New Numbers On Tuberculosis Burden Must Galvanize India To Act

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Dr. Madhukar Pai

Last week, WHO released its 2016 Global TB Report. The news, unfortunately, is not good. The report shows that the TB burden is actually higher than previously estimated, mainly because of new data from India. In 2015, there were an estimated 10.4 million new TB cases worldwide. Six countries accounted for 60 per cent of the total burden, with India accounting for 27 per cent of the global cases, followed by Indonesia, China, Nigeria, Pakistan and South Africa.

An estimated 1.8 million people died from TB in 2015, of whom 0.4 million were co-infected with HIV. Gaps in testing for TB and reporting new cases remain major challenges, as they have in the past. Of the 10.4 million new cases, WHO estimated that only 6.1 million were detected and officially notified in 2015, leaving a huge gap of 4.3 million cases that are “missing” — either not diagnosed, or managed in large unregulated private sectors and not notified to TB programs.

Global TB elimination is an impossible goal without significant progress in this emerging superpower.

India continues to bear the brunt of the TB epidemic, with 2.8 of the 10.4 million new TB cases that occurred in 2015. TB is also a major killer of Indian people. The latest Global Burden of Disease estimates from Institute of Health Metrics and Evaluation, published earlier this month, show TB to be the sixth leading cause of deaths in India. In 2005, TB was the sixth leading cause of deaths in India, and ten years later, in 2015, it holds its place as a leading killer of people in India.

These new estimates from WHO and GBD are disappointing and underscores the need for greater investments in global TB control. In particular, India really needs to wake up to the enormity of the epidemic in the country, and put some serious money behind its under-funded TB program. Global TB elimination is an impossible goal without significant progress in this emerging superpower.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000, while India was estimated to have over 79,000. TB is no longer a major killer of people in China, and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centres (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

So, why does India struggle with a much higher TB burden? There are many reasons. For one, India has many social determinants that fuel the TB epidemic — poverty, malnutrition, smoking, and indoor air pollution. Secondly, India has under-funded TB control for a very long time. And much of the focus was only on the public TB program. It is only recently that the national TB program has seriously started to address the problem of TB in India’s large, dominant, private sector.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done (unlike China and other high TB burden countries). Furthermore, the Indian national TB program was (and still is) heavily reliant on insensitive diagnostic tools such as sputum microscopy. India is “fighting the TB war with 19th century cannons.” All of this meant that India has been under-diagnosing and under-reporting the burden of TB for a long time.

With new research, our understanding of the true burden of TB in India is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market.

In addition, although India made TB notification mandatory in 2012, it has taken a few years for private sector notifications to accumulate. Now, thanks to several public-private partnership programs, significant increases are being noticed in case notifications from private sector.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem. This will not happen without high-level political commitment.

Last week, on the same day of the WHO TB report release, The Lancet published a comment by the Indian Health Minister Mr Jagat Prakash Nadda and Dr Poonam Khetrapal Singh, head of India’s WHO Regional Office for South East Asia.

Overall, the path forward for India is very clear — acknowledge the reality of a massive TB epidemic, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem.

In their Comment, they acknowledged that TB is a bigger problem than imagined in India and other Asian countries, and suggested that TB should be made a top priority on national agendas. They also argue that political commitment should be translated into a comprehensive national TB control plan, and such a plan must be fully funded and implemented promptly by an empowered body that reports to the highest levels of government.

These statements by the Indian Health Minister is very impressive and progressive, as is the commitment from Dr Soumya Swaminathan, India’s Secretary of the Department of Health Research about India’s plans conduct prevalence surveys, develop innovative new tools for TB, address social determinants such as malnutrition, and create an India TB Research Consortium.

Hopefully, these leaders will deliver on the vision that they have articulated, and make TB a national priority in India. In fact, India has already started the process for creating the National Strategic Plan for TB Control in India (2017-2023). This plan must be ambitious, and fully funded by the Indian government. Otherwise, future TB reports will continue to bring bad news.

Madhukar Pai is the Director of McGill Global Health Programs, and the Associate Director of McGill International Tuberculosis Centre. (@paimadhu)


This article was originally published in The Huffington Post. See the original article here.

Post-Travel Perspectives: Working for the Kigezi Health Foundation in Kabale, Uganda

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Neil Verma

I traveled to Uganda and joined the Kigezi Health Foundation primarily to expand my knowledge of global health disparities, community empowerment and rural medicine. Adequate nutrition remains a challenge for several families in the Kabale area with several diseases having clear associations with malnutrition. My work involved studying the impact of rabbit breeding in low-income families as a means to provide adequate nutrition and additional income. The ultimate goal remains to expand knowledge and resources to address public health issues and maximize population health.

My father and grandmother were born and raised in Kabale and these personal ties to Uganda have specifically drawn me to this community. My family’s experiences have provided me perspective on the impact of disease within this community while fostering my desire to provide medical service to the local population.

My experience with the KIHEFO reinforced my desire to engage in rural medicine and global health, addressing healthcare issues through improving the social determinants of health and community empowerment.

