The RSIS Centre for Non-Traditional Security (NTS) Studies' Blog

Tobacco Control: Prioritising Public Health over Free-Trade

Posted in Health and Human Security by NTSblog on June 11, 2013

Public health should not be undermined by economic priorities, especially priorities that are dictated by the tobacco industry. Tobacco control efforts in Southeast Asia face alarming challenges with the Trans-Pacific Partnership (TPP) negotiations. Even though the TPP only involves four ASEAN member countries (Brunei, Malaysia, Singapore and Vietnam), the tobacco industry’s strong lobby presence particularly on intellectual property (IP) negotiations can possibly undermine whatever progress ASEAN has made in banning tobacco advertising, promotion and sponsorship (TAPS). ASEAN countries have imposed bans on TAPS except for Indonesia and the Philippines. Aside from Laos, Malaysia, Myanmar and the Philippines, ASEAN countries have also banned publicity for tobacco companies’ corporate social responsibility (CSR) activities.

A cigarette pack is the simplest but most crucial form of marketing tobacco and a cigarette brand. The tobacco industry will fight long and hard to keep cigarette packs appealing to the public in the guise of protecting their IP rights. The tobacco industry has been aggressive in protecting their IP rights to legally counter stringent tobacco control policies in Australia and Singapore under the framework of trade agreements such as the Trade-Related Intellectual Property Rights (TRIPS) Agreement. It is then not surprising that Thailand’s new graphic health warning (GHW) regulation to be implemented in October 2013 has already met strong opposition from tobacco companies. Thailand will have the largest GHWs in the world, covering 85 per cent of the front and back of cigarette packages. Currently, Brunei has the largest GHWs in tobacco products in ASEAN (75 per cent), followed by Thailand (55 per cent), Singapore (50 per cent) and Malaysia (50 per cent).  By November 2013, Vietnam will also require GHWs (50 per cent) on tobacco packages. Indonesia’s ‘fresh’ tobacco control law introduced in January 2013 is still relatively weak, with regulations still pending. As noted in a previous blog, ASEAN critically needs leadership to go ‘plain’ as Australia did.

With social media, marketing tobacco across borders has never been easier, even in countries with strict tobacco control regulations and even without free-trade agreements. Tobacco companies are also exploiting CSR through charities and ‘sustainable’ tobacco farming to gain political leverage and promote tobacco. Indonesia and the Philippines still allow TAPS at points-of-sale (POS) such as convenience stores and road side stalls, and in social media along with Myanmar and Vietnam. The ASEAN Focal Points on Tobacco Control (AFPTC) has emphasised that ASEAN has to ‘step-up’ the implementation of comprehensive bans on TAPS and the harmonisation of cross-border tobacco advertising through all media platforms, including the internet.

These challenges can be overcome through strict regulation and monitoring by ASEAN governments. Tobacco control policies with ‘teeth’ are not only prudent but also imperative if they are to be effective. The implementation of ASEAN member-states’ commitments to the WHO Framework Convention on Tobacco Control (FCTC) (including non-signatory Indonesia as noted in a previous blog) warrants extremely strong political will and less interference on public health policy formulation from the tobacco industry. Negotiators in the TPP have to acknowledge that the FCTC requires that multilateral agreements be compatible with the FCTC including taxation and price measures. Tobacco products should thus be excluded in free-trade agreements to discourage industry opposition to government policies on tobacco control, particularly on banning tobacco advertising, promotion and sponsorship to reduce demand.

This blog post has been written by Gianna Gayle AmulShe is a Research Analyst at the Centre for Non—Traditional Security (NTS) Studies in the S. Rajaratnam School of International Studies (RSIS).


Avoiding Pandemic Fatigue: Financing Pandemic Preparedness and Response

Posted in Health and Human Security by NTSblog on May 15, 2013

Pandemic fatigue is avoidable but inevitable. Existing mechanisms for financing pandemic preparedness may not be sufficient in the event of a pandemic outbreak especially with health security threats emerging from a lethal SARS-related novel coronavirus in the Middle East and an H7N9 outbreak in China.

At the global level, there is the WHO Pandemic Influenza Preparedness (PIP) Framework which includes ‘sustainable and innovative financing mechanisms’ to compensate the lack of donations to the WHO PIP vaccine stockpile. Since 2012, organisations, including influenza vaccine, diagnostic and pharmaceutical manufacturers using the WHO Global Influenza Surveillance and Response System (GISRS) have contributed USD 18 million to the WHO through a partnership contribution mechanism under the framework. In December 2012, the WHO signed an agreement with GlaxoSmithKline (GSK) to ensure the availability of pandemic vaccines and antivirals to developing countries in real time (10% of vaccines as they come off the production line and 10 million treatment courses of antiviral medicine).  Funding for the WHO’s operations however, has been drastically cut for the past two years due to budget reductions in donor countries, forcing massive lay-offs of WHO staff in its headquarters and in key global health hubs. Sending a WHO team to China to monitor and assess the H7N9 outbreak, for example, was hampered because of budget limitations.

At the regional level, there is the nascent ASEAN Multi-sectoral Pandemic Preparedness and Response Framework Action Plan which embeds pandemic response into the region’s disaster and emergency management platform – the ASEAN Agreement on Disaster Management and Emergency Response (AADMER). This came about with the financial support of the USAID Technical Assistance and Training Facility (TATF) for ASEAN which amounted to USD26million dollars (from 2007-2012). As of writing, no new funding has been announced for the further operationalisation of the action plan. In addition, there is the ASEAN Regional Stockpile of Antivirals against potential pandemic influenza for ASEAN. The USD58.85 million earmarked for the regional stockpile from 2006 to 2013 was granted by  the Japan-ASEAN Integration Fund (JAIF) and later on by the Japan Trust Fund on Health Initiative.

Notably, most of the relevant funding have either ended in 2012 or are closing this year.  Thus, a new stimulus may have presented itself with the threats of H7N9 and the novel coronavirus but a new surge for funding would be critical if the frameworks, action plans or stockpiles are expected to adequately function and meet the demands for pandemic response. One solution is to tap into the resources of global foundations and multilateral initiatives which can offset bilateral assistance gaps, if not further support pandemic preparedness and response in the region. The Rockefeller Foundation for example has already funded a number of initiatives for such objective, including a disease surveillance network initiative to increase the capacity of the Asian Disaster Preparedness Center (2007-2011) amounting to USD 280,000. Donors and national governments however need to have an integrated and coordinated strategy. Surge in funding would not matter if objectives overlap and when local health infrastructures are compromised when comprehensive programs are sacrificed for disease-specific programmes to meet donor priorities. Ensuring the effectiveness of current aid for pandemic preparedness and evidence-based interventions can help lay out how funding can be more consistent in the long term.

This blog post has been written by Gianna Gayle AmulShe is a Research Analyst at the Centre for Non—Traditional Security (NTS) Studies in the S. Rajaratnam School of International Studies (RSIS).

Asia, the Millennium Development Goals, and the post-2015 development agenda

As the Millennium Development Goals (MDGs) period draws to a close, the global community is reflecting on their outcomes and looking ahead to the post-2015 development agenda. Significant progress has been made on some of the eight MDGs since they were established in the year 2000, but this has been uneven geographically. For example, the World Bank estimated that the goal to halve the incidence of extreme poverty (MDG1) was achieved globally in 2010, but Sub-Saharan Africa has only made moderate progress towards this goal[1].

Assessing the outcomes of the MDGs has highlighted strengths and weaknesses of the goals themselves. In terms of its successes, the MDGs boldly strived to attain progress in a broad range of critical issue areas which were unevenly prioritised across the world. The goals were simplified so that they could be understood by the masses. Simultaneously, the MDGs provided a platform for comprehensive partnerships between a range of stakeholders including NGOs, companies and governments in countries in various stages of development.

Nonetheless, the MDGs were not without their shortcomings. A widely-held criticism is the lack of participation in the formation of the goals, which led to an agenda driven by the UN and donor countries. It was argued that some countries and regions were inherently disadvantaged by their capacity to respond to MDG priority areas and indeed measure their progress. The UN was also criticised for not adequately addressing climate change in the MDG targets.

Asia made significant progress in the area of poverty reduction, with remarkable success in industrialising countries such as China and India boosting the global average. Nonetheless, the region is still home to the largest proportion of world’s poor and fragile countries will still require substantial aid to progress in coming years. Progress towards the goal of eradicating hunger and malnutrition was less apparent and remains a major challenge. In terms of education, Asia made some progress in terms of the number of enrolments and the completion of schooling, but did not quite meet the target. The region is not on track to meet the target on child mortality, and there is significant room for improvements in terms of maternal health.

As the MDGs draw to a close and consultations for the post-2015 development agenda take place in 2013, Asian stakeholders should consider key factors to facilitate continued progress. Given the differing stages of development in the region, universal goals should allow for individual states to address their most pressing challenges within the broader issue areas. Asia’s worrying expansion of inequality in terms of income and access to public services needs to be accounted for in the region’s development agenda. Finally, sustainability goals in the post-2015 agenda will need to find a delicate balance in the need for resource consumption to pursue economic growth and protecting the Asia’s fragile environment.

[1] Note that Sub-Saharan Africa needed a growth rate 28 times its historical average during the MDG period to achieve the target of halving poverty.

