Ebola in a war zone

Global health officials have warned that combating Ebola in the northeastern Congo outbreak is complicated by multiple armed groups in the mineral-rich region and a restless population that includes one million displaced people and scores of refugees leaving for nearby Uganda every week.

The Associated Press reports that insecurity means health workers might have to change a vaccination strategy that proved successful in Congo’s previous Ebola outbreak.

The ‘ring vaccination’ approach of first vaccinating health workers, contacts of Ebola victims, and their contacts might have to give way to the approach of vaccinating everyone in a certain geographic area such as a village or neighbourhood. That would require a larger number of vaccine doses.

Vaccinations began in early August in the current outbreak, which was declared on August 1 and has killed 11 people in the densely populated region. The World Health Organisation (WHO) has said more than 3,000 Ebola vaccine doses are available in Congo.

While Congo’s previous Ebola outbreak, declared over barely a week before the current one began, set off alarm by spreading to a city of more than one million people on the other side of the country, the current outbreak comes with the threat of armed attack.

An assault that killed seven people in Mayi-Moya, about 40 kilometres from Beni city, was likely carried out by rebels with the Allied Democratic Forces, the administrator of Beni territory, Donat Kibwana, told The Associated Press.

The rebels have killed more than 1500 people in and around Beni in less than two years.

The rebels sent the local population fleeing, Kibwana said.

Beni residents already had been shaken by the discovery last week of 14 bodies of civilians who had been seized by suspected ADF rebels.

The latest attack occurred as the WHO Director-General, Tedros Adhanom Ghebreyesus, was visiting the area to see the response to the Ebola outbreak, which is being carried out in some cases under armed escort.

“The active conflict in the area is a barrier to control Ebola,” Tedros said.

“I call on all warring parties to provide secure access to all responders serving affected populations and saving lives.”

United Nations peacekeepers, Congolese police, and, at times, Congolese troops have been travelling with convoys of health workers as they fan out to contain the outbreak. Hospitals are guarded by Congolese police and military police.

So far, Congo’s health ministry has said 48 cases of hemorrhagic fever have been reported in this outbreak, 21 of them confirmed as Ebola.

Nearly 1000 people are being monitored. Screenings for the virus are being carried out at the heavily travelled border; officials have said travel restrictions are not necessary.

This is Congo’s tenth outbreak of Ebola, which is spread via contact with bodily fluids of those infected, including the dead. There is no licensed treatment, and the virus can be fatal in up to 90 per cent of cases, depending on the strain.

Polio in PNG

In a recent article in the Lowy Institute’s The Interpreter, Kaveri Devi Mishra explained how the news of pulse polio resurfacing in Papua New Guinea has created new challenges for a public health care system already confronting many related health problems.

Polio virus is a potentially deadly disease that can spread through communities, causing paralysis and disability, mostly among vulnerable young children.

The World Health Organization (WHO) has confirmed the outbreak, almost 18 years since PNG was declared a polio-free nation.

Papua New Guinea is already ranked by the WHO as having the worst health status in the Pacific region.

The polio outbreak comes at a time when the country is also facing huge challenges from diseases such as malaria, tuberculosis (TB), cancer, diarrhoeal diseases, pneumonia, and HIV/AIDS.

By landmass, population and economy, PNG is the largest nation among Pacific island countries, yet the country’s health indicators have either stalled or gone backwards over the past 30 years.

There is only one doctor per 17,068 people in PNG, which is exceedingly insignificant.

PNG has 0.58 health workers per 1000, whereas the WHO recommends 2.5 health professionals per 1000 people for maintaining primary health care.

Ms Mishra says that India might offer a model for eradication. While it was once a hotbed for the polio virus, a massive, nationwide campaign of eradication in India saw it eventually declared polio-free in 2011.

But precautionary measures are still in place. Given India’s population is 1.2 billion and PNG’s is only 8 million, surely PNG can likewise apply stringent measures against polio

Drugs use the source of one in four new hepatitis C infections

Two in five people who have injected illicit drugs in the past year are living with hepatitis C, highlighting the urgent need for prevention and treatment, new Australian research shows.

Researchers from the Kirby Institute at the University of New South Wales and the National Drug and Alcohol Research Centre (NDARC) estimate that 6.1 million people who inject drugs are living with hepatitis C globally, with one-quarter of new infections occurring in people who inject drugs.

