Health Policy and Initiatives

In March at the Carter Center in Atlanta, South Sudan’s minister of health announced that Guinea worm transmission had been stopped within South Sudan. It has been fifteen months since the last reported case, and the disease has a life cycle of twelve months. That means the disease is gone from South Sudan, though it could be reintroduced from elsewhere. The World Health Organization is expected to certify South Sudan as free of Guinea worm. Elimination of Guinea worm is a massive, even spectacular, achievement orchestrated by an American non-governmental organization, the Carter Center, working with African ministries of health, numerous local partners, and a veritable army of village volunteers. In 2016, there were twenty-five reported cases of Guinea worm in the world, in South Sudan, Mali, Chad, and Ethiopia, but now, the disease is found only in the last three. Those three countries have a better health infrastructure than South Sudan, with its ongoing civil war and massive displacement of population. Hence, if the disease can be eliminated in South Sudan, it is likely soon to be entirely eliminated from the face of the earth. That would make it the second human disease after smallpox to be eliminated. It is to be hoped that polio will be the third. When the Carter Center began its campaign in 1986, there were an estimated 3.5 million cases worldwide. Present in ancient Egypt and mentioned in the Old Testament, Guinea worm is (or was) a scourge of the poor. It is a parasite, the larvae of which are transmitted in water. After the larvae is ingested by a human body, a three-foot worm develops. The worm then makes its way out of the body through a sore, often on a foot, by excreting an acid. Guinea worm itself is not fatal, but it is excruciatingly painful, debilitating, and increases vulnerability to other diseases. There is no cure for the disease. Modern treatment is the same as it was for the ancient Egyptians: the emerging worm is carefully wrapped around a stick to prevent infection. Guinea worm can be prevented through the filtering of water. That requires a public education campaign. The Carter Center had the imagination to take as its focus a disgusting but non-fatal disease that almost exclusively plagues the poor. With its campaign against Guinea worm, it might be argued that the Carter Center has done more than most official assistance programs to mitigate the lives of the African poor. A UN publication announcing the end of Guinea worm in South Sudan noted that former president Jimmy Carter, the founder of the Carter Center, announced in 2015 that he had been diagnosed with cancer: “He said he was responding well to treatment and he expected to outlive the last case of Guinea worm. President Carter is now 95 and cancer free, and Guinea worm disease just lost the fight in South Sudan.”   

Toyin Saraki is the founder and president of Africa’s premier maternal and children’s health charity, the Wellbeing Foundation Africa, and a long-standing advocate for universal immunization in her native Nigeria. Polio, a vicious disease that primarily affects children and leaves them severely disabled, reared its ugly head once again in Nigeria last year, two years since it was last detected in the region. Up to this point, global polio eradication efforts had managed to defeat polio in all but two countries—Afghanistan and Pakistan. Its reemergence speaks volumes to Nigeria’s inability to continue to deliver the most basic health care, begging the question: why does universal immunization remain unfulfilled?  This Tuesday was World Polio Day, and it is worth reflecting on the mistakes made and the challenges ahead in tackling this disease. Eradication is finally within our grasp, and we would be remiss to let this opportunity slip through our hands. To understand polio’s reemergence, it is important to understand the landscape in which it occurred, my native Nigeria. In 2016, four new cases of polio were reported, three of which were in Borno state, at the heart of Nigeria’s conflict ridden northeast. The reappearance of polio in this region is no coincidence—Boko Haram has wrought immense destruction to the Lake Chad basin, destroying an estimated 75 percent of basic infrastructure in northeastern Nigeria. Vaccines typically require cool conditions in order to maintain their potency. In the hot, dry, and remote northeast, this is near impossible with the destruction of so much infrastructure and frequent power outages. As a result, swathes of Nigeria’s most vulnerable children have been denied access to this cheap and simple preventative measure.    Another hurdle to universal immunization is the inadequate monitoring systems that track which immunizations people have received and ensure that a patient’s vaccinations are up-to-date. Nigeria suffers a severe lack of personal health records, rendering health statistics a product of mere guess work. In the absence of effective recordkeeping, it is nearly impossible to hold people that need vaccines accountable. In this sense, polio’s return to Nigeria is merely a symptom of a much larger failure in Nigeria’s public health system. Personal health records would serve to ensure access and delivery of vaccines. They would also put everyone in the system, and create impetus for improvement in healthcare as a response to accurate monitoring of health outcomes.   In 1990, polio coverage in Nigeria was 55 percent. By 1999, it had plummeted to 19 percent. Although polio coverage rebounded and was almost universal at the time of last year’s outbreak—polio coverage reached 90 percent in high-risk states—this remains suboptimal, and alludes to a striking lack of government commitment to the cause.    One solution to the problems facing polio immunization, as well as that of other preventable diseases, is the implementation of universal primary healthcare. Primary healthcare forms the cornerstone of basic health provision and, when present, is typically the area of healthcare responsible for immunizing local populations. What’s more, in many remote regions in Nigeria, which have the lowest immunization levels nationally, primary health is commonly the only form of healthcare access. It must therefore be prioritized, to give all people access to basic healthcare provisions, including crucial vaccinations.   For universal primary healthcare to be implemented in Nigeria, more needs to be given towards Nigeria’s failing healthcare system. In 2001, all members of the African Union pledged 15 percent of national spending to healthcare in the Abuja Declaration. Ironically, Abuja has not met this commitment, only spending a third of the pledged 15 percent on health care.  Fortunately, since the new polio cases were reported in 2016, there has been a renewed immunization drive. The international community and Nigerian government is set to vaccinate as many as 30 million children against polio. This drive must be sustained, and there is no room for complacency.   Investment in health infrastructure and reliable electricity are vital for remote areas, followed by the implementation of universal primary healthcare and adequate record-keeping. Yet none of this will be possible in the absence of greater commitment to the cause.   We know how to prevent polio, but children in my native Nigeria continue to be denied access to this basic but necessary vaccination. The reemergence of polio is tragic, but we should use it as an impetus to address the shortcomings of Nigerian healthcare. Greater government commitment to the sector is critical to preventing future outbreaks of illnesses like polio, protecting Nigerians of today and of the future.   