ASEAN’s Critical Infrastructure and Pandemic Preparedness

Posted in Health and Human Security by NTSblog on January 22, 2013

With a myriad of existing ASEAN bodies established to address the threat of pandemics, ASEAN’s challenges lies on bridging capacity gaps in health systems among member states and ensuring the protection of critical infrastructure. ASEAN defines critical infrastructure as:

“The primary physical structures, technical facilities and systems which are socially, economically or operationally essential to the functioning of a society or community, both in routine circumstances and in the extreme circumstances of an emergency.”

A robust and sustainable framework must encapsulate the protection and strengthening of critical infrastructure and ensure the continuity of essential services in the region in the event not only of an outbreak of a pandemic but also of any disaster or emergency. The plans and strategies of the public and private sectors in such circumstances should complement each other and conform to a minimum standard of preparedness. The International Organization for Standardization (ISO) for example, has developed ISO 22301 on business continuity management systems to enable organizations, whether they are governments or businesses, to protect against, prepare for, respond to and recover when disruptions such as pandemics or natural disasters strike.

Such plans require resources, and the challenges of pandemic fatigue and donor fatigue looms at this stage when preparedness plans have already or are in the process of being drawn. For example, the UN Central Fund for Influenza Action’s (UNCFIA) budgets for 2008 and 2010 were huge (USD16.83  million and USD19.22 million, respectively) compared to the meager USD2.48 million budget for 2012.

These plans, however, would only matter if they are operational. Funding inconsistencies therefore impede the realisation of a long-term approach towards strengthening both health and non-health sectors for pandemics, natural disasters and emergencies. As a region home to developing countries and a plethora of risks to emerging infectious diseases and natural disasters anticipated every year, ASEAN must be able to allocate a continuous and efficient flow of resources, invest on health system strengthening and build up public and private sector partnerships. ASEAN must also be able to utilise the existing ASEAN Infrastructure Fund (AIF) not only to finance necessary infrastructure projects but also ensure that in building the region’s critical infrastructure. Through improving capacities in telecommunications, energy, transportation, food, water, sanitation and health and financial institutions, each member state would make strides towards better protection during difficult times and greater continuity of operation despite lack in human resources.

Australia’s Move to Plain: Stripping the Glamour of Tobacco

Posted in Health and Human Security by NTSblog on December 11, 2012

Plain packaged tobacco products in Australia usher in the beginning of a new era for the Framework Convention on Tobacco Control (FCTC).  With the Tobacco Plain Packaging Act (TPPA) and the Australian High Court’s ruling against the tobacco industry’s appeal to the unconstitutionality of the act, the tobacco control lobby for plain packaging in Southeast Asia now has a tough precedent that can be used to defend the constitutionality of similar laws that may be proposed. The EU at some point also considered plain packaging after the High Court’s verdict. This is comparable to Canada’s tough implementation of graphic warnings on tobacco products in 2001 after which 63 countries have followed suit.

The WHO Director General Margaret Chan has expressed her hopes that the Australian High Court’s evidence on the positive health impact of plain packaging can support efforts in other countries to develop and implement strong tobacco control measures and further reduce the tobacco industry’s influence on government.

The law effectively stripped tobacco of its glamour- banning brand colours, logos and design on packages. With larger graphic health warnings and brands in standard shape, location, color, font style and size, Australia made tobacco products packaging as filthy as their contents are. If Australia is tough enough to remove the tobacco industry’s ability to use packages to promote tobacco use, then it can also be done in Southeast Asia.

In Southeast Asia, Singapore and Thailand can also move towards plain packaging. With its already strict tobacco control regulations, Singapore will be introducing new graphic and text health warnings, banning misleading descriptors and lowering maximum tar and nicotine limits by 2013. Thailand, the first Southeast Asian country to follow Singapore’s graphic warning regulations in 2005, has required tobacco producers to display statements about toxic or carcinogenic substances on cigarette labels covering 60% of each side of the package since January 2012. If Singapore and Thailand can drive the plain packaging agenda further to ASEAN, the region may see healthier generations unburdened by chronic non-communicable diseases (NCDs) such as cancer, heart attack, diabetes and lung diseases attributed to smoking tobacco. The socio-economic burden of the costs of treating NCDs has contributed to deepening health insecurities in the region. Taking a step further with plain packaging can potentially reverse this trend.

Breaking the Habit (II): Smoke Gets in Your Eyes

Posted in Health and Human Security by NTSblog on August 10, 2012

Both the dilemma and the solution for lifestyle-related illnesses lie on political will and priorities. The tobacco industry can get smoke in the government’s eyes as it dangles a superficial economic boost – but at a high cost for the health of generations of its populace. The World Health Organization (WHO) warns about the tobacco industry’s interference in governments’ attempts at tobacco control, including: ‘exaggerating the economic importance of the industry’ and intimidating and threatening governments with lawsuits. Governments must stop being misled by the perceived economic potential of the tobacco industry.

Cradling the tobacco industry puts both the smoker and non-smoker’s health at risk. If multinational tobacco companies pour in foreign investments in a country and generate domestic employment and tax revenue, governments irrationally prioritize misperceived economic growth in the short term over public health concerns. Governments should recognize the high costs of health care for long-term tobacco-related illnesses to generations of their population and devise sustainable strategies for effective tobacco control. By implementing these policies, governments can help ensure that the expenses for cigarettes and for related health services needed to treat diseases attributed to a lifestyle that embraces smoking will flow instead to feed hungry mouths, ensure safe drinking water, send children to school or provide basic health care. Disturbingly, the poor smokes more, with 80 percent of the world’s one billion smokers coming from low- and middle-income countries where the lack of awareness of the dangers of smoking and from easy access to cheap cigarettes is often prevalent.

The effectiveness of tobacco control initiatives to increase health security is highly dependent on the political will of national and local governments to strictly implement tobacco control policies that will essentially hurt the tobacco industry- from the tobacco farmers to manufacturers, to distributors and importers of tobacco products, to the tobacco advertising industry, down to the public relations and legal firms that consider big tobacco a cash cow industry. Effective tobacco control is also dependent on civil society and the private sector to engage in productive partnerships with government to promote awareness of the dangers of tobacco use and consumption. The task does not stop there, strictly implementing and monitoring tobacco control policies will eventually enable every individual’s right to breathe clean air- one unpolluted by toxic chemicals dangerously packed in one cigarette.

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Breaking the Habit (I): The Growing Pains of Achieving a Smoke-Free ASEAN

Posted in Health and Human Security by NTSblog on August 10, 2012

Conflicting government and regional tobacco-control policies are part of the growing pains of achieving a smoke-free ASEAN. Despite global and regional initiatives, almost 20 per cent of tobacco-related deaths in the world occur in this region and tobacco consumption and the lifestyle associated with it poses a threat to health and human security.

It may be the habit that is the hardest to break but let’s face it, smoking kills. Globally, tobacco kills one person every six seconds according to the WHO. It kills more people every day but the irony of it is that tobacco-related diseases like cancer, heart disease and asthma among others are chronic or non-communicable diseases that can be prevented. With more than 125 million smokers (30 per cent of the ASEAN population), ASEAN is a viable target market for the tobacco industry and a potent locale for a health crisis.

As the leading cause of preventable death in the world, the gravity of the problem of tobacco use and consumption among the world’s population is undeniable. Tobacco control has slowly been included in the global health agenda since the detrimental long-term effects on one’s health were exposed in 1964. ASEAN in particular has considered tobacco use as a health crisis and has seen how smoking-related healthcare costs and the long-term health risks on both smoker and non-smoker (even the unborn child) weigh heavily on health security. This is evident as ASEAN health ministers’ apparently recommended that tobacco be excluded from the ASEAN Free Trade Agreement (AFTA) tariff list during their talks last July. However, it is unclear what will come out of this recommendation. On a positive note, the ASEAN Headquarters in Jakarta was recently declared as a smoke-free environment as part of the Towards a Smoke-Free ASEAN campaign. Do these initiatives give ample warning to the tobacco industry that ASEAN is serious in strictly abiding by the WHO Framework Convention on Tobacco Control (FCTC) and implementing a smoke-free ASEAN? It did establish the ASEAN Focal Points on Tobacco Control with the aim to protect generations of the ASEAN community from the threats posed by tobacco on health, society, the economy and the environment. Regrettably, this is where the travails of effective implementation come into play.

This September, Jakarta will host one of the largest gatherings of the tobacco industry in Asia- the World Tobacco Asia 2012. Although ASEAN reported that Indonesia has declared seven smoke-free cities and two smoke-free provinces including Jakarta, its welcoming arms to multinational tobacco companies paint a conflicting picture. How could Indonesia declare Jakarta a smoke-free province and all the while host a tobacco exposition in the same province where a supposedly smoke-free ASEAN Headquarters is located? The organizers do know that Indonesia remains one of the few remaining countries which has not signed or ratified the FCTC. Given the millions of smokers in the region, this seems to be an exciting prospect for market expansion from a corporate standpoint but an atrocity from the perspective of health security.

These contradictions are part of the growing pains of achieving a smoke-free ASEAN. This is where tobacco industry interference has come into play and will be discussed in the next blog post.

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Non-Communicable Diseases: Beyond International Health (II)

Posted in Health and Human Security by NTSblog on September 27, 2011

The first United Nations High-level Meeting on Non-Communicable Diseases recently took place in New York and culminated with government leaders pledging to make greater efforts to address the NCD challenge, enshrined in the official declaration of the summit. Among the commitments were implementing tax measures to reduce tobacco and alcohol consumption, improving access to vital medicines, and pushing for universal health coverage.

