenatal diseases caused more than 11 million deaths in developing
countries primarily in India and Sub-Saharan Africa.


Together diarrhoeal diseases and lower respiratory infections (including pneumonia)
caused 4.4 million deaths or 40% of total global deaths in 2001. Lower respiratory
infections were responsible for killing 3.8 million people of which 2.6 million or 68% came
from the developing world.


1.8 million people died from diarrhoeal diseases in 2001and nearly all were in the
developing world.


Tuberculosis, measles and malaria pose continuing threats to human populations. They
killed 8 million people in 1990 in the developing world and yet barely registered their
presence in the developed world.
It has been estimated3 that:


If malaria had been eliminated three decades ago, Africa’s GDP would be up to US$100
billion


A reduction in mortality rate by 50% over the next 5 years would be achieved if US$1 billion
is spent on drugs in Africa in treating 70% of new TB cases.


The cost of preventing or treating HIV/AIDS, Malaria or TB is between US$0.05 and US$10
per person.


Combating Malaria in Sub-Saharan Africa will require US$1 billion a year.


A baby girl born in Africa, south of the Sahara desert, faces a 22 per cent risk of death before
the age of 15 because of infectious diseases that affect children disproportionately. In China
the risk is less than 5 per cent. In industrialized countries the risk is just 1.1 per cent.
Ironically, the vast majority of these deaths could have been prevented with existing
interventions measures.


Measles is the most preventable contagious disease. The cost of the vaccine is about 25 cents
a dose. The challenge is to make vaccines available to affected regions.


Poliomyelitis has proven hard to eradicate. However, WHO hopes to do so in 2007. The challenge is to contain localized outbreaks that threaten this goal as follow-up to
the eradication of smallpox.

Africa continues to experience the highest HIV/AIDS prevalence rates in the world. Swaziland,
Botswana, Zimbabwe, South Africa, and Namibia rank the top five countries with prevalence
rates that range from 22.5% to 38.6%. [Tables 7] The prevalence rates for Lesotho, Zambia,

Malawi, Central African Republic and Mozambique range from 13.7% in Mozambique and 20.9% in Lesotho.
It is somewhat misleading to list HIV/AIDS as the number one cause of mortality because
HIV does not actually kill its victims. They succumb to opportunistic infections eventually.
The main killer is Tuberculosis which accounts for about 50% of deaths in AIDS patients.
The data shows that when deaths from HIV/AIDS Tuberculosis are combined with deaths
from non HIV/AIDS related Tuberculosis, TB becomes the number one killer or the
greatest single killer in Africa followed by malaria. Together TB and Malaria accounted for
over one in five deaths. Tuberculosis affects one person every second and it is the leading
killer of women.

According to the Medlinks Organization,


On average, it would costs US$10,000 a year to treat a person afflicted with HIV/AIDS
in the developed world . On average, less than US$10 per person is spent on health care
in Africa. The combined GNP for Sub Saharan African countries is US$320 billion.


It would cost about US$253 billion to treat the estimated 28 million people or more who
have HIV/AIDS in Africa for one year at current costs.


Approximately, US$7 billion is estimated as the total amount spent on health care by
all countries in Sub Saharan Africa in one year. The Province of British Columbia in
Canada spends over C$5 billion dollars annually or the equivalent of approximately
US$ 3.9 billion on health and medical services.


In 2005, the total amount spent on HIV prevention in sub-Saharan Africa, from all
sources, excluding South Africa, was US$165 million


US$2.5 is estimated as the amount needed to prevent HIV/AIDS in sub-Saharan Africa.


Improvements in sanitation reduced the number and effects of epidemics such as
cholera, diarrheal dehydration, amoebic dysentery, and typhoid. However, about 1.1
billion people lack access to clean drinking water in spite of these improvements. The
challenge is to redesign sanitation programs to reach more people.

(e) Some New Challenges
About 500,000 people worldwide are affected by influenza or the “flu” each year. A new
strain, the West Nile Virus, has joined the frequently mutating “flu” community. An
important challenge is to develop a new vaccine to combat avian flu before it causes an
epidemic and to provide mosquito nets to persons in the affected regions as soon as the virus
emerges.

Sudden Infectious Disease Outbreaks in Africa constitute a major global challenge. There
were 28 major outbreaks in 2003 in 28 African countries involving 11 diseases, over 47,000
cases and more than 2,700 deaths. There were 16 outbreaks resulting in 43,487 cases in 2004.
Although there were fewer diseases, nevertheless almost as many cases, 43,000, were
reported which resulted in more than 1000 deaths.5 Of significance is the re-occurrence of
infectious diseases outbreaks with high case fatality rates.

Six infectious diseases accounted for 17,899 cases. Hemorrhagic Fever is said to have re-
emerged in 2005.The emergence of Hemorrhagic fever in 2003 with a Case Fatality Rate of
58% and again in 2005 pose a special challenge for public health in Africa.


