Life expectancy up, but Africa still behind – WHO

A new report has highlighted the disturbing extent of health inequality across the globe, showing that while life expectancy has risen at its fastest rate since the 1960s, sub-Saharan Africa still lags the rest of the world by a considerable margin.

The World Health Organisation (WHO) figures show that global life expectancy increased by five years between 2000 and 2015 – the fastest increase since the 1960s.

The African region had the strongest growth, up by 9.4 years, driven by improvements in child survival, malaria control and access to retrovirals for HIV treatment.

The increase has narrowed the gap between African life expectancy and European life expectancy by 4.9 years since 2000.

But even so, a child born in Africa in 2015 can only expect to live to the age of 60, compared with the global average of 71.4 years.

A child born in Sierra Leone has a life expectancy of just 50.1 years, more than 33 years less than a child born in Switzerland (83.4). An Australian (82.8 years) can look forward to three more decades than an Angolan (52.4 years).

“The world has made great strides in reducing the needless suffering and premature deaths that arise from preventable and treatable disease,” WHO Director-General Dr Margaret Chan said.

“But the gains have been uneven. Supporting countries to move towards universal health coverage based on strong primary care is the best thing we can do to make sure no-one is left behind.”

The World Health Statistics: Monitoring Health for the SDGs report shows that the declines in life expectancy experienced in the 1990s, caused by the AIDS epidemic in Africa and the impact of the collapse of the Soviet Union on eastern Europe, have been reversed.

“The global average increase in life expectancy at birth since 2000 exceeds the overall average rate of life expectancy increase achieved by the best performing countries over the past century,” WHO said.

“The world as a whole is catching up with those countries, and improvements in outcomes for all major causes of death have contributed to these huge gains.”

WHO said it was worth considering a proposal to measure premature mortality – deaths before the age of 70 – as it was more sensitive to interventions.

“There were an estimated 30 million deaths under age 70 in 2015 and, if the Sustainable Development Goals (SDG) mortality targets had been achieved in 2015, this would have been reduced to 19 million deaths,” the report said.

“This represents a 36 per cent reduction (almost 11 million averted premature deaths) – close to the proposed 40 per cent target.”

Had those deaths been averted, five million people would not have died from infectious diseases, malnutrition, and child and maternal mortality. A further five million would not have lost their lives to non-communicable diseases, and 900,000 people would not have died from injuries.

The report found that Japan topped the life expectancy list, at 83.7 years, and Sierra Leone was the lowest (50.1).

Healthy life expectancy, a measure of the number of years of good health a 2015 newborn can expect, stands at 63.1 years globally – 64.6 years for women and 61.5 for men.

On average, women (73.8 years) live longer than men (69.1 years) in every country of the world. Scandinavian countries had the lowest male-female gaps (Iceland 3.0 years, Sweden 3.4) while some former Soviet countries were among the highest (Russia 11.6 years, Ukraine 9.8 years).

The full report can be found on the WHO website at http://www.who.int/gho/publications/world_health_statistics/2016/en/

Maria Hawthorne

World told to get ready for plain packaging

Australia has received a big filip in its fight to protect its tobacco plain packaging laws after the World Health Organisation launched an international campaign declaring that all governments had to “get ready” plain packaging.

Since it introduced the world’s first plain packaging laws in 2012, Australia has been playing virtually a lone hand in a global battle with major tobacco companies determined to have the laws overturned.

So far, Britain, Ireland and France have joined Australia in passing plain packaging legislation, and both, Canada and New Zealand have announced plans to introduce plain packaging legislation.

Tobacco companies have failed in successive bids to have the laws overturned by national courts and international tribunals.

The latest setback came last month when the highest court of the European Union ruled in favour of regulations that give its member states the option of implementing plain packaging for tobacco products.

This followed the acceptance of the Permanent Court of Arbitration sitting in Singapore of Australia’s argument that it did not have jurisdiction to hear a claim by Philip Morris Asia that the legislation breached trademark protection laws.

The WHO used World No Tobacco Day to join the fight, launching its “Get ready for Plain Packaging” campaign for more effective health warnings on tobacco products around the globe.

The WHO said tobacco packaging was a form of advertising and promotion, often misled consumers and served to hide the deadly reality of tobacco use.