While the unanimously-approved declaration has been lauded as an important step forward by some, criticism has been equally pronounced. Among them was the assessment that a major barrier to overcoming the NCD challenge is a lack of enthusiasm from the developed world. It was simultaneously noted that this also opens a unique window of opportunity to emerging economies to lead the effort. Brazil, Russia, India, China and South Africa have high NCD burdens and it was argued that although these countries could use this as a springboard for greater advocacy, there remains no strong indication that they are ready to undertake this endeavour.

Others have claimed that the declaration was watered-down from the originally proposed call to action and that the document did not specify targets, unlike the declaration that resulted from the 2001 HIV/AIDS summit. Doubts were expressed about the possibility of generating political will, financial investment and social momentum towards access to affordable medications to treat NCDs; contrasting the Global Fund to Fight AIDS, Tuberculosis and Malaria’s USD 22.4bil funding to a lack of financial commitments towards addressing NCD challenges.

Some critics have been particularly skeptical, calling the summit “a whimper rather than a bang”. This “whimper” was attributed to various factors including the effects of the global financial crisis on public health expenditure, links between technological and economic progress and the rise of NCD risk factors, and world leaders’ readiness to pay lip service to the cause but unwillingness to make accompanying political commitments. This is particularly distressing in light of the World Health Organization (WHO) saying that USD 1.20 per person per year in cheap interventions could dramatically reduce the occurrence of NCDs worldwide.

There is no doubt that the implications of the rise of NCDs will continue to extend beyond the purview of health, posing greater challenges to human security worldwide. The socio-economic opportunity costs of the globe’s 36 million NCD deaths (of which nine million occur among those under the age of 60, and 90 per cent occur in developing countries) has severe and far-reaching ramifications for international development, growth and prosperity.

It can also be argued that difficulties in mobilising support to fight NCDs can be linked to the nature of NCDs themselves. Many NCDs are associated with lifestyle and consumption factors, and cannot simply be cured by developing a vaccine or drug. Political, let alone financial support is difficult to generate given this lack of a clearly defined or certain pathway to cure. It remains to be seen whether the current wave of political momentum on the NCD issue will be sustainable over the coming years given the unique set of challenges it faces.

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Potential Public Health Ramifications of the Philippine Reproductive Health Bill (II)

Posted in Health and Human Security by NTSblog on June 13, 2011

Recently, Philippine president Benigno ‘Noynoy’ Aquino III declared his support for The Responsible Parenthood, Reproductive Health and Population and Development Act of 2011, more commonly referred to as the RH bill. The bill has been a contentious issue for the past several months, although its history predates its reputation. First introduced to Congress in 1998, the bill aims to guarantee reproductive, maternal and child health and ensure universal access to methods and information on birth control.

This blog is the second entry of a two-part series addressing the different aspects of the Philippine RH bill and highlight what public health goals the bill is trying to achieve.

HIV/AIDS in the Philippines

Although UNICEF estimated that the prevalence of HIV among adults in the Philippines in 2009 was less than 0.1 per cent, they also estimated that 8.7 per cent of the Philippine population was HIV positive. HIV/AIDS has also received renewed interest in the country, in part thanks to the media’s highlighting of the 172 new cases detected this year. At first glance, this may appear to be a small figure for a country as populous as the Philippines – but perceptions of the severity of HIV/AIDS in the country have been exacerbated by a number of alarming predictive figures. For example, the Philippine AIDS Council has claimed that the number of HIV cases in the country is anticipated to reach 46,000 by 2015 unless major steps are taken to curb disease spread.

Late last year, UNAIDS also pointed out that “although the national AIDS response is backed by Republic Act 8504, or the National AIDS Law, the country, through the Philippine National AIDS Council (PNAC), has yet to define its prevention strategy and set standards of quality.” With only five years to the Millennium Development Goal (MDG) deadline, the country continues to fall short of its sixth MDG, which is to halt and reserve the spread of HIV/AIDS.

The proposed bill hopes to aid the anti-AIDS cause by calling for the “prevention and treatment of HIV/AIDS and other, sexually transmitted infections (STIs)/sexually transmitted diseases (STDs)”. One of the main methods proposed is the widespread distribution of condoms and ensuring both access and availability. Those who object to the RH bill, however, argue that scientific data proves that HIV/AIDS continues to spread in many countries where condom use is prevalent. Objectors also say that the use of condoms only provides a “false sense of security” which encourages individuals towards increased sexual activity, which leads to higher incidence of HIV/AIDS infection.

The Philippine Department of Health (DOH) has warned, however, that if enacted the RH bill will not eradicate the problems of HIV/AIDS spread and poverty and that the best way to curb the spread of HIV is to educate the sectors of society most at risk of contracting the disease and to convince them to have themselves tested regularly.

As controversy continues to surround the RH bill and its tenets, it remains to be seen whether the bill will pass in Congress. Meanwhile, it will be interesting to continually monitor the evolving HIV/AIDS situation in the Philippines – and what alternative forms of action the government will take to control it, especially in the event of the bill failing to make it past voting.

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Potential Public Health Ramifications of the Philippine Reproductive Health Bill (I)

Posted in Health and Human Security by NTSblog on May 19, 2011

Yesterday, Philippine president Benigno ‘Noynoy’ Aquino III declared his support for The Responsible Parenthood, Reproductive Health and Population and Development Act of 2011, more commonly referred to as the RH bill. The bill has been a contentious issue for the past several months, although its history predates its reputation. First introduced to Congress in 1998, the bill aims to guarantee reproductive, maternal and child health and ensure universal access to methods and information on birth control.

This blog is the first part of a two-part series that will address different aspects of the Philippine RH bill and highlight what public health goals the bill is trying to achieve.

Maternal and child health and mortality

The maternal mortality ratio (MMR) in the Philippines (94 deaths per 100,000 live births) may be low when compared to other nations such as Afghanistan (1,400 deaths). However, contrasted with some of its regional neighbours including Thailand and Singapore (48 and 6 deaths respectively), the Philippines is still several steps behind. The RH bill seeks to reduce this ratio through a series of measures, including the employment of midwives for skilled birthing attendance and emergency obstetric and neonatal care personnel, equipment and supplies at hospitals, with special provisions for those in geographically isolated and depressed areas.

According to the Philippine Department of Health (DOH), ten to eleven maternal deaths daily could be reduced if they had access to basic healthcare and essential minerals like iron and calcium. They also stated that effective family planning could reduce maternal mortality by about 32 per cent. The RH bill aims to achieve this by calling for universal availability and access to information on maternal, infant and child health and nutrition practices (i.e. breastfeeding). These provisions of the bill will also aid the Philippines towards achieving the 5th Millennium Development Goal (MDG) – to reduce the MMR by three-quarters and achieve universal access to reproductive health by 2015.

Additionally, the RH bill touches on the contentious issue of abortion. Official estimates in 2005 put annual abortions at 400,000 to 500,000, and rising, the World Health Organization (WHO) estimates nearly 800,000 cases per year. According to the DOH, nearly 100,000 women who have unsafe abortions every year end up hospitalised due to post-procedure complications. Although abortion is still recognised as illegal and punishable by law (the bill itself calls for the proscription of abortion), the RH bill states that “the government shall ensure that all women needing care for post-abortion complications shall be treated and counselled in a humane, non-judgmental and compassionate manner” – a measure that will undoubtedly further the maternal health cause.

Despite the evident public health benefits that could occur if the RH bill were to be passed, it remains to be seen whether President Aquino’s newly minted support will be enough to pass the bill. More importantly, it is yet unknown the political will needed to support the passing and effective implementation of the bill will prevail over the politically and religiously-centered controversies that currently dominate the RH bill conversation.

Health Security Post-Japanese Quake and Tsunami

On 11 March 2011, a 9.0 magnitude  earthquake occurred in the Pacific Ocean just off the northeastern coast of Japan, near the coastal city of Sendai in Miyagi prefecture. The National Police Agency said that as of 21 March, the death toll and number of those reported missing came to a combined total of 21,911.

The earthquake and resultant tsunami have had significant health impacts on the Japanese population. Japanese public health officials have struggled with water treatment and distribution systems that have been contaminated by ocean water and oil, gas, pesticides, and decaying bodies carried inland by the waves. There are also worries of cross-contamination of waste water and treated water, escalating fears of the spread of water-borne diseases. Treating trauma, crush wounds and respiratory illnesses in tsunami victims has been identified as a pressing health priority. According to some, rapidly diminishing stocks of medical supplies and the mental health of the tsunami and quake survivors continues to challenge health response systems.

These public health concerns have been exacerbated by fears of health ramifications from exposure to nuclear radiation following explosions at the Fukushima Dai-Ichi nuclear power plant. Although radiation health risks have been described as low, certain experts have warned that radioactive releases of steam from the plant could last for months. This has prompted widening fears of long-term public health, food security (such as radiation contamination in food from Japan) and environmental ramifications not only for the Japanese, but also for neighbouring countries and across the Pacific.

The post-quake period has seen what some have called a bubbling ‘cauldron of fear’ from the potential health ramifications of the crisis. Countries as far away as Finland have had to reassure their populations. US nuclear plans are in question.  The Philippine and Malaysian governments have publicly urged citizens to stop circulating hoax text messages encouraging rumours of radiation rain.

However, it remains important to recognise that Fukushima rates 5 on a seven-step scale of nuclear incidents. This places it on par with Three Mile Island, which resulted in no deaths and had no impact on the incidence of cancer in the region. It also places two rungs below Chernobyl at 7. Radiation experts have also said that given the nature of the manufacturing industries in Japan, there is little danger of radiation contamination in food reaching harmful levels.