Environmental health may become a major issue in future because it transcends national
boundaries. The 1999 European ministerial conference on the environment and associated
health Changes declared that "Human-induced changes in the global climate system and
in stratospheric ozone pose a range of severe health risks and potentially threaten
economic development and social and political stability."6 People everywhere have begun
to wonder if recent catastrophic events such as the Tsunami in Asia and Katrina hurricane in
the United States are due to changes in climate. Future public health challenges may include how to deal with the effects of stratospheric ozone depletion, resource
degradation, land degradation and desertification.7 Early in the 20th century, Villagers in
countries along the boarder of the Sahara desert were self sufficient through subsistence
farming. The expansion of the desert has continued to displace the inhabitants of adjacent
villages who in turn became refugees and dependent on outside food sources. The impact of
expanding tropical deserts in developing countries poses future challenges to human
health in adjacent countries.

Acute Pesticide Poisoning may lead to a major public health challenge in the future particularly
in the developing world.8 It is estimated that 11 million cases of pesticide intoxications occur
annually in Africa in the 80’s.9 As early as the two decades ago, Africans were suffering from
pesticide poisoning in the thousands. For example, during this period, the numbers of cases of
pesticide poisoning were 128,000 in Malawi, 175,000 in Cameroon, 240,000 in Mozambique,
272, 000 in Uganda, and 384,000 in Tanzania.10 Acute Pesticide Poisoning may constitute a
silent challenge to public health, given the little attention it has received over the years.

The manner in which Health Services are made available to rural communities in the developing
world could pose a future challenge to public health. There are current inequities in the delivery
of health services between rural and urban areas of all developing countries. 95% of one year old
children are immunized for Measles in Canada compared to 49% in Coté d’Ivoire, 47% in
Malawi and 56% in India.

Over 75% of persons with advanced HIV/AIDS in Canada receive antiretrviral combination
therapy compared to 7% in Ghana, 17% in Coté d’Ivoire and 20% in Malawi - countries with
high HIV/AIDS prevalence.

The degree of collaboration between NGOs and Government in developing a national plan for
health service delivery and implementation is important for community health services. Both
groups were found to work at different objectives in executing health and social service programs
to communities in Africa11 and South-East Asia12.
Challenges of Program Development, Delivery and Sustainability

Since the advent of scientific medicine, the framework for bringing together people who need
care and those who provide care is based on the biomedical model which is governed by four
principles or assumptions.13


Definition of Disease. Disease is “to be fully accounted for by deviations from the norm of
measurable biological [somatic] variables.


The Doctrine of Specific Etiology. Each disease has a specific cause and a deviation from
the norm.


The Assumption of Generic Diseases. Each disease has distinguishing, specific features that
are universal to human beings. Its symptoms and processes are expected to be the same
across time frames and in different cultures and societies.


The Scientific Neutrality of Medicine. The practice of medicine adheres to the values of
science, namely scientific rationality, objectivity and neutrality.
While the four principles have, for the most part, guided the successful and effective practice of
medicine, especially in institutional settings, they appear to be quite limited in their application in
social and cultural environments. For example, the APGAR score is used to evaluate how well a
newborn baby will thrive. Populations with small babies and small stature may deviate
considerably from the norm. The average value of a variable for a specified population may not
correspond to an ideal standard. In other words, the specific characteristics of populations and
their life situations are critical to understanding and interpreting the significance of average

values and of deviations from universal or ideal standards of health. For example, adolescents
with personality crisis in developed nations are generally viewed as “normal” to this
developmental stage. The same characteristics may be viewed in terms of “deviance” in some
non-western societies.

The cause of a disease may be viewed differently in non-western societies. We know that certain
diseases are specific to certain populations and not generalizable to other groups. For example,
glucose-6-phosphate dehydrogenase deficiency is unique to black populations as Tay Sachs
syndrome is to the Jewish population. The manner of a person’s behavior, appearance, style of
speech, and economic circumstance often influence objectivity and neutrality in practice.

A different Perspective
As a compliment to the biomedical model, healthl and health care systems are defined in socio-
cultural contexts. Most people in developing countries consider themselves healthy as long as
they are able to go to work or to the farm to earn a living in support of their families. In their
perspective, “health” is the ability to fulfill social obligations. Klienman14 offered a different
view of health care systems. He proposed that all health care systems comprise everything that a
given society does to address the health needs of its citizens. In his view, all health care systems
have three sectors (a) the popular sector or where people treat themselves which entails the
largest personal health expenditure in a person’s lifetime;

(b) the folk sector in which semi professionals, shamans and traditional healers offer their services; and (c) the professionalwhich comprises different “medical systems” and practitioners. In this context, a medical systis defined in terms of any system that has a theory of disease, how to treat it, and how trehabilitate. For example, two parallel medical systems, Aryurvedic and scientific medicine exist
and are recognized by the state in Sri Lanka. In Canada, we have naturopathic and chiropractic
systems among others. In developing countries, people subscribe to different medical systems
including traditional form of care and treatment. They also interpret signs and symptoms in
different ways based on cultural and traditional practices.

