Weekly Global Health Article

   Dengue fever spreading in the Caribbean
   by Jeffrey Bigongiari on July 20, 2010


Dengue-mosquito
Dengue mosquito
Health officials across the Caribbean are concerned about the near epidemic level of mosquito-borne dengue fever, saying it could get more severe as the rainy season progresses.

The high number of cases that have caused dozens of deaths across the area are being blamed on warmer than usual weather and an unusually early rainy season, which has, in turn, caused an explosion in the mosquito population, the Associated Press reports.

Soldiers are going door-to-door in the Dominican Republic to destroy potential breeding pools and warn the public. There have been 27 deaths reported there since the outbreak began.

In Trinidad, the Associated Press reports, hospitals are running out of beds, and in Puerto Rico, it is being called the worst dengue outbreak in a decade. In the U.S. Caribbean territory, at least five have died and another 6,300 cases have been reported as of mid-July, according to the Associated Press. There were only 100 more cases reported during Puerto Rico’s worst recorded dengue outbreak in 1998. In that year, 19 people died and some 17,000 fell sick.

Fifteen more beds have been added to Trinidad’s San Fernando General Hospital and a new clinic has opened to check on those that have been released early to free more bed space. Dr. Anton Cumbrebatch, chief medical officer of the Trinidad Health Ministry, told the Associated Press that he is worried that the number of cases of the more severe hemorrhagic form of dengue will increase. The more people who are infected, the greater the chance they will develop the hemorrhagic form, he told a news conference.

The Dominican Republic is seeing a similar situation. Nurses at a children’s hospital in Santiago have demanded more resources and more personnel. Four children have died this week in Santiago, northwest of the capital city of Santo Domingo.

Senen Caba, president of the Dominican Medical Association, disputed the low numbers being reported by the Dominican Health Ministry, and claims 7,000 people have been reported sick with dengue. Caba told the Associated Press that the last time the country faced a similar epidemic was at least a decade ago.

There is also a fear that the outbreak might spread to the United States. Dengue, once thought gone from the U.S., has been suspected in a case in Miami. Though test results came back negative, a recent study showed that five percent of people living in Key West had been exposed to the disease, which can cause fever, headaches and extreme muscle pain.


Gel found to reduce AIDS risk in women

By David Brown

Washington Post Staff Writer
Tuesday, July 20, 2010



A woman's risk of infection with the AIDS virus can be significantly cut by the use of a vaginal gel, a study has found. The research marks the first success in a 15-year search for a way women can independently protect themselves from contracting HIV infection through sex.

Short of a vaccine, an effective vaginal microbicide has been the most elusive goal in the epidemic.

The research, which was conducted in South Africa and will be presented Tuesday at the 18th International AIDS Conference in Vienna, tested a gel containing the antiretroviral drug tenofovir. While far from perfect, it was unambiguously helpful, reducing the risk of HIV infection by 39 percent in a group of women who used it for about three-quarters of their sexual encounters. Those who used it more consistently experienced 54 percent fewer infections.

If development follows the expected course, more-potent formulations, combined with campaigns to make the product appealing (or even sexy), could result in vastly better protection.

Of the 33 million people worldwide infected with the AIDS virus, 16 million are women. In Africa, 60 percent of people with HIV infection are women, nearly all of whom acquired the virus through sex. For many, the proven methods of preventing infection, such as abstinence, being faithful and using condoms, are either not an option or out of their control. A vaginal microbicide that could be used with or without a man's knowledge is considered essential, missing until now.

"We have never had any kind of tool that has effectively allowed women to protect themselves," said Bruce Walker, an AIDS researcher at Harvard Medical School. "This is really a game-changer."News of the results of the Caprisa-004 study, which leaked out a day before they were to be presented, sent a wave of optimism through the AIDS research community.

"It's groundbreaking," said Catherine Hankins, chief scientific officer of the United Nations' AIDS agency, UNAIDS. "This in combination with [male] circumcision in places where the epidemic is generalized could really turn the tide."