While it remains important to recognise the health security risks and threats that have emerged as a direct consequence of the Japanese tragedy, it is equally important to exercise a measured approach in assessing and analysing them. The overestimation of threat can cause undue fear and panic. Conversely, the underestimation of problems can lead to a lack of commitment to addressing them. This is true to addressing both conventional health challenges as well as any nuclear radiation-related health issues arising from this situation. Ultimately, a moderate and well-informed approach to dealing with health security issues in post-disaster Japan may encourage better direction and strategy in resolving them.

A non-epidemic of epidemic proportions: HIV in the Philippines

Posted in Health and Human Security by NTSblog on March 8, 2011

There have been a recent spate of articles asserting that there is an upward trend in the number of HIV cases in the Philippines, a trend that portends a ‘HIV epidemic’, especially among adolescents. In 2010, there were 1,591 new HIV cases diagnosed, which is a 90 percent increase from the reported 835 infections in 2009, itself a 58 percent increase over the previous year. From 1984 to December 2009, there were 4,424 HIV cases reported and of these, 90% were infected through sexual contact. As of 2007, the main source of transmission is among men who have sex with men (MSM).

Such claims of an impending HIV epidemic in the Philippines are not new, with warnings that it would spread through Asia since the 1980s, after the first individual diagnosed with HIV was reported in 1984. However, according to the UNAIDS, ‘no significant epidemic HIV transmission has yet been detected in the Philippines and, as a result, the official national HIV prevalence estimate has been reduced from an initial 50 000 in the early 1990s to 26 000 a few years ago and, most recently, in 2003, to about 9 000.’ Although seemingly troubling, the rising trend is not indicative of a problem of epidemic proportions. It could reflect the increasing ability of the public health service to conduct HIV tests amongst populations who could not access health facilities previously.

According to the UNAIDS, as of 2009 the national prevalence of HIV remains at about 1% of the population but amongst most at-risk populations (MARP), it increased from 0.08% in 2007 to 0.47% in 2009. The prevalence of individuals who have been infected through sexual contact suggests the need for more awareness and education about the disease and the methods of transmission, while increasing the availability of contraceptives. However, in order to maximise gains, such a strategy should be more specific, targeting MARP rather than a nationwide plan of dissemination that some may favour as they fear a widespread HIV epidemic. Repeated warnings of an HIV epidemic may prompt people to be more aware of the disease, but it is more likely to create an overinflated sense of dread and panic that does not address the problem but may increase stigmatisation of the disease and of affected populations. A more measured attitude towards countering the spread of HIV may encourage directed plans that could more effectively address the dominant means of transmission in various countries, in order to achieve the MGD on reducing the rates of HIV transmission globally.

Cancer in developing countries

Posted in Health and Human Security by NTSblog on February 9, 2011

4 February was World Cancer Day, and to mark the occasion, the American Cancer Society (ACS) released a report titled ‘Global Cancer Facts and Figures’. The report noted that changing lifestyles linked to economic growth in developing countries are driving up the global incidence of several cancers. The WHO estimates that 84 million people will die of cancer between 2005 and 2015 without intervention, and there is an increasingly larger incidence of reported cancers in developing countries. Estimates vary: according to a recent article in the Lancet, in 1970, approximately 15% of newly reported cancers were in developing countries, increasing to 56% in 2008, and is estimated to rise to 70% by 2030; while Dr Margaret Chan, Director-General of the WHO has stated that around 70% of cancer deaths occur in developing countries.

Despite the discrepancies amongst estimates, the general prediction is that the cancer incidence is on the rise in developing countries. However, such a trend may not be detrimental to the health of populations in developing regions. As noted in the ACS report, the shift in the global burden of cancer from economically developed countries to economically developing countries is ‘simply due to the growth and aging of the population, as well as reductions in childhood mortality and deaths from infectious diseases in developing countries’. Economic development is imperative to improving health as it is a foundation stone in countering curable infectious diseases such as cholera and malaria through the improvement of basic infrastructure, hygiene and sanitation. The predicted increase in cancer deaths may arguably reflect the epidemiological transition countries experience as they develop into advanced economies where ‘degenerative and man-made diseases displace pandemics of infection as the primary causes of morbidity and mortality’. Populations with increasing life expectancies and lower mortality from infectious diseases would necessarily mean that people would be dying from other ailments, and such a shift is reflected in the increasing incidence of cancer and other chronic diseases.

On the other hand, the ACS report also argued that economic growth could be detrimental to health and could worsen the burden of cancer due to the  ‘adoption of unhealthy lifestyles and behaviors related to economic development, such as smoking, poor diet, and physical inactivity’. Inasmuch as economic development may bring about such lifestyles, the key word here is ‘adoption’. It reflects an active choice in which people have the option of assuming such routines in their everyday lives. However, without economic development and the accompanying infrastructure, adequate sanitation and medical services, many people in developing regions have little say in the matter, subject to the vicissitudes of life and prone to contracting fatal yet easily curable infectious diseases.

Cancer is an increasingly important health priority, but the growing incidence in developing countries may not necessarily be negative. However, it is vital for governments, international organisations and NGOs to address the underlying factors of disparities in cancer survival rates between developing and developed countries, which reflect varied access to health services and differences in the strengths of health systems.

Managing Outbreaks: Is Culling The Only Solution?

Posted in Health and Human Security by NTSblog on January 25, 2011

In the last few days, two East Asian countries – Japan and South Korea – have seen sudden, rapid outbreaks of bird flu (H5N1) and foot and mouth disease (FMD) respectively. The FMD outbreak was first reported in South Korea last week, with some reports claiming that this epidemic could cost South Korea USD1.4 billion in losses from exports, vaccinations, culling and compensation for farmers. Meanwhile, Japan was alerted to new cases of H5N1 in its southwest on 22 January after six chickens found dead at a farm in Miyazaki were tested and found to have died from the virus.

Although FMD and H5N1 are very different diseases, there is a significant common thread in both the Japanese and South Korean outbreaks: both countries have attempted to halt the disease outbreaks by culling a large percentage of their livestock population.

To combat the current H5N1 outbreak, Japan culled 410,000 chickens in Miyazaki in addition to 20,000 chickens in Shimane, where there was a minor H5N1 outbreak last November. This is not, by far, the first time Japan has practiced mass culling in the event of an outbreak: Japan culled about 288,000 pigs, cows and cattle in Miyazaki last year to contain the nation’s first outbreak of foot-and-mouth disease since 2000. Alongside, South Korea’s government has called for the mass culling of animals (pigs and cows because of FMD, chickens and ducks because of H5N1, as well as smaller numbers of other animals like goats) on a large scale. Reports estimate that over a million pigs have been slaughtered and the total number of all animals killed ranges in the millions.

The World Health Organization (WHO) recognises that culling has been successful in East Asia’s high income economies, but culling is not the sole means to achieving the end of eliminating a pandemic threat. For example, in 1997, Hong Kong’s poultry culling schemes successfully led to an averted flu pandemic. In 2003, Japan and South Korea eradicated H5N1 through quarantine and poultry culling strategies, combined improved biosecurity measures for poultry facilities. After seeing the East Asian culling successes, the WHO was supportive of implementing poultry culling in Southeast Asia, “strongly recommending” its practice. Inspired by their neighbours and encouraged by the WHO, Southeast Asian countries began using poultry culling as a widespread H5N1 management and control technique. Unfortunately, it yielded different results. In Thailand, for example, culling resulted in only a temporary respite; after nearly a year of no H5N1 activity, new cases in humans were discovered in July 2006. What did work in Thailand, however, was a very different approach: effective risk communication particularly to rural communities, a comprehensive early detection system, passive and active surveillance, and strong partnerships with the US Centers for Disease Control in order to obtain laboratory technology and training, heightening reaction time in the event of an outbreak.

Ultimately, in examining the best way to respond to a pandemic outbreak, it remains essential to consider the specific circumstances of the country in which the outbreak occurred including its level of socioeconomic developments, and its geographical and climate peculiarities. The response to any pandemic outbreak should be tailored to the nature and pathology of the virus in question and not the contingency plan in place or the perceived appropriate political response.

Health and development

Posted in Health and Human Security by NTSblog on January 4, 2011

The relationship between development and health has often been debated, and remains central to the Millennium Development Goals which promote health as part of an overall strategy for poverty reduction. There are multiple ways which the level of development and the health status of a population are correlated. Poverty potentially leads to the deterioration of health, but health is also a key determinant of economic growth and poor health could aggravate poverty. For example, the poor often disproportionately bear the burden of a nation’s health care costs, and are susceptible to more diseases and suffer more complications as a result of those diseases. Furthermore, poverty and lack of development also renders populations more susceptible to easily curable diseases such as cholera. There is also a strong mutually reinforcing relationship between health and economic growth in the Asia Pacific, as noted by UNESCAP. Poor health may also lead to lower levels of foreign direct investment. Regardless of the cause or effect, there is a strong correlation between poverty and ill health in a number of examples across various regions.

In order to reduce poverty, some argue for improving health, but having a broader strategy of development of economic growth would create greater wealth, contributing to more funds available for improving health infrastructure. A health policy which targets specific health issues or communities in an attempt to improve the health of the most marginalised and affected groups may bring about positive change in the short run, but is largely palliative and fails to address the fundamental lack of development. Inasmuch as it is crucial to address the health status of a population, particularly the most affected, it is arguably more important to improve the overall economic status of the poor in order to bring about sustainable change in the longer term. Comprehensive strategies that work to improve the economic status of populations would be necessary in order for goals such as the MDGs to address poverty and various health targets to be met.