It is the first time that researchers have estimated the global, regional, and national numbers of people who inject drugs who are living with hepatitis C.

Lead author, Associate Professor Jason Grebely, said that, in Australia, almost 40,000 people who have recently injected drugs are living with HIV. However, Australia is one of only four countries worldwide with high coverage of both needle and syringe programs and opioid substitution therapies.

“Australia has been an international leader in its response to hepatitis C,” Associate Professor Grebely said.

“The fact that hepatitis C treatments are available for all individuals, without restrictions based on current or previous drug use, means that we are likely to achieve the World Health Organization goal to eliminate hepatitis as a major public health threat by 2030, including among people who inject drugs.”

However, the outlook is not so bright globally, with only one per cent of people who inject drugs living in countries where needle and syringe programs and opioid substitution programs are widely available.

The greatest number of people with hepatitis C who have recently injected drugs live in eastern Europe, east and south- east Asia, and North America, and more than half of them live in just four countries – Russia, the United States, China, and Brazil.

“It is concerning that more than half of all hepatitis C infections among people who have recently injected drugs occur in countries with inadequate coverage of harm reduction services,” Judy Chang, from the International Network of People Who Use Drugs, said.

“The global elimination of hepatitis C as a public health threat will not be achievable unless we improve access to harm reduction services, de-stigmatise drug use and drug users, and improve the overall health of people who use drugs.”

The researchers estimate that about 71 million people world- wide are living with hepatitis C.

The research was published in Addiction on 24 July.

[Correspondence] Qualifying the promise of Universal Health Coverage

In his recent Comment (April 7, p 1342),1 Richard Horton underlined the importance of the Universal Health Coverage (UHC) campaign, promoted by WHO on World Health Day 2018. He also problematised UHC on two counts: first, by arguing that, although UHC might sound like a finite achievable goal, it is not so in practice, and second, by underlining that UHC is not sufficient by itself, but must be coupled to targeted political actions, including legislation and programmes that address specific national health problems, such as diabetes and safer water.

WHO praises Greece for giving asylum seekers universal health coverage

The Greek Government has taken steps to address the health of 60,000 migrants and refugees currently living in the country, by granting access to primary health care (PHC) services, coordinated for migrants and Greek citizens alike by the Ministry of Health.

The World Health Organisation has congratulated Greece on the effort.

WHO Director General Dr Tedros Adhanom Ghebreyesus and WHO’s Regional Director for Europe Dr Zsuzsanna Jakab, visited Greece in June at the invitation of the country’s Prime Minister Alexis Tsipras, to inspect the implementation of a WHO-endorsed plan for refugee and migrant health.

WHO’s Public Health Aspects of Migration in Europe (PHAME) program works to strengthen the capacity of countries’ public health services to deal with large influxes of migrants.

Speaking at a recent regional WHO meeting, Prime Minister Tsipras said the issue of access to health services was of critical importance because “protecting human dignity and health is not a privilege or a luxury”.

WHO has been working with Greece on a European Union-funded project to ensure that the reform plan follows WHO policy recommendations.

Dr Tedros congratulated Mr Tsipras for his commitment to universal health coverage, and to ensuring that all residents of Greece can access the health services they need, when and where they need them, without facing financial hardship.

“The investments Greece is making will generate a return not only in terms of better health, but also in terms of poverty reduction, job creation, inclusive economic growth and health security,” Dr Tedros said.

This approach means migrants can access medical support, as well as cultural mediation to ensure that services are appropriate. They are also guided in navigating the health system so that they can, for example, receive the medication they need to manage chronic conditions. Greece has invested in PHC, despite experiencing a severe financial crisis.

For the first time Greece has developed unified PHC services based on community PHC units. Known as TOMYs, these units are staffed with multidisciplinary teams of general practitioners, paediatricians, nurses, health visitors, social workers and administrative staff. TOMYs work in collaboration with already existing ambulatory care units, health centres that provide specialised, diagnostic and dental health-care services.

The first TOMY opened in Thessaloniki (Evosmos) in December 2017, and currently there are 94 units in operation. Each unit has a capacity to serve approximately 10,000 people, and they are likely to reach this capacity within a year.