Plain packaging requires tobacco products be sold without marketing gimmicks and with clearly displayed health warnings. Australia was the first country in the world to introduce the legislation. Introduced in 2012, research has indicated that Australia has seen a reduction of 100,000 fewer smokers as a direct result from the plain packaging legislation.

The AMA has been a loud supporter of plain packaging legislation. Past AMA President Dr Andrew Pesce was alongside Federal Health Minister Nicola Roxon as she released the world-first draft Bill and the proposed design for the plain packaging packs.

The WHO said that plain packaging built upon other measures as part of a comprehensive multi-sectoral approach to tobacco control. For more information about the campaign, visit http://www.who.int/campaigns/no-tobacco-day/2016/en/

Kirsty Waterford

We need transformative change in Aboriginal health

Overcoming the soft bigotry of low expectations

Change is complex and invariably poorly managed and understood in Aboriginal affairs, including Aboriginal health. At worst, it is a competition between recycled ideas that have gained or lost currency with changes in the dominance of political ideologies. At best, it is developmental change, a slow and marginal improvement on what we are currently doing.

Comparison of the 1989 National Aboriginal Health Strategy (NAHS) Working Party report and the 1994 evaluation of the implementation of the NAHS with the current National Aboriginal and Torres Strait Islander Health Plan (2013–2023) (http://www.health.gov.au/natsihp) shows that we continue to seek change in the same key areas. Holistic approaches rich in evidence-based thinking, emphasis on community control of health services, inter-sectoral collaboration and improved monitoring and accountability are themes that have repeatedly been highlighted in almost the same way despite the passage of almost a quarter of a century. So what is wrong with this?

Let’s start with the sustainability of public interest in, and commitment to, Aboriginal health and the consequential lack of willingness of our political leaders to live up to their promises. Politicians regularly overpromised and underdelivered in Aboriginal affairs. Former Disability Discrimination Commissioner Graeme Innes describes the “soft bigotry of low expectations”1 as a barrier that people living with disability confront in health care. Sarra has similarly highlighted the impact of low expectations on Aboriginal education outcomes.2 I think the same “soft bigotry” applies to public expectations of Aboriginal health.

It is true that incrementally, slowly, too slowly, things are changing in some areas. Infant mortality in the Aboriginal and Torres Strait Islander population is declining,3 and we have seen significant decreases in avoidable deaths in some jurisdictions4 and improvement in access to medications.5 Aboriginal health is better today than it was in 1971 when the first Aboriginal Medical Service was established, but we need to ask ourselves whether the incremental gains, given elapsed time and effort invested, are sufficient? Where is the tectonic shift that will propel change in Aboriginal health forward at a much more rapid rate? Where is the new strategy that will deliver the Closing the Gap targets on time?

Prime Minister Malcolm Turnbull has said of the Closing the Gap campaign that “we cannot sugar-coat the enormity of the job that remains”6 and has called for innovative and new approaches. Leader of the Opposition Bill Shorten has encouraged us to listen to the “whispering at the bottom of our hearts”7 because it speaks honestly to the unease arising from the knowledge that we can and must do better.

Incremental change is insufficient if our aspirations for Aboriginal and Torres Strait Islander health and the results we deliver are to better align. We need to eschew the soft bigotry of low expectations, of slow incremental change, and embrace a more transformative change agenda.

We need change that not only develops new knowledge but, importantly, puts what we already know into practice efficiently and equitably. The research, for example, supporting the importance of access to high quality, consistent, comprehensive primary health care is extensive,8 but we have largely taken a patchwork approach to coverage in Aboriginal health.

It is still too much the case that Aboriginal and Torres Strait Islander peoples are confronted by a system in which the core services necessary to underscore a successful healthy journey across life are inconsistently available and of varying quality.9 Not all can access prenatal, infant, early childhood, adolescent, adult life and later life services as individuals or as cohorts when, and at a level, they require.10 In this issue, Ah Chee and colleagues provide an example of how transformative change can be implemented through an innovative model based on intervention before Aboriginal children reach school age.11

We need to shift from a program of low expectations to an approach that reinvents organisations and transforms structures, systems, technologies and processes to provide change that transforms the culture of organisations, professions and the workforce and the relationships across societal silos; change that reshapes public policy, financing and accountabilities. We need transformation not incremental change and it will be complex and risky. Tolerating incremental change costs lives, money and economic and social capital.