I had limited proficiency in Ruchiga–the local language–and a greater proficiency with the local language would undoubtedly help address the cultural and linguistic barriers and build rapport with patients. Local medical professionals are already faced with a demanding clinical workload, and learning the language and cultural practices partially alleviates the ethical responsibility of having the clinical staff host foreign medical trainees. Cultural attitudes towards medicine also have an impact on healthcare delivery in Uganda, particularly given that 80% of the population exclusively seek out traditional healers as their primary care providers. The KIHEFO has attempted to partner with traditional healers in order to encourage Ugandans to seek out modern medical services. The differences in particular disease treatment protocols and regimen add to the ethical conflict between my own perspective on healthcare and the approach in Kabale. To cope with these realities, I have relied on a network of former global health students and local professionals to better understand Ugandan healthcare along with their unique approach to addressing disease and suffering in a resource-limited setting.

My work with the KIHEFO will contribute to an academic relationship with McGill University and provide a mutually beneficial opportunity to expand knowledge and resources to address public health issues such as malnutrition and HIV prevention. Furthermore, an ongoing partnership between both parties will allow for expansion of available medical resources, services and additional opportunities for knowledge exchange and learning. The benefits of partnering with North American universities are already visible in the KIHEFO’s maternal clinic, which enjoys the use of a donated portable ultrasound machine. As services continue to grow, medical trainees and residents rotating through Kabale will provide additional training to local staff and counselling to community members in order to improve quality of care and maximize population health.

As a practicing physician, I will be able to use the knowledge gained working with the KIHEFO to advocate for policy changes locally and globally that also focus on the social determinants of health including food security and housing that will reduce health inequities. Learning the practice of rural medicine in Uganda allowed me to develop my awareness of the organization of healthcare in a resource-limited setting. It will give me the skills to strive to become a physician who remains conscious of the challenges of healthcare delivery and to provide the most efficient patient care.

As I have embraced the significance of public health to communities, I am optimistic that I will continue to engage in global rural medicine initiatives and devote myself to career and life as an advocate for global health.

My work with the KIHEFO presents challenges and learning opportunities that will improve my understanding of the disparities in global health, the value of community empowerment in healthcare and the challenges of rural medicine in a developing nation. These skills will serve as a foundation for my desire to pursue a career focusing on global health service and the development of global health policy.

Neil Verma was the recipient of the Ashworth Student Travel Award. Neil is a third-year medical student primarily interested in understanding the social, cultural and economic aspects of health and disease to improve global health.

MEDLIFE McGill presents MICC 2016: Access to Water Conference

Access to clean water is an issue that afflicts hundreds of millions of people around the world and is one of the barriers that prevent communities from escaping the constraints of poverty. In an effort to bring awareness to this problem, MEDLIFE McGill chose Access to Water as the theme in this year’s MEDLIFE Interchapter Conference Competition (MICC).

MICC, which was started by MEDLIFE McGill in 2015, is a weekend-long annual case competition where delegates from MEDLIFE chapters across North America are invited to learn how to make real change in impoverished communities.

This past March, MEDLIFE McGill hosted MICC 2016: Access to Water in Montreal. Participants had the opportunity to learn about the challenges related to access to water through talks given by experts in the field and a number of interactive workshops.

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Participants listening to talks given by experts in the field of access to water.

Participants were then given a chance to incorporate what they learned through a case competition based on Kilimanswaki, a real community in the Moshi District of Kilimanjaro, Tanzania. In Kilimanswaki, there is one well that serves as the water source and some families must travel up to 2 hours to reach it. MEDLIFE is actively working with Kilimanswaki community leaders to provide medical, educational and developmental support.

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Kilimanswaki, Tanzania

Participants were tasked with the development of a four to six year plan to address the lack of access to water in the community, as well as a development plan for the future that would improve the quality of water. There were numerous considerations to keep in mind, such as budget, community statistics, and major ongoing health crises.

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The winners of MICC2016 were McGill’s own Timothy Cheng, Andrew Kim, Jessie Ouyang and Amber Zhao!

Over the weekend-long event, students had the chance to learn from experts, apply their own problem solving skills and collaborate with others to address the real-world problem of the lack of access to water. More information on MICC 2016 and other events hosted by MEDLIFE McGill can be found on the MEDLIFE McGill website.

Follow MEDLIFE McGill on Twitter, Instagram, and Facebook!

The Biography of Malaria: Sonia Shah and “The Fever” Book Review

Vaidehi Nafade

It bears no explaining that malaria is a major global health issue today. According to WHO, in 2015 there were over 200 million cases, and 400,000 deaths, mainly in Sub-Saharan Africa (1). WHO has set ambitious goals for the elimination of malaria, but it is a difficult disease for many reasons – and it has always been.

"The Fever" by Sonia Shah

“The Fever” by Sonia Shah

Sonia Shah says it aptly in her novel, “The Fever: How Malaria has Ruled Humankind for 500,000 Years”: “Despite the fact that we’ve known about malaria since ancient times, and have the drugs, killing chemicals, and know-how to avoid it, something about this disease still short-circuits our weaponry” (2). “Fever” tells the story of malaria, from its evolution into a parasite from a photosynthesising predecessor to its unrelenting presence in today’s world and the public health problem it poses.