Dr Jakab said: “Standing shoulder to shoulder with the Greek Ministry of Health, we have made significant efforts that will continue to contribute to improving the health of the Greek people, including the most vulnerable.”

WHO suggested to Greece that the TOMY teams map the health needs of the communities they serve.

Dr Tedros and Dr Jakab’s visit to Greece coincided with the official launch of the new WHO Country Office in Greece, which will facilitate collaboration with the Ministry of Health and other stakeholders on national health priorities, as well as supporting multicountry cooperation programs. It is the 149th WHO country office worldwide, and the 30th in the European Region.

Dr Andreas Xanthos, Greece’s Health Minister, said that the establishment of the WHO Country Office in Greece significantly strengthens the country’s efforts towards universal health coverage and a sustainable and effective health system.

“This did not happen by chance – it is the result of a whole-of-government strong political commitment to upgrade our country’s cooperation with WHO,” said Dr Xanthos.

MEREDITH HORNE

[Seminar] Sepsis and septic shock

Sepsis is a common condition that is associated with unacceptably high mortality and, for many of those who survive, long-term morbidity. Increased awareness of the condition resulting from ongoing campaigns and the evidence arising from research in the past 10 years have increased understanding of this problem among clinicians and lay people, and have led to improved outcomes. The World Health Assembly and WHO made sepsis a global health priority in 2017 and have adopted a resolution to improve the prevention, diagnosis, and management of sepsis.

Nationals bitter on sugar tax ahead of election

Nationals Deputy Leader Senator Bridget McKenzie, whose portfolio responsibilities include Rural Health and Sport, has spoken out strongly against the introduction of an Australian tax on sugar sweetened beverages (SSBs).

“We know a sugar tax won’t address obesity, because other countries have tried it,” Senator McKenzie said in a statement.

Her Nationals colleague, Agriculture Minister David Littleproud MP, also said in the jointly issued statement: “Let’s not hurt our cane growers, who are already hurting due to low prices, with a government intervention which won’t help solve the problem.”

However, a June report published by the Medical Journal of Australia argues: Australia can no longer afford to wait for a tax on sugar-sweetened beverages.

The report was co-authored by Dr Alessandro Demaio, CEO for EAT and Alexandra Jones from the George Institute for Global Health.

The report reasons: “Governments worldwide are drawing on growing evidence to implement effective pricing policies for SSBs as one cornerstone of a comprehensive policy response.”

At least 30 countries, the Spanish Catalan region and seven cities in the United States have adopted SSB taxes. The World Health Assembly also says there is now sufficient evidence that effective taxation of SSBs are working as intended to reduce purchasing and consumption to support further uptake.

Demaio and Jones also cite in their article new evidence that suggests an agriculture sector will not suffer an adverse employment effect from an SSB introduction and sought to: “reminded governments to pair implementation with robust independent evaluation and to remain vigilant to policy interference by conflicted interests.”

The Australian Medical Association continues to call for a tax on SSBs to be introduced as a matter of priority. AMA President Dr Tony Bartone says the strong position on sugar is because doctors see the direct consequences of obesity every day.

“One of the best ways to achieve a change in consumer behaviour is with a sugar tax. The evidence is in. Price signals work,” Dr Bartone said.

“The AMA strongly supports the introduction of a sugar tax in Australia as part of a broad range of policies to combat obesity and improve the health of the population across all age groups.”

At this stage both the Government and Labor reject the AMA’s call for a tax on sugary drinks to reduce Australia’s obesity problem.

MEREDITH HORNE

American formula to beat breastfeeding

Donald Trump’s United States Administration has sparked outrage at the Word Health Assembly over tactics its delegation used to try to stymie an international resolution promoting breastfeeding.

The US delegation is accused of not only vigorously talking down the resolution, but also of employing bullyboy tactics against other nations to get them to fall into line with America.

The worst accusation is that American diplomats threatened Ecuador with trade sanctions and a withdrawal of military assistance in the South American country’s fight against organised crime and gang violence.

The original resolution encouraged governments across the globe to “protect, promote and support breast-feeding,” but team USA fought against the wording and – according to reports from the meeting in Geneva – acted aggressively towards those supporting it.

The delegation was also reported to have threatened to cut US Government funding to the World Health Organisation.