"Everyone is just delighted. There were a lot of skeptics that the concept would work at all," said Zeda Rosenberg, head of the International Partnership for Microbicides in Silver Spring.

Researchers would need to show that the microbicide is effective in at least one other group of women before it could be licensed for commercial use, several people said Monday. That effort now climbs to the top of the international research agenda, although at a minimum the work will take several years.

A larger study testing tenofovir gel and antiretroviral drugs in pill form as a way to protect women against sexual transmission of HIV is underway in four African countries but will not be finished until 2013. Several other experiments, including ones in which the drug is in a long-acting vaginal ring, are in earlier stages. A microbicide might also be useful in protecting men who acquire the virus through anal sex.

"I think the big challenge is to get confirmatory studies done quickly," Hankins said.
Over the past 15 years, six other microbicides were tested in 11 clinical trials, with none showing protection.

The net impact seen in the study reflects the combined effect of many variables, only one of them the action of tenofovir, which penetrates into the vaginal tissue, protecting the cells that HIV targets for infection. Other variables include the prevalence of HIV infection in the male population; the number of sexual partners a woman had; the amount of AIDS virus ("viral load") in an infected man's semen; concurrent use of condoms; and, most important, the consistency with which a woman used the gel.  For that reason, the researchers said, it's impossible to say how much protection this microbicide might afford any woman.

"We can only approximate it," said Salim Abdool Karim of the University of KwaZulu-Natal in Durban, South Africa, who helped lead the study. "What you see is a mixture of the efficacy of the product mixed with the ability to use the product. It is fundamentally dependent on human behavior."

In the study, a group of HIV-negative women (both city dwellers and rural villagers) were randomly assigned to use a gel that was either 1 percent tenofovir gel or a placebo gel.
The material came packed in syringe-like applicators. A woman was instructed to inject the gel into her vagina no more than 12 hours before intercourse and again within 12 hours afterward (but with no more than two applications in a 24-hour period). Each woman got a monthly AIDS test, and the researchers collected used and unused applicators to verify the women's reports of whether they were using them.

At the end of 2 1/2 years, there were 98 infections in the 889 women. The HIV incidence, measured as the number of new infections for every 100 "women years" in the study, was 5.6 in the volunteers using the tenofovir gel and 9.1 in those with the placebo gel.
That amounted to a prevention effectiveness of 39 percent. Among women who said they used the gel for at least 80 percent of episodes of intercourse, the effectiveness was 54 percent.

Why the drug-containing gel did not work even better perplexed some scientists and will probably be a subject of more study.

"My most likely explanation is that you have to go up on the dose," said Anthony S. Fauci, who heads the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. "You may have maxed out on 1 percent," he said, meaning a more concentrated gel might produce greater protection.

Other scientists speculated that some women who became infected despite using the tenofovir gel might have been exposed to men with very high HIV load (which occurs soon after infection). Others may have had vaginal sores or inflammation that raised their vulnerability.  The Caprisa study also looked at whether tenofovir gel decreased a woman's risk of getting genital herpes, a virus that increases her chance of acquiring HIV if she has intercourse with an HIV-infected man.  Tenofovir provides some protection. Half as many women using gel with the drug in it became infected as did those using the placebo gel.

THE DEATH OF A DISEASE

BY D. A. HENDERSON, MD, MPH

Geneva, Switzerland, May 8, 1980 - The 33rd World Health Assembly declares solemnly that the world and all its peoples have won freedom from smallpox...a most devastating disease...since earliest time. In so doing, it demonstrates how nations working together in a common cause may further human progress."
In May of this year, the World Health Assembly celebrates the 30th anniversary of its historic declaration of global freedom from the ravages of smallpox, the most virulent of all pestilential diseases.
The planned campaign to achieve eradication began in January 1967. That year, 43 countries experienced more than 10 million cases and 2 million deaths. All countries feared the disease and continued long-standing smallpox vaccination programs whether or not they had cases. International travelers were required to carry certificates showing that they had been recently vaccinated.
However, the decision to undertake the global eradication campaign had not been an easy one. Many doubted its feasibility. No disease had ever been eradicated. A vote was taken in the Assembly to decide whether or not the program should be launched. It was endorsed - by a margin of only two votes. The WHO budget provided an allocation of $2.4 million - not enough even to buy the vaccine required each year. A 10-year target called for the last case to occur by December 1976. The program didn't quite succeed - it missed the target by 9 months and 26 days.