Travis Bias, DO, MPH, DTM&H, is a family medicine physician in California and former visiting lecturer at Kabarak University and Busitema University Faculty of Health Sciences. He blogs at The Global Table.  Fred Bisso, MMed, MBCHb, is an otorhinolaryngology consultant at the Mbale Regional Referral Hospital, part-time lecturer at the Busitema University Faculty of Health Sciences, and the immediate past president of the Uganda Medical Association.  Healthcare in Uganda, as well as in many other low-income countries, fails to meet the basic needs of its population. A lack of essential medications, supplies, and nurses are the more obvious causes of inadequate healthcare delivery. Less visible, but perhaps more fundamental, is the problem of leadership: the medical officer on staff at the regional hospital who does not show up for work, and the effects this has on support staff. Leadership failures including poor supervision, limited human resources planning, low or delayed wages, and difficult working conditions result in such absenteeism. Consider also the effect this absent medical officer has on impressionable medical students learning in that facility in which the faculty is already stretched thin. The students are demoralized by the noticeable increase in preventable deaths and the lack of adequate mentorship. As a result, newly graduated doctors commonly seek work or further study outside Uganda, never to return. The sequelae of poor leadership percolate down to trainees and the cycle of shortages of healthcare workers continues. We have witnessed this as physician educators and practitioners in East Africa. While only one of six essential building blocks of any healthcare system, improving leadership amongst senior Ministry of Health (MOH) officials is paramount. Improvement would produce a ripple effect throughout the public health sector, creating positive incentives for recruitment and retention in areas where health workers are most needed. Inspiring nurses and medical staff to commit to quality healthcare delivery and retaining Ugandan medical students once they graduate requires a culture of accountability at the top, both at the local hospital level and within the MOH. Elections often do not result in meaningful changes of leadership in many countries, including Uganda. Accordingly, medical professionals have taken to the streets to have their voices heard. Medical officer interns went on strike across Uganda in mid-2016 in response to a rushed MOH plan that would have substantially changed the educational path to becoming a doctor. More recently, doctors in Kenya went on strike in early 2017. It was only after the imprisonment of the medical society leadership and three months of many avoidable deaths in hospitals throughout the country that these professionals and the MOH agreed to resolve the crisis. Failure of policymakers to effectively engage with those they lead was arguably the primary cause of this unrest.  The President of Uganda is aiming for his country to achieve lower-middle income status by 2020. It is in all of our interests for Uganda to reach this benchmark in order to strengthen our collective global health and improve the lives of many Ugandans. Uganda, however, is being held back by its own leadership failures, which push medical professionals away from practicing in Uganda. Without adequate human resources for health to direct and dispense its existing healthcare resources, the Ugandan health system will go nowhere.