If we continue to rely on the slow and incremental, we will continue to bear these unacceptable costs. Without transformative change, we are doomed to be haunted by the whispers at the bottom of our hearts.

The health of indigenous and tribal peoples across the world: The Lancet–Lowitja Institute Global Collaboration

The Lancet and the Lowitja Institute have collaborated on a study of the health and wellbeing of indigenous and tribal peoples around the world. The findings were published simultaneously in Melbourne and London in mid-April 2016 under the title Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study (Anderson et al, doi: http://dx.doi.org/10.1016/S0140-6736(16)00345-7).

In supporting this work, the Lowitja Institute extends its core purpose of valuing the health and wellbeing of Aboriginal and Torres Strait Islander peoples to the global indigenous family of which we are part, as well as our commitment to supporting local and international indigenous health and wellbeing networks.

The purpose of the research was to establish a clear picture of indigenous and tribal health relative to benchmark populations, without making comparisons between indigenous populations. It included data on 28 indigenous populations from 23 countries, covering about half the world’s indigenous peoples.

The research team was particularly keen to ensure that this study looked beyond populations where indigenous data systems are better developed — such as Canada, the United States, New Zealand and Australia, for example — to truly discuss and describe problems from a global perspective.

The data were collated against eight key themes: measures of population, life expectancy, infant mortality, birth weight, maternal mortality, educational attainment, poverty and nutritional status. The data were sourced from published government and non-government reports, supplemented with raw data identified and analysed by collaborators within their own countries.

What was critical — and unique to this study — was the participation of 65 contributors who were able to identify, at country level, the best quality data available. Contributors came from the major global regions, from Africa, Asia, the Americas, the Pacific and the Arctic Circle.

For a number of reasons, there were no comparisons made between indigenous populations. The definitions of indigenous peoples in data systems differ across countries; data collection methods also vary, as do methodological approaches to data analysis. Some of the most important recommendations of this report (like higher quality and disaggregated data) are derived from these challenges.

Broad findings indicate continuing health and social disadvantages for indigenous and tribal peoples across the globe when compared with benchmark populations, with some possible exceptions such as the Mon people in Myanmar. It is concerning that the results indicate that being an indigenous person in a wealthy country does not result in proportionally positive outcomes; on the contrary, some of the worst nutritional results, for example, occur among Australia’s First Peoples.

The article does not offer an explanatory framework because the authors believe that this requires a local analysis of the social and historical circumstances of each population. In offering a high-level explanation of the health patterns observed, the authors point to the social determinants of health, such as education, living and working conditions and access to health care; to distal determinants, such as the legacy of colonisation, racism, discrimination and social exclusion and to ecological change.

The authors believe that we are not going to succeed globally in implementing the United Nations 2030 Sustainable Development Goals without action on the health and social outcomes for indigenous and tribal peoples. They strongly emphasise the need for disaggregated data by indigenous status across all data systems in order to monitor change, and the need for this work to be done with the full engagement of indigenous peoples. In the same vein, while urging caution with regard to individual country particularities, they make recommendations for the development of health systems and policy frameworks within each nation state.

In the context of these recommendations, it is worth noting that in Australia, the National Health Leadership Forum has successfully worked with national governments on some of these challenges and will continue to monitor efforts in this area.

For more information and links to the article, podcast and infographic, please visit http://www.lowitja.org.au/indigenous-tribal-health. Many of the concerns raised by the article will be discussed at the Lowitja Institute International Indigenous Health and Wellbeing Conference to be held in Melbourne on 8–10 November 2016. Please visit http://www.lowitjaconf2016.org.au for more details.

Global emergency call on yellow fever outbreak

The World Health Organisation has been urged to take emergency action over a rapidly spreading yellow fever epidemic that has so far infected more than 2000 people in Africa and Asia.

Health experts at Georgetown University’s Institute for National and Global Health Law, writing in the Journal of the American Medical Association, have warned that “quick and effective action” is needed to halt the spread of the disease, which has already killed more than 250 people in Angola and has appeared in Congo, Kenya and China.