The strategy was simple, consisting of only two components. First was to protect at least 80 percent of a country's population by vaccination, thereby limiting the spread of disease. Second was to begin a program called "surveillance and containment" - to detect cases at the earliest possible time, to isolate them in their homes, and to vaccinate neighbors and friends in a large circle around the infecting houses. The virus could not survive unless it infected one person after another in a continuing chain of transmission. When the patient's contacts were protected by vaccination or previous illness, the virus was blocked and the chain could be broken.

A first, major hurdle for the program was to obtain sufficient heat-stable vaccine. Large, initial donations by the U.S. and Soviet Union provided a basic supply. However, little of the vaccine produced in developing countries was usable. Emergency meetings were convened of the vaccine producers from the two major donors and experts from Canada, the Netherlands and the U.K Standard manuals were developed and members from the group worked on-site with the deficient laboratories. Within five years, more than 80 percent of the vaccine was being produced in the developing countries and all were meeting standards.
New vaccination techniques were introduced that permitted more rapid and effective vaccinations. Jet injectors that could vaccinate hundreds in an hour were superseded by a newly invented simple two-pronged (bifurcated) needle that required much less vaccine and whose use could be taught in a matter of 15 minutes.

Finding outbreaks quickly was essential for the containment strategy. All health centers and hospitals were asked to provide a report every week; two-person teams responded quickly to confirm the diagnosis, to find other cases and to perform vaccination of the patient's contacts. This approach proved to be so effective in stopping transmission that it was given priority over mass vaccination.

Progress in the program was more rapid than any had anticipated. The first successes were in a block of 20 countries in West Africa whose programs were supported by USAID and experts from CDC. These countries had been among the most heavily infected and logistically difficult. Nevertheless, smallpox was on the verge of elimination within three years.

By the sixth year of the program, smallpox had been eliminated from all countries except Ethiopia and four in South Asia - India, Pakistan, Bangladesh and Nepal. This group of countries proved to be far more difficult than had been expected. In the densely populated Asian countries and in Ethiopia, there was a never-ending array of catastrophes and setbacks that left the staff repeatedly reeling in frustration and fatigue - floods, famine, civil wars, kidnapping of teams, political instability, government suppression of reports, and bureaucratic obstacles of every imaginable type. On several occasions, the ultimate success of the program hovered on the brink of a major, perhaps permanent setback. However, a dedicated, resourceful array of national and international staff persisted and eventually celebrated the occurrence of the last case on Oct. 26, 1977.

An important legacy of the program was the demonstration of the importance of surveillance in working out strategies in disease control. It depended on weekly reports being submitted promptly by all health centers and hospitals and containment teams to be sent. The teams were usually on-site within one to two days and this reinforced the fact that the reporting of cases had actionable meaning. It was an approach that was alien to programs throughout the developing world.

Although smallpox vaccination teams had been in use for many years, it was surprising to discover how effective such teams could be when villagers were properly approached and when the teams were well supervised. In Africa, teams could readily average 500 vaccinations daily per vaccinator. Why not increase the number of vaccines being given? In the developing countries, there were few vaccines then in regular use. Resources were a problem and international agencies focused primarily on a foundering malaria eradication effort. Some yellow fever vaccine was administered in heavily endemic areas; BCG vaccine was provided to a few countries by UNICEF; but basic vaccines such as DPT, measles and polio were little used.

In 1970, we convened an international WHO meeting to develop recommendations for a program on immunization that would extend beyond smallpox vaccination - that it include DPT, measles, polio and BCG vaccines as routine immunizations for all children - an Expanded Program on Immunization. This was endorsed by the World Health Assembly in 1974. Eventually, UNICEF took this on as a priority and Rotary International volunteered to raise millions of dollars for polio vaccine. The goal was to reach 80 percent vaccination coverage for all children throughout the world by 1990. And so momentum was established for ever larger-scale programs to make products for better health conveniently available to villagers. These eventually have included many other vaccines, Vitamin A capsules, bed nets for malaria, and others.