Health care is primarily undertaken in
social contexts in all countries except that greater social significance is accorded health care in
developing countries. Therefore the planning and implementation of health care programs should
take into consideration, the socio and cultural contexts of care as well as customs and practices in
the particular environment. An understanding of the social context of care requires participant
observation. The interview setting does not provide key details necessary for understanding how

cultural societies perceive and treat sickness. Sufficient time is needed to acquire relevant
knowledge that would lead to participation by the target group and to achieve collaborative
planning and program implementation.
Sickness is assumed to comprise two segments, namely, disease and illness. Disease is defined as
the objective, measurable aspect of sickness. For example the presence of an infection due to a
virus or germ which is subject to objective determination.

Sickness = Disease + Illness
Disease - The objective, measurable aspect of sickness
Illness - The Experience of Disease [personal and cultural]
Medicine addresses the disease component of sickness quite well. Scientific medicine also has led
to new discoveries and approaches to treatment. On the other hand, medicine has not addressed
the illness component of sickness very well. In this context, illness, defined as the experience of
disease, differs among individuals, from culture to culture and different social settings.
Over the years, many public health programs and associated physical facilities have been
introduced to communities in the non-western world. The majority of these programs and
facilities lie dormant and unused a few years after they have been implemented. These were some
of my observations in Burkina Faso, Malawi and Sri Lanka.

Numerous reasons have been
advanced to explain the situation including the lack of ongoing or sustainable budget or the
failure to train competent personnel. The most important reason is the lack of interest or
ownership in the recipient community. Many programs and services are sometimes considered
impositions that contradict existing cultural norms. HIV/AIDS education that is targeted at
women will be less successful in reducing the prevalence of the disease because of cultural
practices such as the inheritance of the wives of a diseased father, brother or nephew. Similarly,
the prevention of female circumcision through the education of mothers would yield meager
outcome in the absence of the aunts who perform the service traditionally in some cultures.

Many Non Governmental Organizations [NGO], indigenous and foreign, have contributed, and
continue to contribute their efforts to national development in poor nations. Donor countries
depend on NGOs to fulfill their altruistic objectives in these countries.

A close examination of the relationships between NGOs and government officials in many developing countries reveals high degrees of adversarial and competitive relationships. In some countries, NGO field workers
receive higher wages than government field workers. As a result, little cooperation is achieved in
the field as public employees become envious of their NGO counterpart. Some NGOs provide
transportation such as bicycles or motorcycles to local employees to facilitate movement between
villages. Such benefits are not available to government employees. Therefore, large proportions
of government employees resign from their jobs and seek employment with Non Governmental
Organizations.

It is therefore important to understand the dynamics of NGO/Government
relationship in a developing country before planning and implementing a health program. More
importantly, the knowledge gained from this understanding would assist in the development of
sustainable public health and social service programs.
Concerned with the slow pace of health service development in their original countries, some
immigrants from developing countries have begun to advocate and champion development in
their “home countries”. The Augustine Memorial Hospital is one example.

Conceived by a
Nigerian-born and educated physician and gynecologist in Chicago, who emigrated to the United
States in 1974, the hospital is aimed at improving the health of rural communities by making
essential health services and technology available to these communities. Taking into
consideration, the social and cultural contexts of the region, the prevalence of certain diseases, the
absence of quality health services, lack of accessibility to other forms of care, and more
importantly, knowledge of customs and practices, the hospital will have satellite links in order to
reach communities. Although located in the rural area, the hospital will have comparable services
and equipment as found in the western world. Medical students and nurses will be able to train in
community medicine at Augustine Memorial Hospital through linkages to existing medical
schools.

The project is currently in the planning phase and in need of international support as an
innovative high quality health service in a rural region. To my understanding, it is the first such
initiative by an indigene that would respond to rural community health needs while providing
high quality health service. Information on the proposed Augustine Memorial Hospital is
available upon request and I encourage you to explore this initiative. Perhaps, students at this
university may want to gain experience and knowledge as volunteers in a rural African setting
when the hospital is operational.
In summary, the challenges of Global health issues transcend national boundaries and necessitate
international cooperation.

How the world organizes its professional, economic and political resources to meet global health challenges is important for our generation and for those who will
come after us.

Photo: Dr. Godwin Eni and his wife. Dr.Eni(originally from Nigeria) is one of the elders in the African-Canadian community in Vancouver, British Columbia, Canada.

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