The experts, Dr Daniel Lucey and Professor Lawrence Gostin, said that shortages in the supply of the yellow fever vaccine raised the risk of a “health security crisis” if the disease spreads through Africa and reaches Asia (which has never experienced a yellow fever epidemic) or the Americas (where the mosquito that can transmit yellow fever is endemic).

“The WHO should urgently convene an emergency committee to mobilise funds, coordinate an international response, and spearhead a surge in vaccine production,” they said.

Dr Lucey and Professor Gostin said delays in the international community’s response to the 2014 Ebola outbreak that eventually infected 28,646 people and claimed 11,323 lives should serve as a salutary lesson of the costs of a tardy response.

“Prior delays by the WHO in convening emergency committees for the Ebola virus, and possibly the ongoing Zika epidemic, cost lives and should not be repeated,” they said. “Acting proactively to address the evolving yellow fever epidemic is imperative.”

Yellow fever kills around 30,000 people a year, mostly in Africa, and the latest outbreak has added impetus to mass vaccination programs. More than 7 million Angolans have been immunised against yellow fever, and in May the Democratic Republic of Congo Government announced plans to vaccinate 2 million of its citizens.

Dr Lucey and Professor Gostin warned that these mass immunisation campaigns “could be a tipping point in exhausting global vaccine supplies”.

Medical experts have already advised that just one-fifth of normal vaccine dose be administered to avert the risk of an acute shortage if the disease spreads, but Dr Lucey and Professor Gostin said it was time for the WHO to step in.

They said the world health body should invoke procedures similar to those used during the Ebola epidemic to safeguard vaccine supplies.

“Stewardship of scarce vaccine supplies is essential, but requires the WHO’s Director-General to declare a public health emergency of international concern,” they wrote. “[But] it is only by convening an emergency committee that the Director-General could declare a public health emergency of international concern.

“Given the world’s vital health security interest, the WHO’s Director-General should use [the procedures] to authorise a reduced vaccine dose to control the epidemic in Angola.”

Dr Lucey and Professor Gostin said the yellow fever outbreak, combined with the experiences of the Ebola and Zika epidemics, showed that the WHO needed to have a standing emergency meeting that met regularly, rather than having to be formed each time a serious global health threat arose.

“The complexities and apparent increased frequency of emerging infectious disease threats, and the catastrophic consequences of delays in the international response, make it no longer tenable to place the sole responsibility and authority with the WHO’s Director-General to convene currently ad hoc emergency committees,” they said.

Adrian Rollins

[Comment] Who should finance WHO’s work on emergencies?

In May, 2015, the 68th World Health Assembly approved the decision to reform the work of WHO on emergencies by creating a single programme for outbreaks and health emergencies, and an accompanying Contingency Fund for Emergencies (CFE).1 According to latest estimations, the core funding needs for the programme and the initial capital of the CFE will, respectively, range about US$300 million per year and $100 million.2 To respond effectively to emergencies, these resources should be flexible, predictable, and directly accessible.

News briefs

Wearable sensor measures fitness levels, heart function

Researchers from the University of California-San Diego in the US have developed a wearable patch that can measure biochemical and electrical signals in the human body simultaneously, reports Medical News Today. “The device — called the Chem-Phys patch — measures real-time levels of lactate, an indicator of physical activity, as well as the heart’s electrical activity. Put simply, the novel technology monitors a person’s fitness levels and heart function at the same time, and it is the first device that can do so. The patch is made of a thin, adhesive, flexible sheet of polyester, which the researchers manufactured using screen printing. A lactate-sensing electrode is situated in the centre of the patch, and two electrocardiogram electrodes are situated either side. The researchers found that the data collected by the EKG electrodes closely matched the data collected by a commercial heart rate monitor. Furthermore, they found that the information gathered by the lactate sensor closely matched lactate data collected during increasing physical activity in previous studies.”

http://www.nature.com/ncomms/2016/160523/ncomms11650/full/ncomms11650.html

Obesity linked to lower quality of nursing home care

US researchers have found that nursing homes that admitted more morbidly obese residents were also more likely to have more severe deficiencies in care, according to a study published in the Journal of the American Geriatrics Society. Science Daily reports that the study was designed to find out “whether obese older adults were as likely as non-obese elders to be admitted to nursing homes that provided an appropriate level of care”. “The researchers examined 164 256 records of obese people aged 65 or older who were admitted to nursing homes over a 2-year period. They also examined the nursing homes’ total number of deficiency citations and quality-of-care deficiencies to determine the quality of care that the homes provided. The researchers reported that about 22% of older adults admitted to nursing homes were obese. Nearly 4% were considered morbidly obese. Nursing homes that admitted a higher number of obese residents were more likely to have a higher number of deficiencies.”