The achievement of smallpox eradication is a landmark. It is a tribute to an international staff that never numbered more than 150 in the field; to national leaders and staff who capably undertook new tasks; and to the World Health Organization that provided the framework within which all countries could constructively work even during days of the Cold War.

It is the behind-the-scenes drama of this victory that I have endeavored to portray in my book, Smallpox: Death of a Disease (Prometheus Books, 2009)

D.A. HENDERSON, MD, MPH, LED THE WHO'S GLOBAL SMALLPOX ERADICATION CAMPAIGN. HE IS CURRENTLY A DISTINGUISHED SCHOLAR AT THE CENTER FOR BIOSECURITY AND A PROFESSOR OF MEDICINE AND PUBLIC HEALTH AT THE UNIVERSITY OF PITTSBURGH MEDICAL CENTER. HE IS ALSO A DISTINGUISHED PROFESSOR AND THE FORMER DEAN OF THE JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH.



New Research Shows “Kangaroo Mother Care” Reduces Newborn Deaths More than 50 Percent, Proven to be More Effective than Incubators for Stable Preterm Babies

Up To Half A Million Newborn Lives Could Be Saved Each Yea
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WESTPORT, Conn. (March 26, 2010) — Kangaroo Mother Care is one of the most effective ways to save preterm babies, according to a new meta-analysis released today on the effectiveness of this simple, low-cost intervention in which mothers serve as human incubators for their newborns.  The research, led by Dr. Joy Lawn of Save the Children, appears today in a supplement to the International Journal of Epidemiology, which outlines the most effective interventions to reduce newborn and child deaths globally.




A mother practices “kangaroo mother care” with her 11-day-old, premature baby at Gabrielle Traoré Hospital in Bamako, Mali. January 2, 2010. Photo Credit:  Joshua Roberts
The review examined 15 studies in eight low- and middle-income countries, including three randomized controlled trials, and found a 51 percent reduction in newborn mortality when stabilized babies weighing less than four pounds (2,000 gm) received warmth and breast milk through continuous skin-to-skin contact on the chest of their mothers. The findings suggest that up to half a million newborn deaths due to preterm birth complications could be prevented each year if Kangaroo Mother Care were available for all preterm babies, particularly in low-income countries, where newborn mortality rates are highest.  “We are more confident than ever that Kangaroo Mother Care works,” said South African-based Dr. Joy Lawn, newborn health expert for Save the Children, and lead author of the analysis. “No matter if babies are born in Lilongwe, London or Los Angeles, preterm babies need extra care to survive. Kangaroo Mother Care is low-cost and feasible, and we now have proof it is one of the most highly effective ways to give more babies the chance to survive and thrive.”

Kangaroo Mother Care has Greatest Impact During First Week of Life
While increasingly accepted in both high- and low-income countries, a previous meta-analysis of studies did not show Kangaroo Mother Care to have a significant impact on newborn mortality because the benefits of the intervention were examined after one week of age. However, Kangaroo Mother Care has the greatest impact during the first week of a preterm baby's life, when deaths are most likely to occur. Each year at least 1 million of the world's nearly 4 million newborn deaths (deaths in the first month of life) are due to preterm birth complications. Some of the poorest countries in the world are discovering that Kangaroo Mother Care can dramatically reduce newborn deaths. The method was first developed in Colombia and is now practiced in many Latin American countries and in several Asian and African countries.  In Malawi — where 20 percent of all newborns have low birthweight, and more than 20,000 mothers each year bear the tragedy of their newborn babies dying — the majority of hospitals and many health centers provide Kangaroo Mother Care. A recent BBC documentary, Invisible Lives, showed a baby born 14 weeks early and weighing less than 2 lbs (850 gm) who had survived with Kangaroo Mother Care and no technology. Malawi is not the norm, however, as few countries have managed to bring the practice to scale. "The review released today provides sufficient evidence to recommend the routine use of this proven intervention in health facilities for all stable preterm babies," added Lawn. "This is one time when the research from low-income countries is bringing a breakthrough relevant for all countries. For instance, England and Sweden and other high income countries are starting to use Kangaroo Mother Care." 