Coauthored with Ryan Fedasiuk, intern in the International Institutions and Global Governance program at the Council on Foreign Relations. Today is World Health Day. Originally created to mark the founding of the World Health Organization (WHO), the day has since become an opportunity to spread awareness of a subject of major importance to global health each year. For 2017, the WHO campaign focuses on depression, the leading cause of disability worldwide. As the WHO spotlights depression and issues surrounding the illness, it is important to consider just how far the international community has to go in combating this debilitating mental disease. In 2014, the World Health Organization published its first and only report on suicide titled Preventing suicide: A global imperative. But suicide prevention, it seems, was not quite imperative enough. Of the 169 targets specified in the United Nations Sustainable Development Goals in September 2015, mental health was mentioned just once, in target 3.4, when the leaders of the world lumped it together with “preventing noncommunicable diseases” and boldly declared that they would “promote it.” But the world has not fulfilled even this desultory ambition. Although the WHO has accelerated progress on preventing and responding to noncommunicable diseases, the same cannot be said of mental illnesses, particularly depression. Thankfully, the world health community has an opportunity to enact meaningful change at the annual Mental Health Gap Action Programme (mhGAP) conference this October in Geneva by focusing not on reinventing strategy, but on securing legal and financial commitments from countries to enact the mhGAP Intervention Guide (mhGAP-IG) as it stands. In its 2013-2020 Mental Health Action Plan, the WHO outlined four priorities: Greater and more effective national leadership on mental health issues Improved access to comprehensive, community-based mental health care Increased investment in promotion and prevention strategies Strengthened information systems and research collection Halfway through the timeframe, little progress has been made. As a result, the WHO is expected to fall short of its most visible mental health goal: To reduce suicide by 10 percent globally by 2020. Suicide is responsible for eight hundred thousand deaths annually, and while global morbidity has decreased, several countries have seen large spikes of up to 270 percent since the year 2000. Perhaps more hauntingly, for every person who dies by suicide, twenty people survive a suicide attempt—and these figures only reflect the sixty countries for which quality data exists. In the natural progression of global health policy, mental health is the next frontier. In its initial sixty years of operation, the WHO focused chiefly on delivering medicines and containing the spread of outbreaks, providing hundreds of millions of mosquito nets and antiretroviral therapies to developing countries. Once our neighbors no longer looked sick, the WHO narrowed its gaze on largely invisible noncommunicable diseases (NCDs) like cancer, diabetes, and cardiovascular diseases. Governments poured resources into national health organizations and global spending on cancer quickly surpassed $100 billion. The next logical step is to focus on ailments not just of the body, but also of the mind. Since the inaugural mhGAP conference in 2009, mental health has attracted significant international attention. The number of conference participants grew from twenty-seven in 2009 to more than fifty member states and one hundred and fifty partner organizations in 2016, when the highly-praised second version of the mhGAP-IG was unveiled. And although the recommendations outlined in the two hundred-page document are substantial, the world needs more than a plan; it needs commitments to follow through. The mhGAP conference has been an annual occurrence for nine years, but in that time, few countries have revisited or created mental health strategies, and only twenty-eight have suicide prevention plans. Guyana, India, and Japan have taken concrete actions, but for the most part, “mental health” has been reduced to a feel-good public relations buzzword. No minister of health has ever attended an mhGAP conference. What’s more, of the six candidates running for director-general of the World Health Organization, only two mention mental health as part of their vision for WHO priorities. The public health community cannot afford stagnation on mental health. The costs—particularly to world economic prosperity and physical security—are too high. Depression is a devastating disease. By precluding those affected as well as their caregivers from being employed, it often traps people in poverty, resulting in economic and productivity losses that exceed those of most acute physical conditions. By some estimates the costs of untreated mental illness constrain global GDP by nearly 35 percent. Accordingly, the WHO has repeatedly said that investment in mental health services is not only economically sustainable, but also generates a multiplier effect. But without concrete commitments to improving the four categories of the Mental Health Action Plan, the world is poised to regress, and least developed countries (LDCs) will be hit the hardest. More than 676 million people suffer from depression worldwide, with only 10 percent of those diagnosed receiving minimally adequate treatment in LDCs. Mental health is also a national security issue. Nearly 73 percent of current U.S. military personnel in need of treatment are not seeking mental health care, often believing that seeking such treatment will harm their career or lead to superior officers treating them differently. Untreated mental illness creates risks in combat situations. And as the base shootings at Fort Hood and Chattanooga indicate, untreated mental health problems can put even nonactive troops in jeopardy. Finally, the costs of inadequate treatment extend to the home front. More than ninety thousand American soldiers and Marines have served multiple tours of combat, and this demographic is most at risk of developing post-traumatic stress disorder (PTSD), receiving a traumatic brain injury (TBI) which may precipitate dementia, or dying by suicide. One of the greatest challenges to global leadership on mental health is that countries are in such disparate stages of development, which is the reason the WHO began producing the mhGAP-IG in the first place. On one end of the spectrum, suicide or attempted suicide is illegal in twenty-five countries, which leads to under-reporting and under-recording of cases of suicidal ideation and depression. On the other end, countries like the United Kingdom have established large funding guarantees for churches and local clinics to provide mental health services. To make mental health a priority in the global development agenda, it is time for states to put their money where their mouths are. One idea is for national governments to bring policy “gift baskets” to the October meeting, akin to those they presented at the Nuclear Security Summit. Countries should focus on strengthening national capacities to improve mental health and use the multilateral forum to exchange ideas and announce new programs suited to their unique cultures and stages of development. At the national and international level, governments should commit funds to increase the supply, quality, and affordability of psychotropic medicines. By making mental health care a competitive source of national pride, states can make concrete progress toward expanding access, improving data collection, and reducing stigma. While refocusing development on mental health, however, states should be careful to adhere to the WHO’s recommendations as well as the UN Convention on the Rights of Persons with Disabilities. By funding community-based mental health services, as opposed to standalone hospitals or shell organizations, development agencies can reduce overhead costs and curb human rights abuses that have plagued treatment in the past. To reduce stigma, media outlets should change the language they use when covering stories of suicide and self-harm. Evidence suggests that sensationalizing suicide or mental illness simply entrenches stigma and dissuades people from seeking treatment. Addressing the global mental health crisis will be one of the greatest challenges the world health community has ever known, but success would mean prosperity and security beyond imagination. The world’s leaders should pursue peace not just among nations, but within their constituents’ minds.