Lest We Forget: The Global Chronic Disease Burden

Posted in Health and Human Security by NTSblog on December 2, 2010

Although the risks and threats posed by communicable diseases and pandemic viruses are relatively well-known, it must be noted that some of the world’s deadliest diseases remain non-communicable chronic diseases that affect those in both developed and developing countries. According to the World Health Organization (WHO), chronic diseases account for 60% of the world’s disease-related fatalities. An example is pneumonia, which kills an estimated 1.6 million children every year – more than AIDS, malaria and tuberculosis combined.

Despite the epidemiological, social and economic impact of the chronic disease burden, the global response to the problem remains inadequately addressed. Limitations in financial support still hinder capacity development for prevention, treatment and research in many developing countries. Many public health systems are still oriented towards acute care as opposed to primary care, which studies have shown plays an important role in preventing illness and death and has been associated with more equitable distribution of health in populations. There also remains a misconception, particularly in developing countries, that chronic diseases are primarily “lifestyle diseases” for those in the developing world when in truth, chronic diseases are responsible for 50% of the disease burden in low and middle-income countries.

Chronic disease implications upon the state of global health security are widespread, prompting health care system changes across parts of Southeast Asia. For example, Thailand’s public health framework was reformed to better fit the nation’s chronic disease burden with the inception of its universal healthcare scheme in 2002. This scheme offered comprehensive health care that included free prescription drugs, outpatient care, hospitalization and disease prevention, but also medical services such as radiotherapy, surgery and critical care for accidents and emergencies. However, due to financial constraints, it could not cover a great deal of chronic disease management and treatment services.

The chronic disease problem is multilayered and complex, requiring action at various levels – including increased focus on primary care, increased awareness of how lifestyle contributes to the incidence of chronic diseases, greater financial investment in chronic disease management and treatment – to adequately and effectively address the issue.

Finally,  greater cooperation between multiple stakeholders – the WHO, United Nations agencies and bodies, national governments, academic and research groups, civil society and non-governmental organisations, and private sector actors including pharmaceutical and healthcare companies – would enable better management and gradual ease of the burgeoning chronic disease burden and better ensure the health security of populations worldwide.

HPV and cervical cancer in developing countries

Posted in Health and Human Security by NTSblog on November 25, 2010

The Human Papillomavirus (HPV) is one of the most common causes of sexually transmitted disease in both men and women worldwide. It is the leading cause of cervical cancer, and the second biggest cause of female cancer mortality worldwide with 288 000 deaths annually. It remains a comparatively rare disease, with other causes of death such as lower respiratory infections, coronary heart disease, tuberculosis amongst many diseases and conditions being far more common. However, it is interesting to note that, by comparing cervical cancer with other leading causes of death, there is a clear distinction between the lower and higher income groups across regions. There are approximately 510,000 cases of cervical cancer reported annually with nearly 80% in developing countries, more than half of whom are in Asia.

Although reproductive health in general and cervical cancer prevention in particular are not explicitly mentioned as part of the UN Millennium Development Goals (MDGs), it is implied and cervical cancer has significant impact on poverty, education, and gender equity which are the first three MDGs. It may be useful to explore improved cervical cancer prevention as a way to support development as well as to evaluate the benefits that could be gained in relation to interventions that target other diseases in developing countries.

The cervical cancer screening measures in place in developed and resource-rich countries such as North American and European nations have appeared to have attained some measures of success in reducing morbidity and mortality. However, similar attempts to pursue a strategy of wide-ranging and frequent screening of cervical cancer have not necessarily been as successful in developing countries. The differing results of such programmes in developed and developing nations highlights the need to identify more cost-effective screening or prevention methods such as a HPV vaccine which are affordable to developing countries, which have to weigh the benefits of such a vaccination programme alongside existing immunisation schemes and emerging new vaccines. Countries also have to take into consideration the importance of cervical cancer as a cause of mortality in relation to other diseases to be able to ascertain the time and resources that should be expended on different control strategies, perhaps through the use of methods such as examining the years of life lost as an indicator of disease burden.

The successful implementation of an adolescent HPV vaccination programme may create opportunities for strengthening health systems through the establishment of new mechanisms for vaccine delivery and surveillance of impact. There are many challenges to the implementation of such a programme, but an attempt to identify means of providing HPV vaccinations to adolescents in developing countries may help to address other similar challenges to existing health systems. It is imperative to explore the possibility of cooperation between governments and international organisations, and within countries amongst reproductive health, immunisation, child and adolescent health and cancer control programmes.It is only through such cooperation that  the impact of diseases such as HPV and other preventable and curable diseases on populations in developing countries may be mitigated.

The Case of H5N1 in Hong Kong 2010: Raising the Alarm

Posted in Health and Human Security by NTSblog on November 24, 2010

Last week, Hong Kong recorded its first positive case of H5N1 (avian influenza) in seven years in a 59-year-old woman who had recently travelled to China. The Hong Kong government then raised Hong Kong’s bird flu alert to “serious”, meaning there was a “high risk” of contracting the disease.

These events prompted fears of a new wave of pandemic avian influenza across Southeast Asia, and a host of other countries in the region released reports that they were H5N1-free. Some took it one step further: the Philippines declared that their airport authorities were on high alert, Malaysian health authorities announced that their existing mitigation systems to cope with H1N1 were in place and being reinforced, and Taiwanese authorities also declared that they were on high alert. The Indonesian Health Ministry’s director general for disease control and environmental health said that in spite of Indonesia’s two H5N1 fatalities earlier this year, there was “no cause for panic”.

This reaction appears to err on the side of caution if one considers that in the past seven years, H5N1 has killed 302 people worldwide – a stark contrast to the estimated 250,000 to 500,000 who succumb to regular cycles of influenza annually. The disease was expected to be a major threat, with some experts predicting it might kill between 150 and 500 million.

Several days after issuing the high-risk alert, Hong Kong officials then stated that the H5N1 case they discovered was an isolated one and that she could therefore be treated with existing vaccines. Although the authorities’ promptness in diagnosing the case and their transparency in reporting it are admirable, Hong Kong’s methods of dealing with pandemics, evident in its strict containment policies when dealing with H1N1 last year, have been largely shaped by its difficult experience with SARS in 2003.

While H5N1 may cause more than one influenza pandemic as it is expected to continue mutating in birds regardless of whether humans develop herd immunity to a future pandemic strain, the isolated nature of the Hong Kong case raises significant questions of whether the initial response of raising their alert phase was a measured one.  Imperative as it may be that authorities recognise the risks posed by newly discovered infections of potential pandemic viruses, it is just as important to consider the hidden costs of over-caution, among them damage to confidence in public health authorities, unwarranted expenditure on drugs, vaccines and other medical services, and misconceptions of both the disease and the level of threat it poses.

Although pandemics – in particularly influenza strains such as H5N1 and H1N1 – remain a health security cause for concern for many Asian countries, it is vital that the social and political dimensions and consequences of knee-jerk reactions in the event of new diagnoses need to be continually considered in the management of public health situations in the region.

Issues on the prevalence of global AIDS – Part 2: Beyond ARVs: Examining other causes and solutions to HIV/AIDS

Posted in Health and Human Security by NTSblog on November 18, 2010

In a previous post, I briefly looked at production of low-cost ARVs in India and its role in facilitating access to ARVs in developing countries. However, there are many other factors which need to be considered in formulating strategies to reduce the prevalence of HIV/AIDS globally.

Heterosexual transmission of the disease is largely regarded as being the main cause of new adult HIV infections. There has been some degree of consensus on this source as the dominant source of HIV transmission, leading some to assert that in some areas that “unsafe medical injections can be confidently excluded as a major source of HIV infection”. However, the dominant cause may not be as apparent as suggested, as the sources of transmission can differ between regions, countries, and even within countries. Even though heterosexual transmission is a major cause of HIV infections globally, other causes such as drug-injections, unsafe medical care and parent-child transmission for example also need to be identified to see the impact they exert in particular communities.

Inasmuch as it is useful to encourage the use of condoms alongside sex education to reduce the likelihood of spreading HIV through sexual transmission, recognising that other methods of transmission may contribute more to the spread of HIV infections in different areas could help policymakers devise more appropriate strategies to addressing the issue. The identification of the dominant source of transmission could then lead to the implementation of interventions which are more beneficial in stemming the spread of HIV infections.

Proper diagnoses of HIV/AIDS are also imperative so that affected individuals can get the necessary treatment. However, one of the issues with some of the existing recommended case definitions is that they conflate AIDS with other diseases. For example, the one of the recommended case definitions for AIDS surveillance when diagnostic resources are limited state that individuals older than 12 years of age would be considered to have AIDS, for example, if they exhibit signs like weight loss of at least 10% of their body weight and chronic diarrhoea for more than a month accompanied by a persistent cough lasting more than a month, and if these signs are not known to be related to a  condition other than HIV infection. However, according to an article by Charles Gilks in the BMJ, “persistent diarrhoea with weight loss can be associated with opportunistic as well as ordinary enteric parasites and bacteria,” and in “those countries where the incidence of tuberculosis is high and which are using the unmodified clinical case definition for surveillance substantial numbers of people reported as having AIDS may in fact not have AIDS.”