Low-Cost Intervention Provides Options for Care in Low-Income Countries
The effect of Kangaroo Mother Care is expected to be greatest in low-income countries, where other options for care of preterm babies remain limited with few neonatal care units. Babies may be separated from their mothers, reducing exclusive breastfeeding, and overcrowding of several babies in a bed increases the risk of infection. Kangaroo Mother Care halves the risk of infection compared to incubator care.
According to Lawn, funding for child survival is increasing and it is critical to base those investments on proven solutions that have the greatest impact. The supplement and reviews are focused on the development and use of the Lives Saved Tool, or LiST. This free user-friendly computer program helps guide governments and donors on investments in global child survival programs with the most significant results.






“Evidence-based policy and programming are needed to help save the millions of mothers and children who die from lack of basic care every year,” said Robert Black, MD, MPH, professor and chair of the Department of International Health at Johns Hopkins Bloomberg School of Public Health. “LiST is an easy-to-use program that can help policymakers allocate resources based on the latest and best evidence available.”

Supplement Reviews Five Other Solutions for Reducing Newborn Deaths
The Journal’s special supplement includes five other reviews of interventions with great potential to reduce newborn deaths. For instance, one meta-analysis shows how the simple injection of steroids given to women in preterm labor reduces deaths for preterm babies by 53 percent. Other featured technical reviews on newborn interventions provide new evidence summaries on tetanus toxoid immunization, folic acid for prevention of neural tube defects or spina bifida, and antibiotics for preterm pre-labor rupture of membranes.






“We have only five years left to achieve the Millennium Development Goal of reducing deaths for newborns and children,” urged Lawn. “The findings of this study add new confidence that we have interventions that work even for challenging conditions like preterm birth. There is no doubt this interventions can save lives — but the reality is that babies will continue to die unnecessarily unless we prioritize high-impact care and make sure it reaches those who need it most. This evidence is our wake-up call to bring Kangaroo Mother Care and other proven interventions to scale in low-and middle-income countries.”





The World's Two Largest Nations - A Comparison




A Consensus Article on Health Care Around the World
Anup Shah, Health Care Around the World, Global Issues


Early Trial Results Show New Malaria Vaccine Stimulates Strong Immune Response
A new candidate vaccine to prevent clinical malaria has passed an important hurdle on the development path, according to researchers from the University of Bamako in Mali, West Africa and the University of Maryland School of Medicine’s Center for Vaccine Development. In a new study of the candidate vaccine in young children in Mali, researchers found it stimulated strong and long-lasting immune responses. The antibody levels the vaccine produced in the children were as high or even higher than the antibody levels found in adults who have naturally developed protective immune responses to the parasite over lifelong exposure to malaria.

The new candidate vaccine is based on a single strain of the Plasmodium falciparum parasite—the most common and deadliest form of the protozoa—and targets malaria in the blood stage. The blood stage refers to the period following initial infection by mosquito bite when the parasite multiplies in red blood cells, causing disease and death.

The team tested the vaccine in 100 children ages 1-6 in rural Mali. It was shown to be safe and well tolerated, and strong antibody responses were sustained for at least a year. Based on results from this early trial, the research teams will hold a larger trial of 400 Malian children to further evaluate its effectiveness. That study also will examine whether the vaccine—though it is based on a single strain of falciparum malaria—can protect against the other strains of Plasmodium falciparum.