Despite being factually dense, “Fever” does not read like a typical nonfiction. The editorialized style of writing can seem jarring at first, especially in comparison to academic texts or articles – but Shah’s journalistic style brings the book to life, making it into a true biography of Plasmodium. The result is a genuinely enjoyable, relatively light read, despite its heavy topic, that remains accessible to the global health professional or enthusiast alike.

However, even malaria experts will likely find some new information in “Fever”, as its greatest strength is its thoroughness. In true investigative journalist style, Shah’s research for the novel is expansive. While she covers the basics of malaria, such as the different species of the parasite and its clinical features, Shah does not stop there. The novel also describes malaria’s effects on shaping the Roman Empire or colonial America (greater than you would expect), its contributions to humankind’s genetic evolution (much more than just the infamous sickle cell gene), and the pharmaceutical struggle from quinine to artemisinin. It provides a long history of public health interventions and a persisting cultural divide between Western health authorities and malaria-afflicted countries that makes public health interventions so difficult.

Ultimately, “Fever” provides a captivating and detailed story of malaria that will leave any reader with a greater appreciation of a very formidable parasite, and an intellectual concern for how public health will tackle this parasite next.

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Vaidehi is an U3 pharmacology student and an avid reader and writer. Her passion for global health stems from an interest in immigrant and refugee health and cross-cultural medicine.

 

References

1. “Malaria Fact Sheet,” WHO, accessed June 13, 2016. http://www.who.int/mediacentre/factsheets/fs094/en/

2. Sonia Shah, The Fever: How Malaria has Ruled Humankind for 500,000 Years (New York: Picador, 2010). 9.

Global Mental Health Research for Sustainable Development

Sakiko Yamaguchi

The WHO’s global mental health action plan 2013-2020 relies on evidence-based practices. As such, today’s global mental health research is largely focused on the “evidence” to deliver effective mental health interventions in low- and middle-income countries. Although I have no intention to question the need and importance of scientific evidence, we hardly hear about the “sustainability” of evidence-based practice in global mental health despite the fact that “sustainable development” has been a core concept shaping the development agenda since the 1988 Bruntland Commission. Now that mental health and well-being are included in the UN’s Sustainable Development Goals, I would like to explore a question: “How can researchers link global mental health research with sustainable development?”

Sakiko leading a planning workshop in Sudan.

Sakiko leading a planning workshop for a health project in Sudan.

One answer may be found in implementation science, which provides tools and approaches to integrate evidence into health policy and practices (De Silva & Ryan, 2016). An intervention that is found to be effective in the idealized conditions of a research setting may meet a wide range of barriers in a real world context. The exclusive focus on evidence may divert our attention from the role of culture in a specific setting. In this context, global mental health research should find an answer of not only “what works” but also “how it works” by holistically examining the behavioural, organizational, economic, socio-cultural, and political dimensions of the context where evidence is implemented. Furthermore, researchers have the important role and responsibility to share pertinent individual knowledge available with those at the organizational, community, and society levels (Landry, Amara, Pablos-Mendes, Shademani, & Gold, 2006).

The exclusive focus on evidence may divert our attention from the role of culture in a specific setting.

 

While innovative instruments for knowledge sharing still seem lacking, my past work experience in international development reminds me of the notion of “ownership.” With an understanding that the sustainability of the project outcome results from the beneficial output shared among project participants, development partners generally make great efforts to foster a sense of ownership during the project implementation. In global mental health, community-based participatory research may be one possible approach to generate ownership by addressing the unequal power distribution between researchers and community people.

My initial question is still open for discussion. Meanwhile, the consideration of sustainability and ownership in global mental health research may shed light on the ethical aspects of our research process and application of knowledge.

 

About the Author:

Sakiko Yamaguchi is in the 2nd year of her PhD program in Division of Social and Transcultural Psychiatry, Department of Psychiatry at McGill. After working on government projects for social development in low- and middle-income countries, including post-conflict countries (Peru, Afghanistan, Sudan), she decided to pursue her PhD to better understand the long-term impact of violent conflict on mental health, and explore how international community can respond to the unmet needs of the affected people. She is currently in Ayacucho, Peru for her research project on alcohol misuse among the Andean highland population, who is still suffering from the consequence of political violence and the daily hardships rooted in poverty and socio-economic inequality.

 

The new McGill Global Mental Health Program was launched 30 May 2016. Like them on Facebook and learn more here.

 

 

References

De Silva, M. J., & Ryan, G. (2016). Global mental health in 2015: 95% implementation. The Lancet Psychiatry, 3(1), 15-17.

Landry, R., Amara, N., Pablos-Mendes, A., Shademani, R., & Gold, I. (2006). The knowledge-value chain: a conceptual framework for knowledge translation in health. Bulletin of the World Health Organization, 84(8), 597-602.

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