More studies may be required to establish the prevalence of HIV/AIDS globally such that deaths which could be attributed to other diseases which are curable, like tuberculosis and malaria, can be more accurately classified as such. By establishing the main sources of HIV transmission in various regions and countries and identifying the diseases which most affect local communities, appropriate treatment methods could be devised to counter a seemingly insurmountable health crisis.

Health Dimensions of Natural Disasters: Indonesia’s Mount Merapi Eruptions

Indonesia’s geographical location at the intersection of three of the world’s crustal plates makes it particularly prone to natural disasters.  Although Indonesia’s capacity to cope with natural disasters has been enhanced significantly since the 2004 Indian Ocean tsunami, aid workers still claim that the National Disaster Management Agency remains unprepared to cope with the health consequences of the recent Mount Merapi eruptions.

There are two dimensions of health that require consideration in this context. The first dimension of health in the context of the Mount Merapi eruptions relates to the direct and immediate physical consequences of the disaster itself. According to the World Health Organization (WHO), hot ash, gases, rock and magma cause burns, asphyxiation, conjunctivitis or corneal abrasion, and acute respiratory problems. Ashfall can also cause bronchial asthma and other chronic respiratory conditions in both children and adults. Additionally, inhalation of volcanic ash is a health security hazard because it can cause severe respiratory infections.

The second dimension of health within the aforementioned context is the emergency and humanitarian response dimension: the responses of health systems and aid to ensure the health security of vulnerable populations affected by natural disasters. Health risks after a natural disaster are dependent on size of affected/displaced population, proximity of and access to safe water and functioning latrines, nutritional status of the displaced population, vector control, levels of immunity against vaccine-preventable diseases such as measles, management of dead bodies, maternal and child health, public health surveillance systems, and access to healthcare services. Compounded, these problems can cause devastating consequences for the health of affected populations, as seen from Haiti’s post-earthquake cholera outbreak.

Existing response programs have taken these dimensions into account. Indonesia has a National Action Plan for Disaster Risk Reduction and an Emergency Preparedness and Response (EPR) Programme which outline strategic approaches to reducing human vulnerabilities  and health risks during disasters through a variety of measures. These include the establishment of regional crisis centres, increasing capacity building, and strengthening collaboration with the WHO. However, aid workers claim that at ground level, conditions in camps for those affected remain unsanitary, cramped and primed for serious health issues. These shortcomings could be partly due to Indonesia’s low health care expenditure in comparison with its neighbouring countries: Indonesia allocated 2.2 percent of GDP for the health sector in 2007, while the Southeast Asian average stood at 4.1 percent.

While comprehensive national plans and programmes are an integral aspect of health responses to natural disasters, they are best supplemented by similarly comprehensive and concerted efforts on the ground. Legal frameworks, accountability procedures, financial allocation, and organisational structures need to be supported by community plans for risk mitigation, local capacity for emergency provision of essential medical services, supplies, personnel and facilities, and early warning and surveillance systems. If Indonesia can achieve this necessitated level of coordination and facilitation, it will certainly be better equipped to mitigate the health security impact of potential natural disasters in the future.

Issues on the prevalence of global AIDS – Part 1: Impact of low-cost generic HIV/AIDS drugs from India

Posted in Health and Human Security by NTSblog on November 8, 2010

The AIDS Society of India announced that low cost HIV/AIDS drugs would be made available in the country by the end of October. It stated that the new drugs would be launched at the 3rd National Conference of AIDS Society of India (ASICON 2010) which was held in Hyderabad from 29-31 October.

India is the largest supplier of generic anti-retroviral drugs (ARVs) to low- and middle- income countries, providing 80 % of donor-funded ARVs to low and middle income countries. The availability of cheap Indian generic ARVs is due to the laws in India which used to grant patents on processes rather than products, enabling firms to produce cheaper drugs using other methods. However, India signed the Trade Related Intellectual Property Rights (TRIPS) agreement under the World Trade Organization in 2005 which means that it now has to grant patents on products as well as processes for drugs patented after the signing of the agreement.

The availability of cheap generic drugs from India is vital for many in developing countries who simply cannot afford high-cost ARVs. It is important that countries, such as India, work with its trade partners, international organisations, donors, civil society groups and pharmaceutical producers of cheap ARVs to guarantee that there remains enough policy space to continue its role as a provider of low-priced generic medicines. Countries and various entities have to find ways to negotiate between existing intellectual property rights and the desired result of producing low-cost ARVs and also how to encourage pharmaceutical firms to do so. Lowering the costs of ARVs is one of the factors that could help increase the proportion of populations with advanced HIV infection with access to antiretroviral drugs.

Cholera outbreak in Haiti: Lessons for Asia-Pacific’s public health responses

Posted in Health and Human Security by NTSblog on November 3, 2010

There have been reports of a cholera outbreak in Haiti during the past week, with over 4000 infected and 300 deaths. The epicentre of the outbreak is in the Artibonite region, north of the capital, and cases have been reported throughout other regions of the country.

Cholera is still quite common in some countries in the Asia-Pacific, with outbreaks of varying impact in the past year which have been reported to have occurred in Papua New GuineaChinaIndiaNepal and the Philippines for example, despite incomplete reporting because of potential social, political, and economic costs. In developed countries, the disease is uncommon and has a very low fatality rate. In the US for instance, there have been 5 cases of cholera in the past year, and during the period from 1995 to 1999, there were 53 laboratory-confirmed cases, of which resulted in one death.

Cholera is an agonising acute bacterial infection which takes a dramatic toll on the body. The most acute cases can result in death in a matter of hours because of dehydration and loss of electrolytes from severe diarrhoea. Diarrhoeal diseases such as cholera are endemic in Africa, South and Central America and Asia and leads to 1.6 million deaths annually, of which 90% are children under 5. Cholera and other diarrhoeal diseases can be easily treated with clean water mixed with sugar and salt, and in worse cases, intravenous hydration and antibiotics; but only 39% of children with diarrhoea get the recommended treatment.

The outbreak in Haiti underlines how vital structural changes to the existing public health infrastructure, water hygiene and sanitation in developing countries need to take place in order to provide basic treatment for diarrhoeal diseases such as cholera and prevent future outbreaks. By working towards improving people’s sustainable access to safe drinking water, it would address the UN Millennium Development Goal (MDG) on that issue, and allso works towards reaching the MDG on combating HIV/AIDS, as it is likely that people weakened by HIV/AIDS are likely to suffer the most from the lack of safe water supply and sanitation, especially since diarrhoea and skin diseases are two of the more common infections.

The use of vaccines to control outbreaks should also be further examined to explore the economic viability of such measures in developing countries. Basic disaster management and response plans also need to be formulated and implemented in order to restore health services and clean water supplies to prevent the spread of diseases which can be triggered by natural disasters.

However, adequate surveillance, provision of health services, implementation of disaster response plans would not be possible without funding. International organisations and NGOs have to explore ways to collaborate with governments, local communities, and even private institutions to extend assistance to affected populations beyond the provision of aid and to explore development over the longer term. Stemming the spread of diarrhoeal diseases to bring positive lasting change in affected communities and countries therefore requires a multifaceted and all-encompassing approach.

The first WHO report on neglected tropical diseases: a way forward?

Posted in Health and Human Security by NTSblog on October 25, 2010

Recently, the World Health Organization (WHO) released a breakthrough document: the first report on neglected tropical diseases, entitled Working to overcome the global impact of neglected tropical diseases. According to the report, it is now possible to significantly reduce the debilitating impact of 17 neglected tropical diseases that thrive in 149 countries worldwide, almost exclusively in impoverished settings where housing is substandard, living environments are unsanitary and often contaminated and disease-carrying insects and animals are aplenty.

WHO director-general Dr Margaret Chan said in her opening statement at the launch of the report that often, these diseases were “accepted as part of the misery of being poor” although they did not need to be so, and that the strategies outlined by the report could substantially reduce disease burdens and break infection cycles if implemented widely.

The launch of this report is a significant development towards redirecting the international community’s attention towards neglected infectious diseases in a world where HIV/AIDS, malaria and tuberculosis (TB) are often perceived as the three greatest health problems affecting the global poor  (i.e. the United Nations Millennium Development Goals lists the eradication of the three aforementioned diseases as one of its goals, but neglected tropical diseases are not included). This report effectively recognizes the impact of neglected tropical diseases on a global scale and reaffirms the WHO’s commitment to tackling them. Additionally, several multinational pharmaceutical companies have also pledged an excess of USD 150mil towards their long-term commitment to the elimination of neglected infectious diseases through generous drug donations and renewed cooperative efforts with the WHO.

The report states that existing interventions undertaken to mitigate the impact of diseases such as dengue, leprosy and lymphatic filariasis have produced unprecedented results. However, the WHO also recognizes that challenges remain, including the need for stronger delivery systems, the lack of public health coordination with veterinary public health systems in order to better manage and control vector-borne diseases, and the need for public health systems to better respond to changing disease patterns that occur as a result of climate change and environmental factors.

The report itself has proven to be a pioneering document; it is the first of its kind to acknowledge the severe global impact of neglected tropical diseases and to call for a concerted effort among national governments, the private sector, the research profession and foundations towards their control and management (the WHO hopes that some diseases will be ‘completely controlled’ by 2015).

However, structural interventions and developments need to accompany these renewed international commitments to NTDs. Limited capabilities of poor and developing countries to provide access to adequate treatment and prevention programs exacerbate the suffering of those affected. Despite the serious consequences of these diseases, there remains little incentive for pharmaceutical industries to invest in developing new or better drugs for a market that cannot afford them. It remains questionable if the 2015 target will be successfully achieved without parallel developments in medical research and drug development, public health systems (national and international), economic growth and infrastructure in the countries most adversely affected by NTDs.