Thera MA, Doumbo OK, Coulibaly D, Laurens MB, Kone AK, et al. Safety and Immunogenicity of an AMA1 Malaria Vaccine in Malian Children: Results of a Phase 1 Randomized Controlled Trial. PLoS ONE, 2010; 5 (2): e9041 DOI: 10.1371/journal.pone.0009041

 

 

Think Africa's disease burden is Hiv? think again

Women with depression, men with heart disease: Africa has acquired the so-called diseases of the wealthy, but without the wealth.
Chronic, non-communicable diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are by far the world’s leading cause of mortality, representing 60 percent of all deaths, according to the World Health Organization (WHO). Of the 35 million people who died from chronic diseases in 2005, half were younger than 70. WHO projects that, globally, non-communicable disease-related deaths will increase by 17 percent over the next 10 years and even more severely in Africa, where up to a 27 percent increase is projected.
However, international health aid to Africa has largely been limited to communicable diseases, reproductive health and disaster relief. While we must continue to address these issues, African health systems also deserve attention, as they are systematically failing to address chronic disease epidemics. The reasons are many: overburdened health-care systems that are unable to meet the needs of chronic diseases and acute communicable diseases; a lack of donor attention (there is no Millennium Development Goal related to chronic disease epidemics); poor infrastructure; and poor governance. As a result, deaths from cardiovascular disease, depression and cancers may soon overwhelm the fragile health infrastructure of developing countries. Africa’s “double disease burden” of acute communicable disease and chronic disease demands an enhanced response.

AFRICA HERE AND NOW

The most common form of cardiovascular disease, hypertension, is strongly associated with urbanization, and as African nations race to develop, people are moving to cities in droves. The lifestyle changes – including Westernized diets, lower physical activity, and increased consumption of alcohol and cigarettes – associated with urban migration are so extreme that one study in Ghana found that urban dwellers have nearly a twofold increase in hypertension compared to their rural counterparts.
Because cardiovascular disease in developing countries strikes younger working age populations at higher rates than in high-income countries, the economic impact is more severe in terms of lost productivity from illness and premature death. A study of patients attending a cardiac service in Nigeria found that 57 percent suffered from hypertension and 12 percent suffered from some other form of cardiovascular disease. These and other studies make it clear we are missing vital opportunities to slow this epidemic.
© FHIHowever, a lack of epidemiological data on cardiovascular disease in Africa is creating a deadly Catch-22: without reliable data on the disease burden, resources will not be devoted to the problem; without resources, African countries will not be able to make cardiovascular or other chronic diseases a priority.
Mental illness, including depression, is among the most stigmatized of chronic diseases, and also has a shockingly high prevalence, according to some studies. For example, South Africa’s 2003-2004 Stress and Health Survey indicated that 16.6 percent of participants experienced some form of mental disorder in the past 12 month period, and less than a third of those with a diagnosed mental disorder are in treatment. The relationship between mental health and other disease is cyclical: poor mental health increases likelihood of other diseases, and other diseases can fuel mental health disorders. This interrelationship suggests we need to increase attention to mental illness and to treatment integration.
Incidence of cancer worldwide is projected to double over the next two decades, with roughly 26.4 million new cases and 17 million deaths annually by 2030. WHO data shows that in most developed countries, cancer is the second largest cause of death after cardiovascular disease, and epidemiological evidence suggests this trend is emerging in the developing world. Women in developing countries are disproportionately affected: according to the WHO, more than 270,000 women died of cervical cancer in 2007. Human papillomavirus (HPV) is considered the primary cause of this chronic disease. Worldwide it is estimated that one in 10 women are infected with HPV, with rates of almost one in four in Africa. Cases of breast cancer in these countries are growing at up to 10 times the global average.