Health advocates have described the antics as a clear example of the Trump presidency looking after its big business mates – this time in the multibillion-dollar infant formula and dairy industries.

“We were astonished, appalled and also saddened. What happened was tantamount to blackmail, with the US holding the world hostage and trying to overturn nearly 40 years of consensus on best way to protect infant and young child health,” Patti Rundall of the UK-based campaign Baby Milk Action told the New York Times.

The Russian delegation stepped in and modified the text of the resolution before reintroducing it. This cleared the way for it to be eventually passed, with US support.

The WHO and the AMA encourage breastfeeding on health benefits grounds, which is backed up by numerous high-level, peer-reviewed studies.

CHRIS JOHNSON

Active commuting might not be that hard

More than two in three Australians drive to work, according to the latest 2016 Census data. An active commute, where physical activity forms a significant part of the way people travel to and from work, is far easier than often thought – and it could even be a lifesaver.

One of the main hurdles for the uptake of active commuting could be based in an overestimation of the length of time people believe it would take to walk or ride to work, a recent study suggests.

Associate Professor Melissa Bopp, one of the study’s co-authors from Pennsylvania State University, said: “Often people indicate that the reason they choose to drive is that it’s much quicker than walking or biking when, in reality, that may not be the case.”

When the study’s participants were asked to estimate how long it would take them to bike or walk to a common location in town, they found that the majority of people estimated incorrectly. Ninety-one per cent of study participants incorrectly estimated how long it would take to commute with walking, and 93 per cent mis-estimated how long it would take to bike.

In Australia, rates of walking and cycling remain constant and low – even in smaller centres such as Hobart, Darwin and Canberra. Even in the most ‘cycling-oriented’ places (Darwin and Canberra), only about three per cent of commuters cycle.

The World Health Organisation (WHO) launched in June this year its first Global Action Plan for Physical Activity 2018-2030, to encourage an increased participation in physical activity by people of all ages and abilities across the world.

WHO recommends that adults aged between 18 and 65 should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity. For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent. Muscle-strengthening activities should be done involving major muscle groups on two or more days a week.

Active commuting offers an extremely effective health solution to modern sedantry lifestyles as supported by findings from the University of Glasgow published earlier this year in the British Medical Journal, a study that investigated the health benefits of cycling to work.

The Scottish-based researchers observed the incidences of heart disease, cancer, accidents and death, adjusting the study to consider other factors contributing to their health, such as sex, age, smoking, and time spent sitting down.

Cyclists had a 52 per cent lower risk of dying from heart disease, and a 40 per cent lower risk of dying from cancer. In terms of developing the disease at all, they had a 46 per cent lower risk of getting heart disease and a 45 per cent lower risk of getting cancer.

The commuters who walked to work also enjoyed some benefits, such as a 27 per cent lower risk of heart disease and a 36 per cent lower risk of dying from it. However, they did not have a lower risk of dying from any of the causes.

People who cycled combined with other modes of transport had 24 per cent lower risk of death from all causes, a 32 per cent lower risk of developing cancer and a 36 per cent lower risk of dying from cancer.

The Australian Heart Foundation estimates the cost of being inactive in Australia is $805 million each year, with much of the costs relating to healthcare spending ($640 million). The cost of physical inactivity to households is $124 million each year, due to diseases related to lack of exercise.

World leaders will meet later this year to take action on physical inactivity and other causes of NCDs, and mental disorders, when they take part in the Third United Nations General Assembly High-level Meeting on Non-Communicable Diseases (NCDs), being held on September 27 in New York.

The World Health Organisation’s Global Action Plan for Physical Activity 2018-2030 can be found here: http://www.who.int/ncds/prevention/physical-activity/gappa/

MEREDITH HORNE

[Comment] Offline: NCDs, WHO, and the neoliberal utopia

The WHO Independent High-Level Commission on Non-Communicable Diseases presented an important opportunity. Yet, by common consensus, it failed to deliver. The Guardian newspaper reported that, “An independent panel advising the World Health Organisation has stopped short of recommending taxing sugary drinks to reduce obesity after failing to reach a consensus.” WHO scrambled to reassure critics that the agency “still supported taxing” sugar-sweetened beverages. The Commission was left unhappily advocating a set of recommendations substantially weaker than those already existing.