Dengue in the Philippines: Beyond Health Security Implications

Posted in Health and Human Security by NTSblog on October 11, 2010

Southeast Asia is a site for many emerging infectious diseases (EIDs), one of which is the omnipresent dengue fever. The disease is caused by the aedes aegypti mosquito which breeds in stagnant water and thrives in Southeast Asia’s hot, humid tropical climate.  At the end of last month, the World Health Organization (WHO) declared that dengue was becoming one of the fastest emerging infectious diseases in light of a rapid rise in cases across Southeast Asia and the greater Asia Pacific region. In the same statement, the WHO also identified the Philippines as one of the countries hardest hit by dengue.

Last month, the DoH declared dengue outbreaks in six villages within the Central Visayas area, with over 8,000 cases, 63 of which were fatal. Following that, the Philippine Department of Health (DoH) announced that it had recorded a total of over 90,000 dengue cases since January this year – more than double the cases recorded in 2009. Of this number, more than 500 cases have resulted in death.

In the case of the Philippines, there have been repeated calls for a multi-pronged approach to tackle the dengue problem: education on hygiene, the aspect currently being emphasised by the government in a series of anti-dengue campaigns, is only one aspect of protection against dengue.

Non-governmental progressive health, women’s and environmentalist groups in the Philippines have declared their dissatisfaction with how the government has tackled the dengue outbreak situation thus far. They argue that beyond sanitation issues, the dengue problem in the Philippines is exacerbated by problems of poverty, underdevelopment, poor urban planning, deforestation and inadequate public health facilities to cope with disease load.

Even within government, there has been backlash: the Senate President strongly criticised the DoH for allocating more money towards family planning than towards the eradication of dengue. Additionally, the Philippine Council for Health and Development also alleged that the spike in dengue cases in the Philippines “mirrors a government that puts its people’s health behind debt servicing and military spending”, in a scathing critique of the new government of Benigno ‘Noynoy’ Aquino III.

It is evident that the growing spread of dengue in the Philippines  has sparked intense debate over health security’s inextricable links with other issues such as development, urbanisation and environmental security and protection. For example, it has been argued that unmonitored population growth in urban areas have contributed to the rise in dengue, as high density areas are more prone to dengue outbreak. Urban planning problems have also been cited as a potential cause for the rise  in dengue, with stagnant swimming pools in abandoned houses identified as mosquito larva breeding ground.

It is therefore essential that further engagement, collaboration and cooperation between and among actors across various sectors be undertaken in order to effectively eradicate the problem.

Perspectives on Contemporary Challenges in Global Health Research and Its Governance by Dr Tikki Pang

Posted in Health and Human Security by NTSblog on September 28, 2010

The three main challenges to effective health research are unethical conduct, poor transparency and accountability, and inequitable access to the benefits of research, said World Health Organization (WHO) Geneva’s director of research policy and cooperation Dr Tikki Pang at a recent seminar on contemporary challenges in global health research and its governance .

Unethical conduct

Dr Pang said that while more money is being pumped into medical research than ever before, the number of new drugs produced remains low. In recent years, we have seen a shift of clinical trials to the developing world because it is cheaper and offers a larger pool of participants. However, this gives rise to ethics problems as there remains no regulatory infrastructure in place.

While the impact of research in improving health worldwide is immense, there are instances of research going wrong. Pfizer’s controversial clinical trials for meningitis drugs in Nigeria is one such example. This phenomenon, however, is not merely the fault of pharmaceuticals; individual countries are equally responsible for enforcing ethics regulations. According to Dr Pang, as recently as 2004, 90% of clinical trials in China had not been subjected to ethical review.

Poor transparency and accountability

Publication bias continues to be a problem as there is a strong inclination to publish positive and conclusive studies while ignoring or sidelining the negative or inconclusive in health research outcomes. This often leads to studies hiding the evidence of adverse drug effects or omitting vital drug safety information. Dr Pang also said that research has indicated that studies supported by pharmaceutical companies have a significantly better chance of a positive result being reported than studies supported by a non-governmental organisation.

Inequitable access to the benefits of research

There is thus a need to focus on the 3As: availability, access and affordability. The low amount of resources devoted to addressing tropical diseases of the developing world indicates that pharmaceutical companies remain less inclined to make drugs for segments of the population that cannot afford treatment. Statistically, inequitable access to medicines, technology and care is also more pronounced for less privileged sections of any population.

Would better governance of health research help address these challenges? Dr Pang argued that all three challenges are transnational, global issues central to improving health outcomes and that all three would benefit from better global governance in health based on stronger international cooperation.

WHO would play an integral role as it is the only organisation capable of providing a facilitating platform for cooperation between various stakeholders, providing guidelines on biomedical research, and developing international standards for ethical research and review. The WHO has already initiated projects to overcome the aforementioned challenges such as the International Clinical Trials Registry Program (ICTRP) and the HINARI Programme .

Dr Pang’s analyses of the challenges faced by global health research are significant to the promotion and assurance of health security worldwide. Overcoming them will not only result in a  more integrated and efficient research sector rooted in public-private cooperation and collaboration, but also one able to deliver ethically sound results in an equitable, responsible and accountable manner.

Working towards reducing maternal mortality

Posted in Health and Human Security by NTSblog on September 22, 2010

A new report by the World Health Organization (WHO), UNICEF, UNFPA and The World Bank states that the number of women dying from complications during pregnancy and childbirth has reduced by about one-third between 1990 and 2008. Although it represents tremendous progress, it also highlights how much more has to be done to attain the UN Millennium Development Goal (MDG) on maternal health by 2015, which is to reduce the maternal mortality rate (MMR) by 75%. The current annual rate of decline of MMR stands at about 2.3%, but to achieve the MDG, the annual reduction has to reach 5.5%.

In 2008, about 1,000 pregnant women died daily from four main causes, namely severe bleeding after childbirth, infections, hypertensive disorders, and unsafe abortion. [1] 99.5% of these deaths occurred in developing countries, with sub-Saharan Africa and South Asia accounting for 57% and 30% respectively. Pregnancy and childbirth-related complications remain the leading causes of death for women of childbearing age in these regions and the frequency and pervasiveness of maternal mortality is of concern. Dr Margaret Chan, Director-General of WHO, noted that “no woman should die due to inadequate access to family planning and to pregnancy and delivery care.” In order to significantly reduce the high rates of MMR in the developing world, it is imperative that more is done to improve and increase accessibility of reproductive healthcare. Governments, international organisations and local civil society groups need to work towards ensuring universal access to healthcare to help reduce MMR, and that is ultimately dependent on extending and strengthening health systems. The problems of shortage and inefficient distribution of medical professionals and a lack of good medical infrastructure have to be addressed, while also establishing means of financial protection against the costs of seeking medical attention which could further exacerbate existing poverty.

Furthermore, other than addressing the direct causes of maternal mortality like haemorrhage during childbirth and infections, a more comprehensive healthcare strategy that also takes into consideration causes of indirect maternal deaths such as anaemia, HIV/AIDS and malaria is necessary for more effective implementation of policies that seek to reduce MMR. It is only then that we may move closer towards reaching the UN MDG on maternal health.

[1] There are various case studies which identify these causes and analyse factors of maternal mortality, such as Jagdish C. Bhatia, ‘Levels and Causes of Maternal Mortality in Southern India,’ Studies in Family Planning, Vol. 24, No. 5 (Sep. – Oct., 1993), pp. 310-318; I. A. O. Ujah, O. A. Aisien, J. T. Mutihir, D. J. Vanderjagt, R. H. Glew, V. E. Uguru, ‘Factors Contributing to Maternal Mortality in North-Central Nigeria: A Seventeen-Year Review,’ African Journal of Reproductive Health / La Revue Africaine de la Santé Reproductive, Vol. 9, No. 3 (Dec., 2005), pp. 27-40.

Leptospirosis in Malaysia: The Understated Role of Hygiene in Health Security

Posted in Health and Human Security by NTSblog on September 20, 2010

Malaysian health officials announced last month that the country was experiencing an outbreak of leptospirosis after up to ten people died from the disease between July and August. It is caused by exposure to water contaminated with the leptospirosis bacteria found in the urine of rodents, where the bacterium is absorbed through broken skin or soft tissue on the inside of the mouth, nose or eyes. Symptoms of the disease include severe muscle pain, fever, vomiting and headache, and they may last from a few days to several weeks. The fatality rate of leptospirosis ranges from 5 to 40 percent, depending on individual cases and whether the sufferer has prior immunodeficiency. Health officials also added that the number of leptospirosis deaths in Malaysia had tripled in the past six years.

The Malaysian health ministry’s disease control division director attributed the outbreak to poor enforcement of hygiene standards nationwide, adding that leptospirosis was rare in cities like Tokyo and Singapore where hygiene standards were more vigorously enforced. He stated that rubbish and food waste was often improperly disposed of, attracting rodents and increasing the possibility of the disease spreading – particularly among certain occupational groups like those working in the food and beverage industry, cleaners and sewage workers.

Over half of all human pathogens are animal-borne diseases, also known as vector-borne diseases. The Southeast Asian region is particularly susceptible to these diseases as it is home to a diverse host of animals – both wild as well as within the agricultural context. Vector-borne diseases include those carried by mosquitoes such as the West Nile virus, encephalitis and dengue, those carried by wild animals such as avian influenza, those found in household pets such as rabies, and those found in animal products that we consume (for example, salmonella in eggs and E. coli in beef). Additionally, consistently high temperatures create good conditions for certain types of vector-borne bacteria to thrive in water, invisible to and undetected by the human eye.