THE PITFALLS OF MODERNIZATION

A small set of common risk factors are responsible for the majority of chronic disease worldwide: smoking, poor diet, and lack of exercise. Tobacco use is growing fastest in low-income countries as a result of steady population growth and aggressive marketing by the tobacco industry. Poor diet and lack of exercise contribute to the alarming escalation of obesity, hypertension and diabetes. Most of the rise in cancers can also be explained by these common risk factors and infectious diseases, such as sexually transmitted human papillomavirus infection, Helicobacter pylori bacterium infection, and occupational carcinogens. Lessons learned from high-income countries prove that most of the risks associated with chronic diseases are preventable. According to WHO, “if major risk factors were eliminated, it is estimated that 80 percent of heart disease, stroke and type 2 diabetes, and 40 percent of cancer [in Europe] could be avoided.”
© FHIThe nutrition transition in developing countries from home-grown to packaged and processed foods has resulted in increasing rates of adult obesity, a major risk factor for chronic diseases. Recent trends show a shift in obesity prevalence from the rich to the poor. There is increasing evidence that early nutrition can biologically program later cardiovascular health. For example, studies have established that low birth weight followed by fast weight gain increases cardiovascular risk and disease in adulthood. This association of early under-nutrition with CVD risk factors such as obesity has critical implications for developing countries.
The increase in cardiovascular disease in Africa reflects a major epidemiological transition as a result of industrialization, urbanization, economic development, globalization and aging populations. With increased access to antiretroviral medicines, people are living longer, and HIV is now a chronic disease. The disease and the treatment are, however, causing other risks. According to a joint report by the American Heart Association and the American Academy of HIV Medicine, people living with HIV have an increased risk of CVD.  The risk of heart attack is 70 to 80 percent higher among this population as compared to their HIV-negative counter-parts.

WEAK POLICY FORMATION AND IMPLEMENTATION

There are several examples of policies in Africa aimed at addressing the causes of chronic disease. However, in most instances, implementation is lacking. Lack of stakeholder engagement contributes to this failed implementation and is a major barrier to the advancement of chronic disease-prevention legislation. An example of an effective policy may be South Africa’s Tobacco Products Control Act of 1993, which some consider responsible, in part, for the observed decrease in the number of deaths due to smoking-related diseases (including heart disease, cancer and respiratory illnesses). South Africa also has less well-known policies that address mental health and chronic disease generally; however, their implementation is weak.
At the policy formation stage, factors beyond public health must be considered, or policies may not be implementable. For example, anti-tobacco advocacy groups in Nigeria are trying to pass legislation to restrict tobacco sales and keep cigarettes from minors. The bill is being contested by the tobacco lobby, and by farmers and workers who fear they will lose their jobs. Without effectively addressing these competing priorities – in this case, public health, the business sector, and the need for jobs – bills like Nigeria’s will be in jeopardy.

WE MUST RESPOND WITH URGENCY

© FHIWe must act now to address chronic disease in Africa. HIV – an emerging chronic disease and an international priority – provides an opportunity to engage international agencies and donors in strengthening health systems and workforce development, initiatives that benefit a broader array of health needs. It would not be enough, however, to simply piggyback chronic disease efforts on HIV-focused care. Chronic diseases demand their own international movement. A strong first step would be to develop a Millennium Development Goal that speaks to this issue, one that also supports the integration of global health initiatives to improve efficiency and increase likelihood of sustainability.
As with HIV, prevention is always the best medicine. We call on national governments to step up efforts to reduce smoking, improve nutrition, promote exercise, and start chipping away at the root causes of chronic diseases. African governments must play the primary role in reducing rates of chronic disease in their countries. As we are seeing in Nigeria, however, this cannot be achieved without the engagement of communities and other stakeholders.
There is a large knowledge gap on the prevalence and impact of chronic diseases in African countries. Research is needed to assess the extent of these epidemics, including behavioral, vocational and other factors that fuel them. With this information, efforts to fight chronic disease can be accurately targeted for greater impact. There may be some lessons from high-income countries that have succeeded in reducing the burden of many of these diseases.
In many African nations, the public is unaware of the long-term risks of poor diet, smoking, pollutants or infectious agents. They are not educated about warning signs and symptoms. Mass education will require mobilization of local and international government and advocacy groups to highlight the importance of chronic disease and promote healthy diet and lifestyles. Ultimately, the people affected must be empowered to make decisions and take responsibility for their own health and well-being.

Dr. Peter Lamptey is president of public health programs of Family Health International, a global public health and development organization that builds capacities of health systems to address infectious and chronic diseases and other health needs in more than 100 countries in the developing world.