https://www.sciencedaily.com/releases/2016/05/160531182543.htm

Australians among world’s longest-living: WHO

A new report from the World Health Organization says there have been gains in global life expectancy since 2000, with the overall increase of 5 years to a tick over 71 years the fastest rise since the 1960s, and reverses the declines seen in the 1990s. The World health statistics 2016: monitoring health for the Sustainable Development Goals (SDGs) report shows that the greatest increase in life expectancy during 2000–2015 has been in the African region, where it rose from 9.4 years to 60 years, due to reduction in child deaths, progress in malaria control, and better access to HIV antiretrovirals. Globally, the average lifespan of a child born in 2015 is likely to be 71.4 years — or 73.8 years if it is a girl and 69.1 years if it is a boy. The longest life expectancy is in Japan, where children born in 2015 are expected to live 83.7 years, followed by Switzerland (83.4 years), Singapore (83.1 years), Australia (82.8 years), and Spain (82.8 years). Average life expectancy for the United States is 79.3 years. The report also quantifies the causes of death and ill-health that pose significant challenges in meeting the SDGs.

http://www.who.int/gho/publications/world_health_statistics/2016/en/

Beware barbecue brush bristles

Research published in Otolaryngology — Head and Neck Surgery has investigated the epidemiology of wire-bristle barbecue brush injuries. Between 2002–2014, more than 1600 emergency department visits occurred as a result of wire-bristle brush injuries in the US, some of them requiring surgery. According to Medical News Today: “While wire grill brushes may be an effective cleaning tool prior to or following a cookout, the bristles can easily fall off and make their way into people’s food. If ingested, these little strands of metal can cause some serious injuries to the mouth, throat, and gastrointestinal region. The researchers hope their findings will promote greater awareness among manufacturers, consumers, and healthcare providers of the potential health hazards associated with wire-bristle brushes.”

http://oto.sagepub.com/content/154/4/645.abstract

[Comment] Offline: WHO’s phoney war

Margaret Chan closed last week’s World Health Assembly, a festival to display the best of global health diplomacy or an Olympics of broken promises (depending on your view of global health realpolitik), by claiming that, “We can do anything in the world we want to, provided we speak with a united voice.” Whoever wrote this line should be dispatched to the deepest bunker of WHO’s most corrupt member state (there are a good few to choose from). “Speaking” is what the World Health Assembly does supremely well.

[Correspondence] Breastfeeding in the 21st century

The breastfeeding Series papers by Cesar Victora and colleagues1 and Nigel Rollins and colleagues2 are a notable contribution to the maternal and child nutrition field. Both papers comment that the World Health Assembly’s target aiming to increase the rate of exclusive breastfeeding globally in the first 6 months up to 50% by 2025 is achievable, if not unambitious.3 However, the flaws of the target indicator itself were not addressed.

New partnership to tackle polio

Japanese pharmaceutical giant Takeda has teamed up with the Bill & Melinda Gates Foundation in a new push to eradicate polio.

The Gates Foundation is providing US$38 million (AU$52.5 million) to Takeda to develop, license and supply at least 50 million doses a year of Sabin-strain inactivated poliovirus vaccine to more than 70 developing countries.

Takeda president and chief executive officer Christophe Weber said the company was honoured to partner with the Gates Foundation.

“This represents a major commitment by a Japanese company to the health of children in developing countries around the world,” Mr Weber said.

The vaccine will be manufactured at Takeda’s facility in Hikari, Japan, and will be provided at an affordable price to developing countries receiving support from Gavi, the Vaccine Alliance.

“In 2016, the world is closer than ever to eradicating polio,” Gates Foundation global development president Chris Elias said.

“To eradicate polio, we need to ensure that every last child is protected from the disease. This partnership will help to ensure that the world has enough vaccine to get the job done and maintain a polio-free world.”

Polio is so highly infectious that the World Health Organisation considers a single confirmed case to be an epidemic.

Maria Hawthorne