The maintenance and enforcement of strict hygiene standards in Southeast Asia is, therefore, an important aspect of health security in a region already considered vulnerable to such diseases. Measures undertaken by certain Southeast Asian countries during past vector-borne disease outbreaks have focused primarily on eliminating the source of the disease (for example, the mass culling of poultry during the avian influenza outbreak) but less attention has been paid to precautionary hygiene practices and educating the public on the health risks posed by low hygiene.

In spite of the disease control division director pointing out that poor hygiene had a major role to play in spreading leptospirosis, Malaysian health authorities responded to the leptospirosis outbreak by addressing the symptoms instead of the root of the problem. Warnings were issued, cautioning the public against swimming in rivers. Public areas where the bacteria were found were cleaned up. It was made mandatory for all new or suspected cases to be reported to the government.

While this reaction may be adequate to address the small-scale nature of the leptospirosis outbreak, the role of hygiene has once again taken a backseat in the immediate reactions to the problem. It will therefore be interesting to observe where hygiene stands as a human security priority in the event of a similar future outbreak, and how health policy can be adapted to account for this evolving context.

One Fl(u) Over the Cuckoo’s Nest: Pandemic Flu After H1N1

Posted in Health and Human Security by NTSblog on September 14, 2010

Less than a month after the WHO declared the swine flu pandemic over, a new US study has revealed that the H1N1 strain of influenza was in fact even milder than seasonal flu strains. The study also found that like seasonal influenza, children, young adults, pregnant women and people with underlying chronic medical conditions or pre-existing immunodeficiency were at higher risk of hospital admission and serious complications when infected with H1N1.

This is but one in a series of findings in the aftermath of the swine flu pandemic that is changing public perceptions of its severity and the nature of the threat itself, and this change is particularly notable if we observe attitudes towards vaccination. Only a year ago, swine flu vaccines were in short supply worldwide. Today, there appears to be more than enough influenza vaccine to go around. In fact, Australia’s The Age reported that “swine flu doesn’t scare us” and barely 20% of Australians had taken up the offer for a free swine flu jab because it was no longer perceived as a health threat.

However, in this climate of what has been described as a “swine flu fizzle”, experts also warned against complacency and to remain vigilant of other potential pandemics that could happen without prior warning. Avian flu, more commonly known as H5N1, was identified as the next potential pandemic as it can spread quickly and easily from birds to pigs and then to humans. Although no human-to-human H5N1 transmission has been verified, rapid mutations of the influenza virus could still make it possible.  The WHO echoed this call for caution, adding that although the pandemic was over and had only killed 18,600 people worldwide – a far cry from the worst-case scenarios in which authorities said millions could die – that health authorities needed to increase the speed and volume of vaccine production in preparation for the next global outbreak.

The contrasts within the plethora of information being disseminated to the public – on one hand that swine flu is not as severe a threat as we perceived it to be at the outset, on the other hand that we should still be wary of another influenza pandemic that we cannot predict or control – creates conflicted and often confused perceptions of our security and vulnerability with regards to influenza pandemics.  The problem with this is twofold: while viewing the next flu pandemic through worst-case scenario lenses may produce unnecessary panic, not recognizing and taking steps to minimize the risks associated with a potential outbreak could compromise our ability to effectively manage and control it.

It is therefore essential to the effective response to the next pandemic – and the assurance of our health security – that our perceptions of influenza are shaped by a strong grasp of facts instead of rhetoric, a comprehensive understanding of the extent of pre-emptive action we can take, and a measured – not fearful – approach to tackling a new flu pandemic if and when it occurs.

Implications and Perceptions of Singapore’s Ageing Population

Posted in Health and Human Security by NTSblog on September 8, 2010

As of June 2010, the total population of Singapore had surpassed the 5 million mark out of which 9 per cent are aged 65 and above. While low in contrast to Japan’s 23%, Singapore has the highest percentage of elderly citizens among Southeast Asian nations.

This has become a concern for the Singaporean government as a growing ageing population is perceived to have health security implications on two levels: firstly, on the individual health of the elderly person and secondly, on the national public health system that supports them. Such issues reflect non-traditional security/ human security concerns, which emphasise the need for efficient access to resources for the well-being of vulnerable sections of society.

Recent news reports suggest that elderly individuals become increasingly prone to numerous health risks as they age. For instance, the risk of malnutrition among Singaporeans heightens with age, with 3 in 10 elderly Singaporeans at moderate to high risk of malnutrition, making “the elderly more prone to falls and fractures, affecting their level of independence and contributing to greater healthcare costs.”  Furthermore, osteoporosis would increase thanks to a rapidly ageing population as well as potential under-diagnosis and treatment.

It is also perceived that each of these risks places burdens upon the national public health system that takes care of the elderly Singaporean. Statistics show a drop in the number of residents aged 15 to 64 for each resident aged 65 years and over – from 9.9 in 2000 to 8.2 in 2010. This has caused concern of a rising tax burden on working Singaporeans in order to compensate for the percieved increased health costs of the elderly. Other concerns included an insufficient number of medical personnel to take care of the needs of the elderly. A major response to this concern was the announcement of the establishment of a new medical faculty at Nanyang Technological University to cater to the demand for more doctors as the number of senior citizens increased.

However, this may constitute an overreaction to a perceived social problem. The fact that Singaporeans are living longer should not be seen as a disadvantage; instead it should be perceived as testament to the good quality of life and national health care that is enabling people to live longer lives.

Concerns regarding rising tax burdens on working Singaporeans to cater to the increased health costs of the elderly are also overstated. Firstly, in a highly developed country with sufficient resource capacities such as Singapore, the problem is not ‘rising’ health costs, but rather the lack of awareness on utilising the available resources. For instance, elderly individuals who need healthcare coverage the most often go uncovered and long-term care schemes remain underdeveloped. As such, a degree of foresight is needed amongst families to plan for sufficient health security benefits in the future. Secondly, the assumption that the elderly are less inclined or capable of contributing to the economy is flawed:  17.2 per cent of Singaporeans aged 65 and above are still part of the national labour force and that 45 percent of Singaporeans would like to work past the official retirement age.

Given these considerations, perhaps it is time that we began perceiving and treating the ageing population phenomenon as an opportunity to bridge existing gaps in healthcare coverage for the elderly and recognize and encourage their contribution to society and the national economy rather than labeling them a health security hazard.

Feeling bugged by ‘superbugs’?

Posted in Health and Human Security by NTSblog on September 3, 2010

On 10 August 2010, the director-general of the World Health Organisation declared the end of the H1N1 pandemic. However, it would appear that public health threats are never far away as researchers highlighted a new health threat looming on the horizon:  a new class of multi-drug resistant bacteria. The dangers inherent in depicting this phenomenon as one of the most important health issues that would affect all of humanity is that it undermines the public’s trust in authorities. This was seen during in the way public authorities dealt with H1N1 as they appeared to have overreacted to the emergence of a new virus strain. The exaggeration of health threats diverts attention away from more critical health issues, such as curable diseases like malaria and dengue which continue to affect poorer populations.

A paper published in the journal Lancet Infectious Diseases emphasised the apparent rapid spread of these multi-drug resistant bacteria.  The paper published details of bacteria which contained the gene New Delhi metallo-ß-lactamase-1 (NDM-1), which produces an enzyme that enables the bacteria to break down even the strongest antibiotics.

The paper was picked up in the media, giving to a myriad of hysteria-filled reports about potential of so-called superbugs to destroy civilisation as we know it, with one of the more memorable headlines which said ‘Superbug panics world‘.  One of the researchers who worked on the paper said “In many ways, this is it,” he said. “This is potentially the end. There are no antibiotics in the pipeline that have activity against NDM 1-producing Enterobacteriaceae.” Such statements ring of apocalyptic visions and risks causing greater public panic as they are perceived as expert opinion. Instead of more balanced analyses and attempting to communicate the level of risk to the public in a measured fashion, media and government authorities alike exacerbate the level of panic when they overreact to health issues.

The stories published about individuals who have died as a result of exposure to such ‘superbugs’ create the sense that all of us are susceptible to it, anyone, anytime, anywhere. Yet, the reality of the situation is less grim. Taking another multi-drug resistant bacterium, methicillin-resistant Staphylococcus aureus (MRSA) for example, it is a bacterium strain resistant to antibiotics, but despite its supposed ‘superbug’ status, it does not affect most people who are exposed to it. The frequency of infection is low, and occurs in patients who are weakened, old, or have recently emerged from surgery. Furthermore, such ‘superbugs’ are multi-drug resistant strains, not all-drug resistant. Even the report’s authors stated that NDM-1 is susceptible to two types of antibiotics, namely colistine and tigecycline.

Other than causing unnecessary panic and fear, such reports can also be harmful in the way that it diverts attention from other health security issues. Threats to health security are usually greater for the poor in rural areas, especially children. However, the emphasis on the dangers of multi-drug resistant bacteria serves to obfuscate severe public health problems which affect more people globally such as malaria and dengue. While it is crucial to continue research into creating new types of antibiotics to counter multi-drug resistant strains of bacteria, it is also important to recognise the need to attend to the arguably more ‘mundane’ diseases which are perhaps less newsworthy than ‘superbugs’.